Engaging the Private Sector to Improve Reproductive, Maternal, Newborn, and Child Health Services in India

Private medical practitioners are the preferred health service providers across the socio-economic spectrum in India. However, the rapid growth of private sector health services has raised concerns regarding standards of care in private clinical practice. While government policies to engage the private sector through public-private partnerships (PPPs), insurance, and other schemes exist, their implementation has not been rigorously reviewed.

Through the USAID-supported Vriddhi project, JSI India conducted a landscape assessment of reproductive, maternal, newborn, and child health (RMNCH) service delivery in the private sector. The study aimed to collect evidence for a private sector engagement strategy for RMNCH. Using a mixed-methods approach, the assessment gathered information from over 300 respondents, including facility-based private providers; in-patient department (IPD) clinics; out-patient department (OPD)-only clinics; professional associations; pregnant women and mothers with children under five years of age; government representatives at the national, state, and district levels; and social enterprises in 7 districts across 6 states.

The assessment found a number of barriers and facilitators to PPPs for RMNCH service delivery in India, including:

1. Adherence to legal frameworks and standardized guidelines

Overall, only 37 of 87 IPDs had legal registration to provide medical services. Very few facilities were accredited under recommended systems. None of the facilities provided all RMNCH services as per global or national guidelines. There were gaps in knowledge of contemporary treatment guidelines and some practices were inconsistent with rational, responsive, and reliable quality of care. In addition, most facilities lacked standard operating procedures, which could affect treatment quality.

2. Availability of, versus capacity for, RMNCH services

Only 20 of 67 of facilities provided the entire range of RMNCH services. The most commonly provided service was delivery care. However, the number of reported caesarean sections was much higher than expected. Many of the facilities that provided delivery care did not provide newborn care services, missing crucial service delivery opportunities at birth.

The assessment also found a shortage of pediatricians and infrastructure—of 41 IPDs offering newborn care, only 10 had a neonatal intensive care unit. In addition, many providers were not following recommended guidelines for treatment of common childhood illnesses. For example, among providers who correctly recommended zinc and ORS for treatment of diarrhea, only 16 of 22 IPD providers and 10 of 30 OPD providers stated the correct duration of zinc supplementation for diarrhea management. In addition, over half of IPD (23 of 41) and OPD (13 of 21) providers prescribed “higher” order antibiotics (antibiotics which are often more expensive than recommended drugs and which may, if improperly used, contribute to drug resistance) to treat neonatal sepsis.

3. Readiness to partner with the government on RMNCH schemes

Private providers had reservations about participating in a government-supported health insurance program for the poor, citing that the program does not cover actual costs and that reimbursement is often delayed. In contrast, government representatives suspected that private providers submitted inflated bills and wrongful claims under the program, and stated that lack of data sharing by private providers was a major challenge for PPPs. The assessment also found that most private providers did not follow a scientific model for pricing or subsidizing services, but determined prices based on the competition and colleagues’ recommendations.

4. Client perspectives on the quality of private sector RMNCH services

The assessment found that clients (pregnant women and mothers with children under five years of age) often prefer to seek treatment from private providers. Almost all clients highlighted ease of access as a top reason for private sector preference, as well as a belief that government services are only for those who cannot afford to pay. However, clients revealed a preference for government facilities if doctors were accessible around-the-clock. Clients also found private hospitals to be cleaner and would rather seek care in them even though they offered lesser services than public facilities. Many women recounted receiving extensive counseling on birth preparedness, breastfeeding, and postpartum contraception in government hospitals, but not in private facilities, highlighting gaps that adequate, quality nursing care can fill in the private sector.

The results of the assessment were discussed at a national consultation with public and private sector stakeholders. They made some recommendations on the way forward. These include supporting the organization of PPP cells, or bodies that include both public and private sector representatives, and assisting in and facilitating the creation and coordination of PPPs. Vriddhi is currently implementing these recommendations in Delhi, Himachal Pradesh, Jharkhand, and Uttarakhand states.

Vriddhi also identified lead coordinators from health professional associations in each of these states to 1) facilitate private practitioner trainings on government-endorsed RMNCH+A guidelines and protocols, 2) liaise with the leadership of professional bodies to raise issues from private sector providers, and 3) promote use of the RMNCH Practitioners Forum so that it becomes a reference point for informed dialogue on challenges faced by private practitioners in PPPs.

Since July 2017, Vriddhi has supported the implementation of 6 state-level trainings for over 150 medical practitioners in Delhi, Himachal Pradesh, Jharkhand, and Uttarakhand. Sustained investment in this approach has the potential to reach nearly 7,000 private practitioners with PPP cells in 6 states.