Healthcare Mission 2007 Print

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sanjayDOCTORProject Mentor

131, Silver Beach Apts, Suryavanshi HallOff Savarkar Marg, MUMBAI 400 02 8Cell: 989 2000 857. Res:(022)[email protected]

HEALTHCAREHEALTHCARE

INTERVENTIONINTERVENTION

IN THE CIVILIN THE CIVIL

SOCIETYSOCIETY

A strategic explorationto face the challenges

of a changinghealthcare paradigmin India

June 2007ver 1.0

mikrofields


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HEALTHCARE INTERVENTION

IN THE CIVIL SOCIETYA strategic exploration to face the challenges

of a changing Healthcare paradigm in India

~ TABLE OF CONTENTS ~

Introduction............................................................................................................................................................. 1

PART ONE

1 THE EMERGING PARADIGM OF THE CIVIL SOCIETY.......................................................................... 31.1 Evolution of Global Consciousness....................................... 31.2 Relective / Living Systems Paradigm..................................... 41.3 Peaceful Co-existence................................................................. 6

2 THE CIVIL SOCIETY....................................................................................................................................... 72.1 Historical Development............................................................. 72.1 Role for Private Actors: Systems Interface.......................... 8

3 THE NASCENT CIVIL SOCIETY IN INDIA ................................................................................................ 931 The Voluntary Sector in India................................................. 93.2 India Shining............................................................................... 103.3 Plural Indian Society................................................................. 11

4 PARADIGM SHIFT FOR VOLUNTARY ACTORS................................................................................... 124.1 Organisation renewal............................................................... 124.2 The 3 Ps......................................................................................... 124.3 The Struggle to Change........................................................... 14

5 THE MILLENNIUM GOALS......................................................................................................................... 165.1 Global Development Agenda................................................. 16

5.2 The Health scenario in India................................................. 17

PART TWO

6 NATIONAL RURAL HEALTH MISSION 2005 2 012........................................................................... 236.1 Program Matrix........................................................................... 236.2 Role for Panchayati Raj Intermediaries.............................. 246.3 Role for NGOs............................................................................. 246.4 Budgetary Support..................................................................... 246.5 Thrust Areas................................................................................ 25

7 PUBLIC PRIVATE PARTNERSHIPS......................................................................................................... 264.2 Intervention approach for third sector.............................. 264.3 Public private partnerships.................................................... 26

4.4 the Contract State...................................................................... 288 THE INTERVENTION MATRIX ................................................................................................................. 31

5.1 The vertical span5.1.1 Macro Dimension: Millenium Goals ....................... 315.1.2 Micro Dimension : NRHM Goals............................... 33

5.2 The Program Matrix.................................................................. 40

6 THE AGENTS OF CHANGE......................................................................................................................... 426.1 Ground reality............................................................................... 426.2 the road ahead............................................................................... 426.3 Unlocking the potential in the rural india.......................... 436.4 Conclusion...................................................................................... 44

W


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X

Introduction

This document began as a personal study into the India's

public healthcare. It was to understand and plan micro

interventions into community health. I was relying on my

previous experience of having done a similar study

followed by a decade of work in organic farming. What was

intended to be a short research engagement of a few weeks

turned out to have occupied the entire first quarter of

2!. I have decided to free"e the document at this draft

and circulate it amongst my comrades working in the field.

The document examines the issues at a macro and microlevel. The first part examines the societal issues and the

second part focusses on actual interventions. The reader

can read each part independently or together.

I propose to plan and mentor interventions as outlined

in part two. #lso there is an opportunity to create

linkages with organic farming and nutrition. $reventive

healthcare is a sustainable long term solution for coping

with the current healthcare crisis.

The intended impact of the document is to lead social

agents to an internal strategic exploration of how they

wish to intervene into the healthcare sector.

%ome copies will also be shared with state agencies to

engage in dialogue.

The document is being distributed in the #crobat format

as a digital file. %ome paper copies have also been

printed as execptions.

&umbai (une ) 2! %an*ay +octor

I used an orginal copy of &% Windows ,$ -ome and openware software

penoffice 2. /www.penoffice.org0 from %un to write the document. $+1

was created from penffice's in built writer.

X

Healthcare Interventions in the Civil Society Sanjay Doctor |1
http://www.openoffice.org/http://www.openoffice.org/


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PART ONE

N



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CHAPTER 1

THE EMERGING PARADIGM OF THE CIVIL SOCIETY

THE EVOLUTION OF GLOBAL CONSCIOUSNESS

In the post millennium era, the world is moving towards a greater interconnectedness

than ever before. The Butterfly Effect the flirl of a butterfly in Brazil could cause a

tornado in Texas has made us all aware that the mankind must think with a group-

soul rather than as self-centred individuals if we must survive and prosper as a species.

At a spiritual level a new evolving consciousness is arising. Father Bede (Swami

Dayananda, Shantivanam Ashram), in his article, The New Consciousnesswrites:

We are entering a new age. The European civilisation which we have known for the past2,000 years is giving way to a global civilisation which will no longer be centred in Europebut will have its focus in Asia, Africa and South America. Christianity will no longer be aseparate religion but will be seen in the context of the religious traditions of humankind asa whole.

As we enter this new civilisation, the meeting place of the East and West, and of thenations of the world will be science. The changes in contemporary western science haveprovided a new outlook for life for humanity as a whole. The central point is the newunderstanding of the universe which is no longer perceived as consisting of solid bodiesmoving in space and time, but rather, according to quantum theory, as a field pervaded byconsciousness...

I think that is exactly where we are today; the breakdown of the old civilisation and ofthe whole order which we knew, and, within that, the rebirth of meaning, penetrated by anew consciousness. Science recognises that all order comes out of chaos. When the oldscriptures break down and the traditional form begins to disintegrate, precisely then inchaos, a new form, a new scripture, a new order of being and consciousness emerges.

The old is always dying and the new is emerging, and that which is new socially andculturally transforms the old.

...This is really an apocalyptic age.

The old world economics, was based on a two-sector world; there was the Market or

the economy on the one hand, and the State or government on the other. Supported by

the Norths colonisation of the South, the world was divided between two dominating

political systems - socialism and capitalism. These replaced the indigenous feudalism

and monarchy polity. Emir Sader, writes in the New Left Review, (Sept-Oct 2002):

From the moment of the Bolshevik revolution - and especially since the Second World War- the world stage was polarized by the socialist / capitalist opposition, determiningrelatively fixed ideological and political reference points. While the Left proclaimed astruggle between the two systems, the Western superpowers called for a battle of

democracy against totalitarianism was the determining contradiction of the epoch.



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REFLECTIVE / LIVING-SYSTEMS

The evolutionary consciousness of our species has led us to a paradigm shift about

our World reality. Science makes great discoveries about our worlds - mapping the

Human Genome in our internal world and going deeper into the Cosmos in our

external world. The Cartesian-Newtonian view, built on a mechanical world view, is no

longer able to explain the mysteries of Life. We are left with many unanswered

questions. There is a great revival to seek out ancient knowledge. Fritjof Capra, in the

Web of Lifeobserves:

Since industrial society has been dominated by the Cartesian split between mind andmatter and by the ensuing mechanistic paradigm for the past three hundred years, this newvision that finally overcomes the Cartesian split will have not only important scientific andphilosophical consequences, but will also have tremendous practical implications. It willchange the way we relate to each other and to our living natural environment, the way wedeal with our health, the way we perceive our business organizations, our educational

systems, and many other social and political institutions

The planet is looked upon as Gaia, mother earth goddess. The Gaia hypothesisis an

ecological theory that proposes that living and non living parts of the earth are viewed

as a complex interacting system that can be thought of as a single organism. Named

after the Greek earth goddess, this theory postulates that all living things have a

regulatory effect on the Earths environment that promotes life overall. Stephen

Schneider and Penelope Boston in "Scientists on Gaia" (MIT Press) describe:

"James Lovelock and Lynn Margulis coined the phrase the Gaia hypothesis to suggest ...that life serves as an active control system. In fact, they suggest that life on Earthprovides a cybernetic, homoeostatic feedback system, leading to stabilization of globaltemperature, chemical composition, and so forth.

