Public Private Partnership in Meghalaya: delivering healthcare in difficult to access tribal areas

Introduction Meghalaya, a hilly tribal state in India’s northeast, has many inaccessible areas with little or no access to quality health services. With an IMR of 58, Institutional Deliveries rate of 29.7 %, a full Immunization coverage of 32.8 %, and a TFR of 3.8, Meghalaya has one of the poorest health indicators in the country. Faced with challenges of attracting and retaining skilled health workers in these remote settings, the state in 2008, adopted a Public Private Partnership (PPP) approach that involved handing over the management and operations of 29 poorly performing CHCs/PHCs and SCs located in difficult areas to NGOs, through a memorandum of understanding. A study was undertaken to assess the effectiveness of this approach with respect to increasing access to essential health care services. Methodology The study used mixed methods – both quantitative and qualitative tools. Desk review of records and reports was conducted to assess performance of facilities supported by observations made during facility visits with regard to infrastructure development and maintenance, and human resources development. Focus Group Discussions were organized to assess community perceptions with respect to the village health committees and ASHA program.  A structured pre-tested questionnaire was administered to service providers and a sample of beneficiaries. All 32-health facilities managed by the six NGOs (2 CHCs, 19 PHCs, 10 SCs and 1 Dispensary) were covered in the study conducted during November 2011-January 2012. Findings There was recorded improvement of most of the facilities and their functioning in terms of service delivery following the takeover by NGOs. Improvements took the form of infrastructural corrections, better maintenance of buildings, improved staff availability, and better supply of essential drugs and equipments. Since these facilities were performing near zero services at the time of outsourcing management, the first major improvement is the recorded increase in out-patient care in all facilities and in-patient care in the CHCs. Together the 21 facilities (2 CHC/19 PHC) are now seeing approximately 19362 out-patients and 907 inpatient every month.  Ante Natal Coverage had improved in 18 of the 19 sectors. Institutional Deliveries are being conducted at all the 19 PHCs and 2 CHCs with an average of 3-4 per facility per month.  Immunization Sessions are being held regularly and number of fully immunized children has steadily increased. The main gaps were in skills and therefore quality of care- due to the lack of any access to trainings for the service providers. Discussion With better management under PPP, otherwise non-operational health facilities in difficult-to-access underserved areas can deliver effective health care services. With improved availability of quality health care services, healthcare-seeking behaviour can be positively influenced. What helps the NGO succeed where the regular system fails, is a more flexible approach to recruiting, training and deploying skilled health care workers and more important, through good leadership, building a supportive positive practice environment ensuring their retention. Contracting out management of health facilities in difficult-to-access areas, done in isolation from other state support functions limits outcomes. The State needs to supplement the facility level efforts with smooth flow of funds, need-based training programs, regular supply of drugs and logistics, and monitoring and support mechanisms. The state would also need to devise and implement incentive package for retention of key staff in these difficult and inaccessible areas. The PHCs are being managed at an average cost of around Rs. 22 lakhs per annum which is the same as regular PHC. Management requires support to be able to assess and manage the health of populations they serve as opposed to provision of healthcare services to those who coming to the facility and limited outreach service package.


Introduction
Meghalaya, a hilly tribal state in northeast India, has many inaccessible areas with little or no access to good quality health services. With an infant mortality rate (IMR) of 58 infant deaths per 1000 live births, an institutional delivery proportion of 29.7 % of all deliveries, a full immunization coverage rate of 32.8 %, and a total fertility rate of 3.8, Meghalaya has some of the poorest health indicators in the country. Faced with challenges of attracting and retaining skilled health workers in these remote settings, the state adopted a Public Private Partnership (PPP) approach in 2008. The approach involves handing over the management and operations of 29 poorly performing community health centres (CHC), primary health centres (PHC) and subcentres located in difficult areas to nongovernmental organisations (NGO), through a memorandum of understanding. We conducted this study to assess the effectiveness of this approach with respect to increasing access to essential healthcare services.

Methods
We included all the 32 health facilities managed by the six NGOs (2 CHCs, 19 PHCs, 10 SCs and 1 dispensary) in the study. The study was conducted from November 2011 to January 2012. We used a mix of both quantitative and qualitative tools. We conducted a desk review of records and reports to assess performance of facilities. We supplemented this with observations made during facility visits to assess infrastructure development and maintenance, and human resources development. Focus group discussions were organized to assess community perceptions with respect to the village health committees and Accredited Social Health Activist (ASHA) programme. A pre-tested questionnaire was administered to service providers and a sample of beneficiaries.

Results
We found improvement of most of the facilities and the functioning of the health centres in terms of service delivery following the takeover by NGOs. Improvements took the form of infrastructural corrections, better maintenance of buildings, improved staff availability, and better supply of essential drugs and equipment.
Since these facilities were performing near zero at the time of outsourcing management, the first major improvement is the recorded increase in outpatient care in all facilities and in-patient care in the CHCs. In the 21 health centres (2 CHC/19 PHC) of the 32 institutions we studied, every month 19362 outpatients and 907 inpatients were recorded. Antenatal coverage improved in 18 of the 19 sectors. Institutional deliveries are being conducted at all the 19 PHCs and two CHCs with an average of three to four deliveries per facility per month. Immunization sessions are being held regularly and number of fully immunized children has steadily increased. The main gaps were in skills of the providers and therefore, the quality of care. This was mainly due to lack of access to training programmes for the service providers.

Discussion
With better management under PPP, previously nonoperational health facilities located in difficult-to-access and underserved areas can deliver health care services. What helps the NGO succeed where the earlier system fails is a more flexible approach in recruitment, good leadership, building a supportive positive practice environment ensuring the retention of human resources.
If contracting-out management of health facilities in difficult-to-access areas is done in isolation from other state support functions, then the outcomes are limited. The State needs to supplement the facility level efforts with smooth flow of funds, need-based training programs, regular supply of drugs and logistics, and monitoring and support mechanisms. The state would also need to devise and implement incentive package for retention of key staff in these difficult and inaccessible areas.
The PHCs are being managed at a cost of around INR 2,200,000 per annum, which is the same as that spent on a regular PHC. The management requires support to be able to assess and manage the health of populations they serve, in addition to provision of healthcare services to those who come to the facility.