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Critical to Building the Healthcare Last Mile: Government or Private Sector?

June, 2017

Siddhartha Bhattacharya, Country Director India, ACCESS Health International, proposes an integrated redesigned approach built on public private partnerships

The healthcare system in India faces several key challenges in the last mile: a fragmented delivery system, with public and private providers operating in distinct spheres; primary, secondary, and tertiary levels of care fractured from one another. Like in many other countries, healthcare delivery in India is organised from tertiary care to primary care, rather than the other way around. The ability to deliver appropriate patient centered care will be an important step for India to provide high quality health services at a cost Government and citizens can afford. The pressures on cost are increasing due to lifestyle and demographic changes, most specifically the increased cost of caring for chronic care and aging populations. Universal healthcare coverage is not sufficient to address the twin challenges of high quality and affordability. Access alone guarantees neither quality nor affordability.

We propose that an integrated redesigned approach built on public private partnerships is a necessary solution in a mixed healthcare system like India. Government should be a steward of this system and play a role of strategic purchaser of health services with tight linkages between homecare, community healthcare, ambulatory care centers, secondary regional hospitals, and multi specialty and academic medical centers to provide seamless care for each person or family. A redesign at a system level is critical to delivering accessible, affordable and quality healthcare at the last mile.


An integrated approach based on public private partnerships would need to include performance based financing and shift the focus from inputs to outcomes. It would also need to diversify and expand funding pools for prepaid health coverage, targeting subsidies to the poorest populations.

Primary Care

There is an overall emphasis on a preventive and promotive health system that is comprehensive, proactive and pro poor. There is a need to strengthen the performance of the system at the grass root level, tapping into both the formal and informal network of providers and drive an engagement plan. We should build political support among the states for population wide healthcare reforms and communicate clear and measurable benefits of health and wellness.


Quality should be monitored as a leading indicator for health system performance and different components of the health system should be connected through a real time transparent information system that monitors the continuum of appropriate care between primary, secondary, and tertiary levels of care


There is a need for creation of autonomous and accountable structures to govern, finance, and provide health services including independent systems for performance measurement and reporting. Ideally, we should structure the Public Private Partnerships as a risk sharing partnership.

Ideally, primary care should be integrated with secondary and tertiary care, from an access, quality, and cost point of view. The long term vision should be to integrate management and funding across different levels of care and provide incentive to the system managers to focus on prevention, early diagnosis, effective treatment, and a consequent reduction in hospitalization.

It is unrealistic for the private sector alone to assume full responsibility for providing care in the public system. A robust healthcare system should build the technical and professional capacity of state governments to be a steward, strategic purchaser and provider and a performance monitor for the end to end health system that includes both public and private sector. The healthcare model may be customized from state to state, but it is defined by a unified set of objectives: to increase population access to high quality healthcare, to reduce out of pocket payments, and to improve health outcomes.

It is time that we flip the inverted pyramid of healthcare services and usher high quality affordable healthcare to everyone, no matter where they live, no matter what their age is. The National Health Policy for 2017 makes a strong statement of intent in realizing this vision over the next decade.

The opinions expressed in this article are the author’s own.