To see the the Earth (and even the cosmos) as interconnected, living systems has led

to the "reflective/ living-systems" paradigm.



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Table 1 : Comparison of the Cartesian and Living Systems Paradigms

(Source: Global Consciousness Change: Indicators of an Emerging Paradigm by Duane Elgin )

The Cartesian View The Living Systems View

The cosmos is made up of mostly dead matterand empty space and is not "alive."

Our cosmos is a unique kind of "livingorganism" and, as a whole system, isfundamentally alive.

We are floating through vast reaches of emptyspace, and most of life seems to lack any largersense of meaning and purpose.

The entire cosmos is a unified system. Eachaction is woven into the deep ecology of theuniverse. Everything we do matters.

Consciousness-- when viewed from areductionist, mechanistic perspective -- is a byproduct of biochemistry and is located in thebrain.

Consciousness-when viewed from an integrative,living systems perspective-is an ordinarycapacity that permeates the universe andprovides a reflective capability appropriate to

each entity within the universe.

The goal in life is material success and socialachievement.

The goal in life is to develop a balancedrelationship between our inner and outer lives-to live in a way that is sustainable andcompassionate.

The emphasis is on conspicuous consumption.The "good life" depends on having enoughmoney to buy access to pleasures and avoiddiscomforts.

The emphasis is on conscious consumption. The"good life" is an ever-changing balance of innerand outer, material and spiritual, personal andsocial, etc.

Identity is largely defined by material

possessions and social position.

Our sense of self grows through our conscious,

loving, and creative participation in life.

Emphasis is on personal autonomy and mobility. Emphasis is on personal growth and community.

The individual is defined by his or her bodyand is ultimately separate and alone.

The individual is both unique and aninseparable part of the larger universe. Ourbeing is not limited to our physical existence.

It is natural that we who are living use lifelessmaterial resources for our own progress.

It is natural to respect all that exists as integralto the larger body of life.

Cut throat competition is the norm. Youcompete against others to make a killing.

Fair competition is the norm. You cooperatewith others to earn a living.

The mass media are dominated by commercialinterests and are used to promote a high-consumption culture.

The mass media awaken to the challenge ofsustainability and begin to explore moreworkable and meaningful approaches to living.

Nations adopt a "lifeboat ethic" in globalrelations.

Nations adopt a "spaceship Earth ethic" inglobal relations.

The welfare of the whole is left to the workingsof the free market or governmentbureaucracies.

Each person takes responsibility for the well-being of the world, enabling high levels ofdecentralization and freedom at the local level,and a sustainable harmony at the global level.



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PEACEFUL CO-EXISTENCE

Global security and peace are linked to a productive life for all. The report, Investing

in Development, referring to West-led international developmental goals,

The Goals not only reflect global justice and human rights, they are also vital tointernational and national security and stability.

And so as consciousness evolves, it begins to conceptualise the human being and

the value of balance and harmony for peace. Professor Panicker, scientist and

Gandhian philosopher explains the logic in his article, Evolution of Humanity :

Aum Shanti: These two words express the aspiration of humanity for evolution towardsharmony and peace. They denote an attitude of life and a way of living. Aum representsharmony harmony among creation, sustenance and dissolution; harmony among body,mind, intellect, harmony among individuals, neighbourhoods and the world. Harmony,

from Greek harmos (= joint), is literally yoga. Yoga is which joins (Sanskrit yujyateanena yogah).

Yoga leads to Shanti. Shanti means peace peace with oneself or inner peace, peacewithin community and universal peace. Peace from Latin pacisci (= to agree), is a state oftranquillity. From harmony to peace is literally an evolution from joint to agreement, fromcongruence to unity.

Peace comes to individuals from harmony in living, to communities from living in harmonywith neighbours.

Political thought is headed towards a neoliberal outlook, where the Left has

partnered with the Right wing. Again Edir Salami observes:

With the fall of the USSR and the socialist bloc, capitalism was once again sole ruler of theworld scene. The remaining post-capitalist countries reinvented themselves. China opted fora form of market economy as in all likelihood will Vietnam. Cuba sought to defend thebasic gains of the previous period rather than advance towards socialism. The radical shiftin the balance of forces reverberated through the social and political movements. Withgrowing unemployment in Europe, unions were thrown onto the defensive, mounting atbest a partial resistance to flexibilization while rapidly losing members. In the increasinglyinformal and heterogeneous world of labour that was emerging, traditional methods oforganizing had ever less effect. Parties had to confront the universalization of neo-liberalpolicies. European social democracy adapted to this at the very moment when, for the firsttime, the Centre-Left was in power in nearly every EU state; the Communist parties of theregion shrivelled, or vanished altogether. A similar scenario was enacted in Eastern Europe,where former Communist parties took up a radicalized neoliberalism or local versions ofthe Third Way.

It was in this context that local and sectoral forms of resistance ecological, feminist, ethnic,human rights, municipal democracy combined to form the movement that, together withunion organizations and anti-WTO groups, would surface so explosively in Seattle inNovember 1999. If they represent an advance, in creating new spaces in which oppositionforces can come together, many of them also implicitly renounce any attempt to constructan alternative society: as if our indefinite confinement within the limits of capitalism andliberal democracy was accepted as fact.



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CHAPTER 2

THE CIVIL SOCIETY

HISTORIC DEVELOPMENT

The modern idea of the civil society has its roots in the Scottish and Continental

Enlightenment of the late 18thcentury. Freedom from the State in a domain parallel to

the State; where citizens acted according to their own interests and wishes. It was

transformed to its present form in the 1990s when it was used as a tool for a global

move towards democracy against dictatorial countries. In the West, it was used as tool

for social renewal. In developing countries, as privatisation and other market reforms

took place, the civil society become more mainstream as governments retracted. It

became a key element of the post cold war Zeitgeist. It is seen as a key tool for shaping

peoples energy and initiative towards peaceful partnerships with the state.

Defining the Civil Society

The Centre for Civil Society, London School of Economics, defines it as as:

Civil society refers to the arena of uncoerced collective action around shared interests,purposes and values. In theory, its institutional forms are distinct from those of the state,family and market, though in practice, the boundaries between state, civil society, familyand market are often complex, blurred and negotiated. Civil society commonly embraces a

diversity of spaces, actors and institutional forms, varying in their degree of formality,autonomy and power.

Gehard Schroeder, Chancellor of Germany (1998 - 2005), in his article, Civil Society:

redefining the Duties of the State and Society, reflects that,

Society senses that a number of traditional certainties of political and social life are nolonger anchored in place.

He makes a strong case for politics to reorient itself to its primary tasks. These go

beyond the traditional tools of intervention legislation, authority and money. It must

encompass social justice through equal opportunities for all. He sets a new politicalagenda for the state:

How do we want to and how should we achieve justice, participation,solidarity andinnovation in the future ? How can we shape an attractive society which is not exclusiveand in which the talents of all can best unfold ? How can we foster initiative, protect theweak and encourage the strong to make their contribution?



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His concept of a modern civil society is that of a civilisation of change through

political integration and a new civic consciousness greater individual responsibility

that leads to public good. Civil society is becoming the most important centre of social

participation. It will have to create the sense of identity that ties the individual to

the values and goals of a society as a whole.Within this civil society, citizens regain

an element of subsidiarity and self determination.

The global theatre of a civil societies are populated by organisations such as

registered charities, development non-governmental organisations, community groups,

womens organisations, faith-based organisations, professional associations, trades

unions, self-help groups, social movements, business associations, coalitions and

advocacy groups. Brian O Connell, Tufts University, brings together the various players

who constitute the civil society in a star formation:

1) The Individual

2) The Community3) Government4) Business5) Voluntary Sector

From a liberal right perspective, Sara Evans and Harry Boyte in Free Spaces: The

Sources of Democratic Change in America, locate the primary territory of civil society in:

the public spaces, in which ordinary people become participants in the complex, ambiguousengaging conversation about democracy: participators in governance rather thanspectators or complainers, victims or accomplices.

They further elaborate:

particular sorts of public places in the community, what we call free spaces, are theenvironments in which people are able to learn a new self-respect, a deeper and moreassertive group identity, public skills, and values of cooperation and civic virtue.

Civil society exists at the intersection where the various elements of society cometogether to protect and nurture the individual and where the individual operates toprovide those same protections and liberating opportunities for others.

