Governance Framework and Public–Private Partnership for Universal Health Coverage: Findings from India’s Federal Health Structure

Background: The role of private health sector in advancing universal health coverage is being recognised globally. A number of public–private partnership (PPP) strategies have been implemented across the states in India. States are primarily responsible for health service delivery in India. OBJECTIVES: To summarise various PPP schemes and projects in health sector across the states in India and to understand the ecosystem, i.e. policy, legal and institutional framework that are critical for effectively governing the partnerships. MATERIALS AND METHODS: The study was carried out in two stages: a comprehensive desk review, followed by field visits for in-depth interviews (IDIs) of key stakeholders in selected states. A total of 52 IDIs were conducted from various levels of stakeholders. Results: Nearly 250 PPP initiatives in health sector across all Indian states were identified and studied. Partnership with the private sector was predominantly in the areas of emergency transport and laboratory diagnosis and in the delivery of selected primary care services. PPPs in health infrastructure (hospitals and medical colleges) and purchasing arrangements are rapidly emerging across most states. However, only few Indian states have health sector-specific PPP policy or legal and/or institutional framework governing PPPs and organisational units implementing partnership schemes. The capacity to conceive, design, implement and manage PPPs in health sector was found either absent or insufficient in most states. Conclusion: There is a need for developing mechanisms for effective and functional partnerships with the PHS for achieving national health policy goals in India. There is a need for well-enunciated policy and governance framework for private sector engagement. Indian union and state governments need to do detailed assessment of the PHS market behaviour; legal, regulatory and oversight mechanisms; building organisational structures with capacities and developing platforms for stakeholder dialogue. Findings from the Indian context could offer useful insights for other low- and middle-income countries aiming to advance towards achieving universal health coverage.