Reflections on Public-Private-Partnerships for Primary Care in India, Pakistan and Bangladesh: Reflection on Drivers and Pathways

The challenge: Formalised home-grown public-private-partnerships (PPPs) for delivery of primary care services have proliferated in the mixed health systems of India, Pakistan and Bangladesh, increasingly managed and funded by the state. The momentum of PPPs for primary care in South Asian countries is locally driven, substantial in scale but uncoordinated with UHC initiatives. What are local drivers catalysing PPPs? And what can be learnt from local PPP experiences for coherent, impactful and sustained growth under future UHC centred health systems?  

Shift in Trajectory: Public-private partnerships for service delivery are an established tradition in the sub-continent but have noticeably shifted over the last two decades from less formalised arrangements to more purposeful arrangements managed by the state. Earlier forms of PPPs were based on an expectation for free hospital services from trusted private providers with partial state contribution through grant-in-aid agreements, land-for-bed arrangements and occasional joint investment ventures. These historical experiences have paved the way for public-private partnerships (PPPs) designed to address primary care gaps, with clearly defined roles, state-led management, and partial or full financing by the government. Engagement has broadened to include a diverse range of providers including NGOs, private companies, medical universities, laboratories as well as use of intermediary providers to engage with small-scale private clinics, maternity homes, small hospitals. PPPs for primary care have been deployed to fill gaps in urban primary care, management of government PHC centres in rural areas, provisional of additional services (mobile clinics, diagnostic, maternity) within district health systems and supplementation of disease screening and referral services. Importantly, the emergence of local PPPs has resonated in national health policies that have shifted from an exclusive public sector focus to signalling formal engagement of the private sector. However, there is as little progression on translating PPP policy intent into national UHC planning. Progress is hindered by a lack of clarity on the most suitable PPP modalities and insufficient consolidation of lessons learned from local experiences.

Drivers underlying PPPs for primary care: Bangladesh, India and Pakistan have different trajectories of PPPs but common attributes, enablers and barriers. The PPP trajectory is driven by sub-national governments and positioned to needs of local constituencies. Initiation of PPPs has relied on a bottom-up process of ideation and adaptation rather than centrally designed technocratic initiatives. Scaling up has relied on diffusion of practice, adapting innovations from other states and drawing on common local needs as a starting point. Administrative support of executive-bureaucratic coalitions beyond the health sector have been instrumental in instigation of PPPs, countering slow moving bureaucracies and protecting PPPs from turf wars over legitimacy and resourcing. Use of recurrent funding, simplified payment systems, decision space for private partners, relational management support speedy, agile and innovative PPP delivery. Recent use of digital monitoring has helped reduce mistrust on performance, and can be gamechanger for improved delivery.

Constraints in delivering PPPs for primary care: Efforts to introduce transactional procurement processes shaped by donor-driven rules have often been misaligned with the capacities of local governments and private providers, adding layers of bureaucracy. Project-based funding from development sources has further contributed to challenges, including payment delays, slow implementation, and administrative fatigue. Additionally, private sector participation is constrained by concerns around trust, pricing, and reputational risks associated with partnering with governments, deterring better-equipped providers from engaging. Monitoring efforts remain overly focused on service volumes rather than quality metrics and rely heavily on self-reported data from private providers instead of independent verification systems. Furthermore, inadequate investment in government stewardship capacity exposes PPPs to the risks of both under and overspending, compounded by a failure to consolidate institutional learning from past experiences. Finally, the compartmentalized implementation of PPPs often disconnects them from broader national universal health coverage (UHC) strategies and quality regulation frameworks, undermining their long-term integration and effectiveness.

Positioning PPPs within future UHC centric health systems in South Asian contexts – key takeaways:

Attention to pathways and coherence of PPPs are centrally important in the South Asian context, in addition to traditional capacity concerns. Important takeaways from experience in Bangladesh, India and Pakistan:

• Local starting point, ideation and adaptive pathways are required rather than centralized technocratic designs.
• PPPs planning, while allowing diversity of local designs, must take place within a larger national PHC for UHC framework for standardization of targets and quality benchmarks.
• Partnership modalities must balance between too little accountability or attempts at excessive accountability not compatible with country systems and draw in support of administrative power structures beyond the health sector.
• Competencies for engaging with private providers from a business perspective are also important for PPPs while building competencies in traditional contract management skills.

Authors: Shehla Zaidi (University College London), ,Venkat Raman (Faculty of  Management Studies, University of Delhi), Mahbub Elahi Chowdhury(ICDDRB-Bangladesh), Priya Balasubramaniam (Centre for Sustainable Health Innovations, Singapore, Public Health Foundation India), Ammarah Ali (Aga Khan University Pakistan) Farooq Azam (World Bank Pakistan).

Acknowledgement: Sarbani Chakraborty(Technical University Munich) and Catherine Goodman (LSHTM)