ROLE FOR PRIVATE ACTORS: SYSTEMS INTERFACE

It becomes apparent from the above dissertation that any role envisaged by private

actors in voluntary action must create harmony. This is created by cooperation rather

than opposition to the system it requires a strong faith. Rather than taking a contra

or confrontational role, the alignment seeks to become an active participant in society.

It also means a coming of age for voluntary action actors. From being missionary

organisations, the move is towards social enterprisesworking for creating enterprise

value. Whilst passion provides the warmth for the seed to sprout, the actual germ has

to be built around professionalism. Incompetence cannot be condoned for any

participant in the civil society including the state.



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CHAPTER 3

THE NASCENT CIVIL SOCIETY IN INDIA

THE VOLUNTARY SECTOR

Voluntary action actors are often identified as NGOs- non governmental

organisations. The term has been in vogue ever since development work in the post

independence era was driven by foreign aid programs. The PPP (Public-Private-

Partnerships) Sub Group of the Planning Commission summaries the sector as follows:

The voluntary sector in India refers to bodies / institutions set up under the SocietiesRegistration Act, the Indian Trust Act, the Religious and the Charitable Societies Act, non-profit making companies under the Companies Act as well as under any other legislationthat may be recognized by the State Government. The voluntary sector also includesCommunity Based Organizations (CBO), Self-Help Groups (SHGs), which are generallyinformal or unregistered bodies. It does not, however, include all co-operative societies.

The voluntary sector may be broadly classified as traditional, community based andgovernment sponsored. Traditional sector comprises the various religious and charitabletrusts dedicated to spread education, health care, orphanages and rehabilitation homes etc..The Community based Organizations (CBOs) comprise societies for relief from naturaldisasters, neighbourhood societies, micro-credit societies, womens associations, wild lifeprotection committees etc.. Government sponsored voluntary sector comprises agencies

engaged in welfare programmes such as rural development, afforestation programmes,watershed management, health and education services as well as those engaged inresearch and evaluation.

According to one study, the voluntary sector in India can be grouped in five categoriesbased on their main areas of activity as follows:

(a) Religious .............................. .......................... 26.50 %(b) Community Service ............................. ......... 21.30 %(c) Education ............................... ......................... 20.40 %(d) Cultural .............................. ............................. 18.04 %(e) Health.................................. ............................... 6.60 %

Religious and cultural societies put together have a clear edge over other forms ofvoluntary sectors in India. Government sponsored voluntary sector in India in the areas ofsocial sector, such as health and education etc. may, however, soon come to have a largershare.

In regard to mobilization of resources, moreover, it is stated that half of all 72 sources ofreceipts (51%) is self-generated through fees/charges for the services rendered.

This is followed by grants and donations (29%). Amongst the various sources of raisingfunds, donations and charity are mostly adhoc and irregular. Private fund raising is,furthermore, more time consuming. Similarly, while collection of funds from fees and user

charges are market determined, grants-in-aid are rule bound and more dependable



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INDIA SHINING

After 60 years of independence, there is a trickle down effect of the development

work done by the actors and India appears to rated high in the growth rate scorecard.

Key parameters, as stated by the Finance Minister P. Chidambaram in his Feb 2007

budget speech, are as below:

Manufacturinghas become the main driver of growth.Per capita income has increased by 7.4%

Savings rate is 32.4% and investment rate is 33.8%Foreign exchange reserves $180 billion

Table 2: Key Growth Rate in Gross Domestic Product (GDP) metrics

(Source: RBI report- Macroeconomic and Monetary Developments, Third Quarter Review 2006-07)

(All figures are in percentages)

SECTOR

2001-05 2004-05 2005-06 2006-07

AVERAGE Q1 Q2

AGRICULTURE SECTOR

Share of real GDP

2.3

22.2

.7

20.8

3.9

19.9

3.4 1.7

Manufacturing Sector

Share of real GDP

6.2

19.6

7.4

19.5

7.6

19.3

9.7 10.5

Services

Share of real GDP

8.1

58.2

10.2

59.7

10.3

60.7

10.5 10.7

Growth of Real GDPat Factor Cost

6.4 7.5 8.4 8.9 9.2



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THE PLURAL INDIAN SOCIETY

A strong media, dominated by the urban elite press , support the brand of the

Indian Tiger.This split in society between the haves and have-nots, the old schoolversus the new is exemplified by a poem, published in the Times of India, on 26

January 2007:

There are two Indias in this country.One India is straining at the leash, eager to spring forth and live up to all the adjectivesthat the world has been showering recently upon us.The other India is the leash.

One India says, give me a chance and Ill prove myself.The other India says, prove yourself first and maybe then youll have a chance.

One India lives in the optimism of our hearts.The other India lurks in the scepticism of our minds.

One India wants. The other India hopes.One India leads. The other India follows.

But conversions are on the rise.With each passing day more and more people from the other India have been coming overto this side.

And quietly, while the world is not looking, a pulsating, dynamic new India is emerging.An India whose faith in success is far greater than its fear of failure.

An India that no longer boycotts foreign-made goods but buys out the companies thatmake them instead.History, they say; is a bad motorist, It rarely ever signals its intentions when it is taking aturn.

This is that rarely-ever moment. History is turning a page.For more than half a century, out nation has sprung, stumbled, run, fallen, rolled over, gotup, dusted herself and cantered, sometimes lurched on.But today, as we begin our 60th year as a free nation, the ride has brought us to the edgeof times great precipice.

And one India - a tiny little voice at the back of the head - is looking down at the bottom ofthe ravine and hesitating.

The other India is looking up at the sky and saying, its time to fly.

The civil society will be dominated by players at two scales. One will be corporate

entities working with the state on mega projects like the 4 lane highway, airports,

ports and other infrastructure projects. They enter the theatre of developmental work

for the purpose of economic development leading to larger markets in the long run.

Others will continue their work at the micro scale; more ideology based or just plain

legacy. It is these we focus on.



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CHAPTER 4

A PARADIGM SHIFT FOR VOLUNTARY ACTORS

What could be a new role for these players which would benefit societyand at the same time keeps alive the spirit of human society equal

opportunities, social justice ? Can they be financially viable and find an

ecological niche to sustainably draw resources from the system for their

survival and for executing their programs.

ORGANISATION RENEWAL

Firstly, they must undergo a change management exercise. Change is all around us.

Remaining static, subscribing to dogmas and living in an antiquated business model is

the bane of most of the actors grasping for breath. It implies movement.

Secondly, they must create a revenue generation model. Funding is transformed into

a revenue model. Non-profits must become social enterprises.

These enterprises must tune themselves to global consciousness. They must became

shapers rather than adaptors of globalisation. Programs must originate from the filed

data rather than merely implementing international aid agency agendas. Indigenous

knowledge must be harnessed to find solutions.

The 3 Ps

Being a civil society actor is not them same as being employed in social service or in

a part time feel good hobby. Membership to the club requires competence. At an

organisation level, it means lfrom the Strategy - Structure Systems model to a

harmonious model built around the Purpose Process People. as proposed by

Sumantra Ghoshal. In an article A New Manifesto for Management (1999), Sumantra

Ghoshal, Christopher A. Bartlett, and Peter Moran explain:



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A different management model is now taking shape, based on a betterunderstanding of individual and corporate motivation. As companies switch theirfocus from value appropriation tovalue creation, facilitating cooperation amongpeople takes precedenceover enforcing compliance, and initiative is valued morethan obedience. The managers primary tasks become embedding trust, leadingchange, and establishing a sense of purpose within the company that allows strategyto emerge from within the organization, from the energy and alignment created bythat sense of purpose. The core of the managerial role gives way to the "three Ps":purpose, process, and people replacing the tradition al "strategy-structure-systems"trilogy that worked for companies in the past.

Christopher A. Bartlett is the Daewoo Chair of Business Administration at

Harvard Business School, explains further in Organizational Overhaul,

Were coming from a corporate model based on 3 Ss: Strategy, Structure, andSystems. Strategy was set by allocating the scarce resource (capital). Structure wasdesigned to hold units accountable (divisionalized). Systems provided the means for

the elaborate planning and control process to work. The integrated model createdclear management roles and responsibilities based on delegation and control. Topmanagement were strategic resource allocators who managed scarce capitalresources, allocated them across competing needs, then measured, evaluated, andcontrolled them. Middle management managed the process that supported topmanagements activities. They sent the capital budgets up; they controlled againstthe objectives top management sent down. Front line managers were the operatingimplementers who lived within the budgets and controls of the top managers.

Todays critical scarce resource is no longer capital. Quite the opposite, since mostcompanies today are awash in capital. It is now information, knowledge, andexpertise. In essence, its people and the processes that link them to leverage theirknow-how. With all of these organizations competing for information, knowledge,and expertise essentially, peopletoday s corporate competitive advantage residesin the people in the company and the organizational capability thats built aroundthem. Organizations need to change the way they operate. Some organizationalmind-shifts are crucial.

1. From Strategy to Purpose

In order to create organizational learning, companies have to create a sense ofshared purpose and belonging for all individuals. Companies are no longer simplyeconomic enterprises. Managers must create and manage companies as socialinstitutions as well. Its no small order, but top management must convert thecontractual employee of an economic entity into a committed member of apurposeful organization: Attracting a scarce resource-smart, capable people-dependsincreasingly on creating not just a place where they come to work, but a place wherethey can belong, especially in a world where so many social institutions(communities, neighborhoods, families) are dysfunctional or completely brokendown.

The heart of creating an environment where learning can take place is creating aninternal environment where people can and do relate to each otherformall y andinformally. Social networksare the key link in developing and diffusing expertisethrough the organization.



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2. From Structure to Process.

The organization is not just a hierarchy of tasks and responsibilities, but also a portfolio offlexible roles and relationships. The main task of the organization is to shape behaviors ofpeople and create an environment that enables them to take initiative, cooperate, andlearn. Formal organization charts are no longer the issue. Now, linking assets and

resources through redefined relationships is key.

3. From Systems to People

Restructure systems to reflect the new source of competitive advantage. The old systemwas structured to measure, evaluate, and reward people around financial measures. Notsurprisingly, people were viewed and treated as costs.

Now, with people the source of competitive advantage, Human Resources is the criticalfunction in todays organization. HR practices and policies should no longer be abrogatedto some functional unit miles away from the CEO. The chief HR officer, along with the

learning and knowledge management officers, should be literally and figuratively close tothe CEO, with equal (if not greater) standing than the financial officers.

Until organizations can learn to attract, motivate, develop, and retain superior people andbuild a community where these people can leverage their knowledge and expertiseeverything else they do is supplemental. Transforming organizations relies upontransforming human behavior. Creating an organization based on self-discipline, trust, andsupport is about creating this behavioral context. People are the foundation on which all ofthis is built. The most sophisticated systems and technical structures will be completelywasted if theres leakage of talent, a demotivated workforce, or a culture that doesntsupport sharing of knowledge.

THE STRUGGLE TO CHANGE

Many of the voluntary organisations find themselves in the bind of being a Missionary

organisation. Henry Mintzberg, Professor of Management Studies at McGill University

in Montreal created this term. These organisations are founded on the ideals and

vision of a strong personality who subscribes to a strong philosophy. This permeates

into all strategies and methods of the organisation. Its a double bind. On one hand it

provides a strong will action allowing for great movement.

.., in a missionary organization the shared values and beliefs among the members hold thecompany together. The mission counts above everything, - to preserve it, extend it andperfect it. The mission attracts people that share the same values, and the shared concernmotivates employees to sustain the companys strategy, because the individuals goals areintegrated with the organizational goals. Hence, the common mission increase efficiency,chances to discover opportunities and the capacity for innovation.

Many NGOs were founded with a legacy of Gandhian Ideology and Vinobas

Sarvodaya movement. Founded on strong ideologies of swaraj, frugalism and selfless

service, they have now grown into organisations funded by huge grants from the state.

The Council for Advancement of Peoples Action and Rural Technology (CAPART) has

assisted over 12,000 organisations.



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Caught in the older model of donor intermediary recipient , they became

dependent on donors for funds and slowly all indigenous agendas and ideologies were

sacrificed for programs determined by international donors and the state. A new

vocabulary was learnt. As a result capacities were built around competencies required

for this role. Strong documentation, academic approach to development work and

distancing themselves from the beneficiaries through field units. Quality of work is

assumed to be linked to scale. Numbers dominate the reports. As Globalisation comes

to Indian shores, economic liberalisation requires the state moving away from the

donor status. Internal pressures from the staff and project affected people (PAP) has a

stressful bearing on the workings. Operating costs shoot off the ceiling as the staff

demands compensation and benefits equal to the corporate sector. Somewhere the

legacy of the voluntary sector has created a myth that voluntary work is social work

and therefore salaries are to be nominal. But the nature of development work has

changed, the emphasis being on creative problem solving, strategic decisions all

which rely on the individual professional manager as a working asset. Salaries get

transferred from non-value costs to principal costs.

Once the internal reorganisation takes place, it is necessary to find a vehicle for

work and a section of society to work with. The divide between urban and rural India

has been the driving determinant. Instead we must look right in the midst of our

societys fabric: - in its warp and weft. Because whilst one India moves on, it leaves

another behind. There is an India of those who do not receive the same opportunities

as the elite shining India. They remain defranchised, and resourceless to better their

lives to the same extent as the privileged. Cutting across geographical or social

categories, they exist interpolated in the very fabric of our society. Until now, they

struggled with basic wants of food, clothing and shelter. Now its their aspiration to

receive the same opportunities in life and to enjoy a quality of life which mustbe

satisfied. as enshrined in the fundamental rights of the constitution.

Article 21 has been expanded after reading with Arts. 14 and 19. In Francis v/s

Administrator A. (1981 SC 746) the ruling states:

It includes the right to live with human dignityand all that goes with it, namely the barenecessities of life such as adequate nutrition, clothing and shelter over the head and facilitiesfor reading writing and expressing one self in diverse forms, freely moving about and mixing

and commingling with fellow human beings (para 7) .Denial of basic services inspite of a citizen charter, religious discrimination despite a

secular constitution and gender emancipation are issues awaiting direct action.

We will restrict ourselves to healthcare for the purpose of this paper.



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CHAPTER 5

THE MILLENNIUM GOALS

A GLOBAL DEVELOPMENT AGENDA

The well-being of all people especially those billion-plus living in extreme poverty

has become a global concern. In 2000, United Nations initiated the Millennium Goals

Project to remove extreme poverty by 2015. The goals reflect the basic life issues faced

by a defranchised population in the poor and developing countries.

We will have time to reach the Millennium Development Goals - worldwide and in most, oreven all, individual countries - but only if we break with business as usual.

We cannot win overnight. Success will require sustained action across the entire decadebetween now and the deadline. It takes time to train the teachers, nurses and engineers; tobuild the roads, schools and hospitals; to grow the small and large businesses able tocreate the jobs and income needed. So we must start now. And we must more than doubleglobal development assistance over the next few years. Nothing less will help to achievethe Goals.

Kofi A. Annan : United Nations Secretary-General, 2000

For developing nations around the world , the issues and targets identified are the

new goals for development. Globalisation demands adherence to a global mindset.Alignment to these goals will allow a partnership with the state and donor agencies.

These goals are no doubt built from quantitative research and the feedback received

from transnational voluntary agencies working across the world. However it may be

observed that the agenda is one seen through the viewpoint of the developed countries

and with built around a socio-religious consensus, especially of the Church.

One of the biggest challenges to be addressed in the under-developed world is that

of the growing population and the strain on the global resources. However the Roman

Catholic church and its auxiliary medical wing do not advocate family planning

through contraception or sterilisation. As a result only passive methods of familyplanning are advocated. This reflects in the Millennium Goals which drops this priority

from the list. It also agrees with the fundamental Islamic edicts which prohibit any

form of contraception but circumvents this issue through the advocacy of condoms to

prevent Aids. Nevertheless its a beginning and voluntary actors in India and the state

must adapt these goals to the Indian context.



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5 of the 8 goals specifically address health issues. It draws us to the conclusion that

in the race for global economic development, a large part of the human community

struggles with existence itself. The goals are so basic that for the developed world and

elite class, they are presumed to be available by default. A large part of of the human

race stands a very narrow chance of survival in the coming decades if these issues are

not addresses. Also if this was to be the case, global security and well being would be

severely compromised.

Table 4: Millenium Development Goals

Millennium Development Goals

1 Eradicate extreme poverty and hunger

2 Achieve universal primary education

3 Promote gender equality and empower women4 Reduce child mortality

5 Improve maternal health

6 Combat HIV / AIDS, malaria and other diseases

7 Ensure environmental sustainablity

8 Develop a global partnership for development

THE HEALTH SCENARIO IN INDIA

The United Nations works through the World Health Organisation (WHO) to drive

health care interventions and reforms around the world. Its statement on the website

(www.who.org) under the heading Macroeconomics and Health presents its policy:

Health is an intrinsic human right as well as a central input to poverty reduction and socio

economic development. Cost-effective interventions for controlling major diseases exist, buta serious lack of money for health and a range of system constraints hamper global andnational efforts to expand health services to the poor. The high burden of preventablediseases in poor countries and communities calls for strategic planning of investmentsacross health and health-related sectors to improve the lives of poor people andpromote development.



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Responding to this urgent need, a macroeconomics and health process helps place healthat the centre of the broader development agenda in countries. It engages Ministries ofFinance, Planning and Health to act in tandem with development agencies, civilsociety, philanthropic organizations, academia, and the private sector. Together, theycan take forward a shared agenda for addressing financial and systemic constraints to theequitable and timely delivery of quality health and social services. This work will contribute

toward achievement of the Millennium Development Goals, global objectives such as "3 by5", and national health targets.

Countries are driving the macroeconomics and health process, which takes into accountcountries unique health and macroeconomic variables. WHO, working closely withgovernments and their partners, advocates for a more prominent role for health withincountries macroeconomic agendas. It also offers technical expertise to support countryefforts for developing long-term multi-sectoral investment plans. The work is carried out inline with three themes:

Achieving better health for the poor Increasing investments in health Progressively eliminating non-financial constraint

The WHO works in India through its India Office. Its intervention strategy is

explained by it as:

The Country Cooperation Strategy (CCS)is a medium term, adaptable country specificstrategy that provides the framework of cooperation between WHO and the country. Itarticulates a vision and selective priorities for the work of WHO for health developmentthat are based on systematic assessment of country needs and expectations as well as acountrys commitment and capacity. The CCS is, in turn, translated into operational plansthat are linked to regular budget and extra budgetary funding.

The CCS is more than a document and it reflects the values, principles and corporatedirections of WHO as one organization and is developed in a spirit of partnership andmutual respect in the context of the countrys overall efforts for health development. It is atool that helps in the process of placing health at the centre of sustainable development,articulating the linkages between poverty and health, and calling for greater equity inhealth.

WHO South East Asia Office ( SEARO) in its document, Status Report on

Macroeconomics and Health: India, 2004 set its agenda for India:

Indias total health expenditure as a percentage of GDP was 4.9% in 2000. Governmentspending on health in India is 0.9% of GDP. In 2000, general government expenditures on

health represented 17.8% of total health expenditures and health spending onlyrepresented 5.3% of the general government budget.

Indias health care sector is marked by an extremely high ratio of private spending. Privatehealth spending represents 82.2% of total health expenditures. The proportion ofpublic spending is increasing. The ratio of public expenditure on health to total publicexpenditure was 1.4% in 1980-81, 1.5% in 1990-91, and 1.8% in 1998-99. TheCommission on Macroeconomics and Health recommends that countries increase healthexpenditures by 1% of GNP by 2007.



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Table 5: Social Indicators-Present Status in India

Source: World Development Report 2004 & Tenth Plan Document, Government of India.

KEY PARAMETERS MeasureMeasure % of population below poverty line (1999-2000) 26.1 %

Prevalence of severe malnutrition in children of 1-5 years, (1996-97) 6.2 %

revalence of moderate malnutrition in children of 1-5 years, (1996-97) 44.3 %

Under-5 Child Mortality, per 1000 (2001) 93

Maternal Mortality per 1 lakh live births (1998) 407

Children (6-14 years) not attending school (in millions) 42

Primary pupil-teacher ratio (2000) 40

Male Literacy Rate (2001) 75.9 %Female Literacy Rate (2001) 54.2 %

Literacy Rate among Scheduled Castes (1991) 29.6 %

population having access to improved water source (2000) 84 %

population having access to improved sanitation facilities (2000) 28 %

India constituted a Task force, National Commission on Macroeconomics and

Health, led by P. Chidambaram, Union Finance Minister and and Dr. A. Ramadoss,

Union Health Minister. The report published in 2005 became a well planned strategy

document under the stewardship of the technically competent ministers. It sets astrategy for Indias public health system:

India s health system: The delivery of health care services

The principal challenge for India is the building of a sustainable health system .Selective, fragmented strategies and lack of resources have made the health systemunaccountable, disconnected to public health goals, inadequately equipped to addresspeoples growing expectations and inability to provide financial risk protection to the poor.Access to medical care continues to be problematic due to locational reasons, bad roads,unreliable functioning of health facilities,transport costs and indirect expenses due to wage

loss, etc. making it easier to seek treatment from local quacks. This explains the grossunderutilization of the existing health infrastructureat the primary level contributingto avoidable waste.

The reasons for this failure can be attributed to three broad factors: poor governance andthe dysfunctional role of the state; lack of a strategic vision; and weak management. Thestructural mismatch in the institutions at the Centre and State levels, with manydepartments and agencies duplicating work or working at cross-purposes makegovernance in health ineffective. Contributory factors for a dysfunctional health system areunrealistic and nonevidence- based goal-setting, lack of strategic planning and inadequatefunding.



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The Way Forward

Improving health in India will require building up the health system in the next ten totwenty years. Five core concerns emerge when facing the challenge of improving health inIndia:promoting equity by reducing household expenditure on total health spending andexperimenting with alternate models of health financing;

(1) restructuring the existing primary health care system to make it moreaccountable;

(2) reducing disease burden and the level of risk;

(3) establishing institutional frameworks for improved quality of governance of health;

(4) investing in technology and human resources for a more professional andskilled workforce and better monitoring.

These concerns need to be addressed by stimulating the process of reform. Reforms shouldaim to overhaul the existing system that is dominated by low-quality health care, is costlyand unaffordable for the majority of the people, and where the public sector is under-funded, poorly equipped and constrained by bureaucratic procedures. If India is to staycommitted to achieving the National Health and Population Policies in 2010 and theMillenium Development Goals in 2015, this Commission recommends that public spendingbe increased from the current level of 1.3% to 3% of GDP in the next few years. Theadditional resources can form the building blocks for implementing the Commissionsrecommendations for a strong and viable health care system in India.

Further it makes an important statement regarding the future role of the state in

public health:

Gradually shift the role of the State from being aprovider toapurchaserof healthcare

A structural outline of the public health care interface is mapped:

Ensure that the three tiers of the primary health system are embedded within thecommunity........ We recommend a shift in the provision of services from the currentconcept of individual vertical programmes to a comprehensive package of servicesconsisting of three components:

(1) a core packageconsisting of public goods and costing Rs. 150 per capita, tobe made universally accessible at public cost;

(2) a basic package consisting, in addition to the above, surgery and medicaltreatment costing Rs. 310 per capita;

(3) a secondary care package costing Rs. 700 per capita and consisting oftreatment for vascular diseases, cancer and mental illness, and referrals.

The report also outlined the costs involved for their plan and the financial strategy

to meet this requirement:

Government would require a five-fold increase in the budget or Rs 1 lakh crore @ Rs 1160per capita per year if it is to be the sole provider of the comprehensive package of servicesconsisting of preventive, promotive and curative services.



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Achieving MDG goals and the Tenth Plan objectives in India, in this scenario, will bepossible only if there is a significant increase in resources, targeting areas and populationgroups with low health indicators and focusing on the upgradation of the health systemthrough a well sequenced process of reform.

Our estimates indicate that public investment for provisioning of public goods and primary

and secondary services alone will require about Rs 74,000 crore or 2.2% of GDP at currentprices.

The breakup of Rs. 74,000 crores is as follows:

Rs 33,000 crore capital investment required for building up the battered health infrastructure

Rs 9,000 crore premium subsidy for the poor under a mandatory Universal Social HealthInsurance programme covering the entire country over the next 15 years

Rs 41,000 crore recurring costs towards, salaries, drugs, training, research.

In a next logical sequence the government decided that instead of a new health

policy, last published in 2002, it would come out with a thrust program, funded in part

with international funding. Also it would dovetail its program with Millennium Goals

so that India stands a chance of showing some achievement in its report.



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PART TWO

N



25/46

CHAPTER 6

NATIONAL RURAL HEALTH MISSION 2005 2012

NRHM Mission Matrix

A major thrust is the National Rural Health Mission 2005

2012. After the National Health Policy 2002, this is the first

strategic health policy document published by the Government.

Its presents the framework:

Table 6: National Rural Health Mission Matrix

STATE OF

PUBLIC HEALTH GOALS ACTION PLAN

Public health expenditure in Indiahas declined from 1.3% of GDP in1990 to 0.9% of GDP in 1999. TheUnion Budgetary allocation for healthis 1.3% while the State sBudgetaryallocation is 5.5%.

Union Government contribution topublic health expenditure is 15%while States contribution about 85%

Vertical Health and Family WelfareProgrammes have limitedsynergisation at operational levels.

Lack of community ownership ofpublic health programmes impactslevels of efficiency, accountability andeffectiveness.

Lack of integration of sanitation,hygiene, nutrition and drinking waterissues.

There are striking regionalinequalities.

Population Stabilization is still achallenge, especially in States withweak demographic indicators.

Curative services favour the non-poor:

for every Re.1 spent on the poorest20% population, Rs.3 is spent on therichest quintile.

Only 10% Indians have some form ofhealth insurance, mostly inadequate

Hospitalized Indians spend on anaverage 58% of their total annualexpenditure

Over 40% of hospitalized Indiansborrow heavily or sell assets to coverexpenses

Over 25% of hospitalized Indians fallbelow poverty line because of

hospital expenses

Reduction in Infant MortalityRate (IMR) and MaternalMortality Ratio (MMR)

Universal access to publichealth services such asWomen s health, child health,water, sanitation & hygiene,immunization, and Nutrition.

Prevention and control of

communicable and non-communicable diseases,including locally endemicdisease.

Access to integratedcomprehensive primaryhealthcare,

Population stabilization,gender and demographicbalance.

Revitalize local healthtraditions and mainstream

AYUSH.

Promotion of healthy lifestyles

AccreditedSocial HealthAssociate (ASHA)

Strengthen Sub-Centres,Primary Health CareCentres and CommunityHealth Centres

Prepare District HealthPlan

Sanitation and Hygiene

Disease ControlPrograms

Public PrivatePartnerships

Health FinancingMechanisms

Reorient MedicalEducation



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ROLE FOR PANCHAYATI RAJ INTERMEDIARIES

The state envisions the empowerment of local governments to manage the delivery

through panchayati raj mechanisms termed Panchayati Raj Intermediary (PRI):

1. States to indicate in their MoUs the commitment for devolution of funds,functionaries and programmes for health, to PRIs.2. The District Health Mission (DHM) to be led by the Zila Parishad. The DHM will

control, guide and manage all public health institutions in the district, Sub-centres,Primary Health Centre (PHC) and Community Health Centre (CHC).

3. ASHAs would be selected by and be accountable to the Village Panchayat.4. The Village Health Committee of the Panchayat would prepare the Village Health

Plan, and promote intersectoral integration5. Each sub-centre will have an Untied Fund for local action @ Rs. 10,000 per annum.

This Fund will be deposited in a joint Bank Account of the Auxillary Nurse Midwife(ANM) & Sarpanch and operated by the ANM, in consultation with the VillageHealth Committee.

6. PRI involvement in Rogi Kalyan Samitis for good hospital management.

7. Provision of training to members of PRIs.8. Making available health related databases to all stakeholders, including Panchayats

THE ROLE FOR NGOs

The role envisioned for NGOs is based on patterns of the past. They play a non-

structural role in supportive tasks and sub-contracting of some non-value services.

ROLE OF NGOs IN THE MISSION1. Included in institutional arrangement at National, State and District levels, including

Standing Mentoring Group for ASHA2. Member of Task Groups

3. Provision of Training, BCC and Technical Support for ASHAs/DHM4. Health Resource Organizations5. Service delivery for identified population groups on select themes6. For monitoring, evaluation and social audit

BUDETARY SUPPORT

In his budget speech 2007, the Finance Minister has made the following provisions:

Table 7: Key Budgetary Allocations in Union Budget 2007

Indias Gross Domestic Product(Source: Country profile. Economic Intelligence Unit,The Economist)

Rs. 35,00,000 crore(US$ 797 billion)

1.0 Plan expenditure Rs. 205,100 crores

2.0 Total outlay for health and family welfare

Rs. 15,291 crores(increase of 21.9%)

Share of expenditure

7.6%

2.1 Outlay for NRHM for 2007-08[inflation estimate 5.3%]

Rs. 9,947 crores(increase is of 21.0%)

4.8%

3.0 In comparison Defence expenditure Rs. 96,000 crore 47%



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THRUST AREAS

And so this is the story of Indias healthcare. Poised with an acute understanding of

the environment, the mission is a blueprint without the public finance to put into

action. The plan has 3 main thrust areas:

(1) Building a cadre of voluntary health workers (ASHA)

(2) Upgrading standards of existing health facilities to meet the specifications of

Indian Public Health Standards (IPHS)

(3) Encouraging indigenous and local health traditions (AYUSH) as alternative

alternative medicinal systems to allopathic medicine.

Without an influx of resources from the third sector, the mission is unviable. And

so the interim action calls for a creating / upgrading actors in the civil society to fulfil

the Millennium Goals. The need for voluntary actors to enter and participate with the

state in PPP partnerships is needed more than ever before.

It is not that India does not have the financial resources to meet the expense. The

priorities are different. Defence takes away 47% of the budgetary allocation. A mere

10% diversion of funds to meet the fundamental living standards lacks the political

will. Until corrective action takes place, the People must seeks the solution with their

own resources.

THE HISTORY OF MANKIND is one of continuous development from

the relm of necess t! to the relm of freedom" This process isnever endin#" In n! societ! in $hich clss e%ists& clss stru##le

$ill never end" In clssless societ! the stru##le 'et$een the ne$

nd the old nd 'et$een truth nd flsehood $ill never end" In the

fields of the stru##le for production nd scientific e%periment&

mn(ind m(es constnt pro#ress nd nture under#oes constnt

chn#e) the! never remin t the sme level" Therefore mn hs

constntl! to sum up e%perience nd #o on discoverin#& inventin#&

cretin# nd dvncin#" Ides of st#ntion& pessimism nd

complcenc! re ll $ron#" The! re $ron# 'ecuse the! #ree

neither $ith the historicl fcts of socil development over the

pst million !ers& nor $ith the historicl fcts of nture so fr(no$n to us *i"e"& nture s reveled in the life of celestil 'odies&

the erth& life nd other nturl phenomen+"

,hn#es in societ! re due chiefl! to the development of the

internl contrdiction 'et$een the productive forces nd the

reltions of production& the contrdiction 'et$een the clsses nd

the contrd ct on 'et$een the old nd the ne$) it is the

development of these contrdictions tht pushes societ! for$rd

nd #ives the impetus for the supersession of the ne$ societ! $ith

the ne$" Chairman Mao Tse-Tung



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CHAPTER 7

PUBLIC PRIVATE PARTNERSHIPS

INTERVENTION APPROACH FOR THIRD SECTOR

A strong case is made out for forging a partnership and working together with the

state to create a sustainablepublic health system. A study of the government plans and

its public public documents shows that there is an implicit leaning on the private

actors to carry out the unfinished agenda of the government. Inadequate funding, lack

of managerial skills and shortage of qualified medical and paramedical professionals

haunts the system.The framework laid out in the NHRM plan will fail to meet the

goals without private sector intervention.Its theoretical approach will not stand its

test of time in the field. The intentions and goals are in public interest but it is for theprivate actors to build a credible public health delivery system.

Private actors must build their capacities to become professional agencies which can

measure their output of service against a measurable, a metric.

A metric would describe (i) the key performance indicators to be quantitatively

measured (ii) the periodicity of taking the measurement and (iii) how the data received

would be interpreted.

Just being a sole provider of civil health services in a remote area or providing freee

services is not enough. They must deliver quality and adhere to the health standardslaid out by the government. In the next 5 years, competencies must be built to tender

for providing public healthcare services and compete with state-owned providers.

PUBLIC PRIVATE PARTNERSHIPS

Wikipedia, the open source knowledge bank provides an introduction:

Public-private partnership (PPP) is a system in which a government service or private

business venture is funded and operated through a partnership of government and one ormore private sector companies. These schemes are sometimes referred to as PPP or P3.

In some types of PPP, the government uses tax revenue to provide capital for investment,with operations run jointly with the private sector or under contract (see contracting out). Inother types (notably the Private Finance Initiative), capital investment is made by theprivate sector on the strength of a contract with government to provide agreed services.Government contributions to a PPP may also be in kind (notably the transfer of existingassets).



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Typically, a private sector consortium forms a special company called a "special purposevehicle" (SPV) to build and maintain the asset. The consortium is usually made up of abuilding contractor, a maintenance company and a bank lender. It is the SPV that signs thecontract with the government and with subcontractors to build the facility and thenmaintain it. A typical PPP example would be a hospital building financed and constructedby a private developer and then leased to the hospital authority. The private developer

then acts as landlord, providing housekeeping and other non medical services while thehospital itself provides medical services.

The government has successfully tendered partnerships with the private sector

under the agesis of Public Private Partnerships also known as P3 partnerships. The

Planning Commission in its report, Public Private Partnership by the PPP Sub-Group

on Social Sector (Nov 2004) conceptualises P3 as:

2.1 Public-Private-Partnership - The Concept

...The term private in PPP encompasses all non-government agencies such as the corporate

sector, voluntary organizations, self-help groups, partnership firms, individuals andcommunity based organizations, PPP, moreover, subsumes all the objectives of the servicebeing provided earlier by the government, and is not intended to compromise on them.Essentially, the shift in emphasis is from delivering services directly, to servicemanagement and coordination.

It is further explained that the responsibility of delivery remains with the

government. It is an out-sourcing of service deliverables. The potential benefits would

be:

1. Cost-effectiveness-since selection of the developer/ service provider depends oncompetition or some bench marking, the project is generally more cost effective than

before.2. Higher Productivity- by linking payments to performance, productivity gains may be

expected within the programme/project.3. Accelerated Delivery s ince the contracts generally have incentive and penalty

clauses vis-a-vis implementation of capital projects/programmes this leads toaccelerated delivery of projects.

4. Clear Customer Focus- the shift in focus from service inputs to outputs create thescope for innovation in service delivery and enhances customer satisfaction.

5. Enhanced Social Service- social services to the mentally ill, disabled children anddelinquents etc. require a great deal of commitment than sheer professionalism. Insuch cases it is Community / Voluntary Organizations (VOs) with dedicated volunteerswho alone can provide the requisite relief.

6. Recovery of User Charges- Innovative decisions can be taken with greater flexibilityon account of decentralization. Wherever possibilities of recovering user charges exist,these can be imposed in harmony with local conditions.

The model for the partnership, in 3 roles, is explained;

The government may collaborate with the private developer/service provider in anyone of the following ways:Funding agency: providing grant/capital/asset support to the private sector engagedin provision of public service, on a contractual/noncontractual basis.Buyer: buying services on a long term basis.Coordinator: specifying various sectors/forums in which participation by the privatesector would be welcome.



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Contractual Framework:

The contract mirrors the basic objective of the programme /project, the tenure ofagreement, the funding pattern and of sharing of risks and responsibilities. The need todefine the contract very precisely, therefore, becomes paramount under PPP.

Projects/programmes under PPP may, however, broadly be classified under three headsnamely; service contract, operations & maintenance (management) contract and capitalprojects, with operations & maintenance contract.

THE CONTRACT STATE

The Contract is the foundation of the partnership. To understand the implict

meaning of the Contract under law,

A contract is a legally binding exchange of promises or agreement between parties thatthe law will enforce. In common law jurisdictions there are three key elements to thecreation of a contract. These are offer and acceptance, considerationand an intentionto create legal relations.

The conference document of Revisiting the Contract at the Institute of Development

Studies, University of Sussex (2005), in its commentary states:

All advanced industrial societies are in the process of reforming their employment andwelfare arrangements. This represents an attempt to modernise social, economic andpolitical institutions established in the post-war period, and before. Modernisation has beenseen associated with the movement towards a more contractualand individualised society.

We are witnessing a paradigm shift in the way in which public services of all kinds

housing, education, and community care, as well as health will be delivered. Market

principles of choiceare being introduced into the public sector and contract becomes

the vehicle for achieving the goals of increased efficiency, choice, quality, and

accountability. This is seen by some social scientists as a shift towards the contract

state, in which the traditional market is replaced by quasi-markets. It has a major

implication for the way in which the third sector will be treated as contractors. In a

Quasi-market purchasers funded by taxation buy services from providers. The

purchasers may buy for themselves or on behalf of the end users. The providers are

either for-profit or non- profits, publicly or privately owned. It is designed to reap theefficiency gains of free markets without losing the equity benefits of traditional systems

of public administration and financing. A notable example would be the National

Health Service Internal Market in United Kingdom (introduced in 1990): under this

system, the purchase and provision of healthcare in the UK was split up, with

government-funded GP fundholders "purchasing" healthcare from NHS Trusts and

District Health Authorities, who competed against one another for the GPs custom.

This led to increased efficiency, as hospitals now needed to offer procedures at lower

costs in order to win patients and funding, but without losing the main equity benefits

of the NHS (healthcare remained free at the point of service and financed through

taxation).



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Awarding the contract is suggested in either of the following traditional ways:

1. Competitive Bidding through a well documented and transparent process

2. Competitive Negotiation3. A pro-active method for voluntary actors

Swiss Challenge Approach

The Swiss Challenge approach refers to suo-motu proposals being received from theprivate participant by the government. The private sector thus provides

all details regarding its technical, financial and managerial capabilities, all details regarding technical, financial and commercial viability of the

project/programme

all details regarding expectation of government support / concessions.The government may examine the proposal and if the proposal belongs to the declaredpolicy of priorities, then it may invite competing counter proposals from others (in the spiritof Swiss Challenge approach) giving adequate notice. In the event of a better proposalbeing received, the original proponent is given the opportunity to modify the originalproposal. Finally, the better of the two is awarded the project/programme for execution.

In the case of Complex negotiations, a master contractor / Mother NGOmay be

appointed who will then award sub-contracts. Payment to the private sector could take

the form of: (a) contractual payments (b) grants-in-aid and (c) right to levy user charges

for the asset created / leased-in. Even the monitoring is outsourced to external

agencies:

Involvement of third party/independent agencies for monitoring appears to be preferableas they leave the government hassle free over the project and minimize governmentcontrol.A certain percentage of the cost of the project needs to be, therefore, earmarkedfor contract management. The government and the developer/service provider couldmutually decide the third party. The third party involvement could be further supplementedwith provision for adjudication by the (higher) judiciary.

India has already adopted the PPP model of healthcare as follows:

Ministry of Health & Family Welfare : Department of Family Welfare

The Department has the following schemes, under the Reproduction and Child Health (RCH)Programme, being implemented fully/partially through public-private partnership, namely;



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PPP O!ective " #unction $ervice Provider

Sterilisation (forPopulation

Stabilization)

Improving access to sterilization

services through involvement of

private / NGO health facilities.

Beneficiaries are the acceptors of

family planning services, bothtubectomy and vasectomy.

Private Practitioners/NGOs

having medical facilities.

Mother NGO

(MNGO) Scheme

Involvement of NGOs for

supplementing and complementing

medical services provided by the

Government, especially in unserved

and underserved areas.

NGOs with fixed assets

amounting to Rs.2 lakhs, with

at least 3-5 years experience in

health and family welfare.

There is a network of 500 field NGOs in 439 districts, overseen by 102

mother NGOs which have been till recently founded directly by the

Department of Family Welfare (Government of India). The scheme has

been revised recently and decentralized to State levels.

Social Marketing

of Contraceptives

(viz. Condoms / OCPs)

through social

agencies SMOs /

NGOs

To make available Condoms/ Oral

Contraceptive Pill (OCPs) to users at

highly subsidized rates with the aim

of birth spacing / prevention from

AIDS / STD, through Social

Marketing Organizations (SMOs /

NGOs). Beneficiaries are eligible

couples and other users through out

the country.

Social Marketing Organizations

(SMOs / NGOs) network, The

Social Marketing Organizations

(SMOs)/NGOs network. Any

NGO registered under the

Societies Registration Act and

having a minimum of 3 years

experience in the area of

operation and having requisite

infrastructure and staff is

eligible to apply.

Contractual

appointment of

Addl. ANM,

Public Health

Nurse , Lab

Technician.

Improving the condition of sub-

optimal manpower at district and

sub district levels through trained

staff appointed on contractual basis.

Beneficiaries are pregnant women,

children and others availing

reproductive child healthcare (RCH)

Services.

Auxiliary Nurse Midwife

(ANMs), Public Health Nurses

(PHN) and Lab. Technicians.

Client: State Government State

Health and Family Welfare

Society for the Voluntary

Sector (SCOVA).

Hiring of Safe

MotherhoodConsultant

Improving the condition of sub-

optimal manpower at district and

sub district level for safe abortion

services and maternal health care

services available in the Primary

Health Centres (PHCs) and

Community Health Centres (CHCs).

Private doctors (Obstetric and

Gynecologists)

Beneficiaries are pregnant

women for antenatal care and

post natal care and women

with unwanted pregnancies

desiring termination of

pregnancy.

Vande Mataram

Scheme

Improved access to ante and post

natal care to pregnant and lactating

women free of cost.

Members and volunteers of

Federation of Gynecological

Society of India (FOGSI).



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CHAPTER 8

THE INTERVENTION MATRIX

Voluntary Actors (VA) may plan their intervention in a matrix : The vertical array

(columns) refers to the span of the choices.The horizontal array (rows) refers to the

scale of operation.

THE VERTICAL SPAN

There are 2 dimensions: (1) The Millennium Goals and and (2) NHRM Goals:

MACRO DIMENSION : THE MILLENIUM GOALS(adapted to Health Intervention Strategy)

Goal 1: Eradicate Extreme Hungerand Poverty

Target. Halve, between 1990 and 2015, theproportion of people who suffer from hunger

Indicators.(1) Prevalence of underweight children under five years of age(2) Proportion of population below minimum level of dietary energy consumption (FAO)

Goal 2: Achieve Universal PrimaryHealth Education

Target.By 2015, children will be able to receivehealth educationin primary schooling.

Indicators. (1) Health Literacy rate of 15-24 year-olds

Goal 3: Promote Gender Equalityand Empower Women

Target. Eliminate gender disparity in healthsector

Indicators.(1) Share of women in wage employment in the health sector

Goal 4: Reduce Child Mortality Target. Reduce by two-thirds, by 2015, theunder-five mortality rate

Indicators.(1) Under-five mortality rate (2) Infant mortality rate (3) Proportion of 1 year-old children

immunized against measles



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Goal 5: Improve Maternal Health Target. Reduce by three-quarters, by 2015, thematernal mortality ratio

Indicators.1. Maternal mortality ratio (2) Proportion of births attended by skilled health personnel

Goal 6: Combat HIV/AIDS, Malariaand other diseases

Target. Have halted by 2015 and begun toreverse the spread of HIV/AIDSTarget. Have halted by 2015 and begun toreverse the incidence of malaria and other majordiseases

Indicators.1. HIV prevalence among pregnant women aged 15-24 years 2. Condom use rate -

contraceptive prevalence rate 3. Condom use at last high-risk sex 4. Percentage of population aged 15-24

years with comprehensive correct knowledge of HIV/AIDS

Goal 7: Ensure Environmental

Sustainability

Target. Integrate the principles of sustainabledevelopment into country policies and programs

and reverse the loss of environmental resourcesTarget.Halve, by 2015, the proportion of peoplewithout sustainable access to safe drinking waterand basic sanitationTarget. Have achieved by 2020 a significantimprovement in the lives of at least 100 millionslum dwellers

Target 1 Indicators.(1) Proportion of land area covered by forest (2) Ratio of area protected to maintain

biological diversity to surface area (3) Energy use (kg oil equivalent) per $1 GDP (4) Carbon dioxide

emissions per capita and consumption of ozone-depleting CFCs (ODP tons) (5) Proportion of population

using solid fuels . Target 2 Indicators. (1) Proportion of population with sustainable access to an improvedwater source, urban and rural (2) Proportion of population with access to improved sanitation, urban and

rural Target 3 Indicators.(1) Proportion of households with access to secure tenure

Goal 8: Develop a GlobalPartnership for Development

Target. Develop further an open, rule-based,predictable, nondiscriminatory trading andfinancial system (includes a commitment to goodgovernance, development, and poverty reduction(both nationally and internationally)Target.In cooperation with developing countries,develop and implement strategies for decent andproductive work for youthTarget. In cooperation with pharmaceuticalcompanies, provide access to affordable essentialdrugs in developing countriesTarget. In cooperation with the private sector,make available the benefits of new technologies,

especially information and communicationstechnologies

Indicators. Market access: (1) Proportion of total country exports (by value and excluding arms) to

developed countries admitted free of duty (2) Average tariffs imposed by developed countries on

agricultural products and textiles and clothing from developing countries (3) Agricultural support estimate

fas percentage of GDP (4) Proportion of ODA provided to help build trade capacity

Other Indicators: (1) Unemployment rate of young people aged 15-24 years, each sex and total (2)

Proportion of population with access to affordable essential drugs on a sustainable basis (3) Telephone

lines and cellular subscribers per 100 population (4) Personal computers in use per 100 population and

Internet users per 100 population.



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MICRO DIMENSION : THE NRHM GOALS

Goal 1: Accredited Social Health Associate (ASHA) First health touchpoint in village. Women Volunteer with basic training

(1 ASHA / 1000 population )Role: (A) Community mobiliser, awareness and local health planning

(B) Promote good health(C) Provide minimal package of primary care intervention.

Responsibilities(1) create awarenessand provide information to the community on determinants of

health such as nutrition, basic sanitation & hygienic practices, healthy living andworking conditions, information on existing health services and the need for timelyutilization of health & family welfare services.

(2) counsel womenon birth preparedness, importance of safe delivery, breastfeedingand complementary feeding, immunization, contraception and prevention ofcommon infections including Reproductive Tract Infection/Sexually Transmitted

Infection (RTIs/STIs) and care of the young child.(3) mobilize the community and facilitate them in accessing healthand health relatedservices available at the village/sub-center/primary health centres, such asImmunization, Ante Natal Check-up (ANC), Post Natal Check-up (PNC), ICDS,sanitation and other services being provided by the government.

(4) work with the Village Health & Sanitation Committee of the Gram Panchayat todevelop a comprehensivevillage health plan.

(5) arrange escort/accompany pregnant women & children requiring treatment/admission to the nearest pre- identified health facility i.e. Primary Health Centre/Community Health Centre/ First Referral Unit (PHC/CHC /FRU).

(6) provide primary medical carefor minor ailments such as diarrhoea, fevers, andfirst aid for minor injuries. She will be a provider of Directly Observed TreatmentShort-course (DOTS) under Revised National Tuberculosis Control Programme.

(7) depot holderfor essential provisions being made available to every habitation likeOral Rehydration Therapy (ORS), Iron Folic Acid Tablet (IFA), chloroquine,Disposable Delivery Kits (DDK), Oral Pills & Condoms, etc. A Drug Kit will beprovided to each ASHA.

(8) inform about the births and deaths in the village and any unusual healthproblems/disease outbreaks in the community to the Sub-Centres/Primary HealthCentre.

(9) promote construction of h ousehold toilets under Total Sanitation Campaign.

Process Indicators: 1) Number of ASHAs selected by due process 2) Number of ASHAstrained 3) % of ASHAs attending review meetings after one yearOutcome Indicators: (a) % of newborn who were weighed and families coun

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