Role of private-public partnership in health education: a survey of current practices in udaipur city, rajasthan, India.

BACKGROUND: The concept of a public-private partnership (PPP) has been proposed as a potential model for providing education services besides public finance and public delivery. The present study was conducted to survey the current practices of Private-Public Partnership (PPP) in health education in Udaipur city, Rajasthan, India.
METHODS: A questionnaire survey was conducted among organizations involved exclusively and actively in health education in Udaipur city, Rajasthan, India. The pretested self designed structured questionnaire consisted of 21 items pertaining to the current practices of private-public partnership (PPP) in health education. Descriptive statistics were used to describe the data.
RESULTS: On the basis of inclusion criteria, 50 personnel from 2 private dental colleges, 1 private medical college, 2 Non Government Organizations (NGOs) and 1 health museum were selected. Only 15 (30%) of participants agreed that they have a written reference policy that outlines the services they provide to the general public. Regarding the collection of health education materials available, majority 35 (70%) had printed books followed by audio visual (AV) materials (slides, videos, audio cassettes) [22 (44%)]. 35 (70%) of participants reported that they loan only pamphlets and broachers to the public. Thirty four (68%) of participants provide information about oral health. Only 23 (46%) of participants reported that their institution/organization undergo periodic evaluation.
CONCLUSIONS: Results of this survey show that that most of the PPP were involved in delivering health education, mostly concentrated on general health. Only few of them were involved in oral health education. The role of PPP in health education is integral to the effort of promoting a healthier population. This effort continues the trend and broadens the scope of involvement for further studies.

INTRODUCTION

“To address emerging threats to health, new forms of action are needed. There is a clear need to break through traditional boundaries within government sectors, between governmental and nongovernmental organizations, and between the public and private sectors. Cooperation is essential; this requires the creation of new partnerships for health, on an equal footing, between the different sectors at all levels of governance in societies”.[1]

Globalization has been accompanied by a reassessment of the strengths and limitations of public/governmental, private/commercial, and civil society institutions in grappling with world problems. Particularly in the health arena it seems to be recognized that intractable problems require not just better coordination of traditional roles but also new ways of working together in order to achieve a synergistic combination of the strengths, resources, and expertize of the different sectors.[2] According to the United Nations Development Program (UNDP), the broadest definition of PPPs includes agreement frameworks, traditional contracting, and joint ventures with shared ownership.[3] Public-private partnerships are being increasingly encouraged as part of the comprehensive development framework.[4] The concept of a public-private partnership (PPP) recognizes the existence of alternative options for providing education services besides public finance and public delivery.[5]

In the last two decades, there has been a growing concern over the performance of the health care delivery system in India. A number of Public-private partnerships (PPPs) have entered the arena of health care delivery.[6] Health spending in India at around 4.8% of GDP is not considered at par with spending in Organization for Economic Co-operation and Development member countries. Therefore, while there has been considerable success in developing physical infrastructure and coverage of primary health care provision, significant challenges remain across the country in health care provision, especially in terms of accessibility, coverage, rural areas, ineffective management, and inadequate quality and availability of health care professionals. Public-private partnership (PPP) models have been successful internationally in helping alleviate some of these challenges. A number of PPP models have been proposed for the health care sector.[7] The Potential public-private partnership models in health care are: (1) Primary Healthcare Center Adoption, Management Contracts, and Mobile Clinics, (2) Build, Own, and Operate Diagnostic Centers, (3) Hospital Private Finance Initiative (PFI) Scheme.[7]

Health education in India has a long history, however its formal integration into health services is less than fifty years old.[8] Health education is a fundamental necessity in a welfare state. People need health education consistently. Formal programs in health education did not develop until recent times in India and other developing nations.[9] World Health Organization defines it thus: “Health education is the part of health care that is concerned with promoting healthy behavior”.[10] The mandate of health educators in India is to bring about changes in health behaviors on both the individual and community levels as agents of social changes.[8] NGOs and other professional organizations have joined with government agencies all around the country to improve health education.[11] Hence, the aim of the present study was to survey the current practices of private-public partnership (PPP) in health education in Udaipur city, Rajasthan, India.

METHODS

Study design and study population

The cross-sectional self administered structured questionnaire survey was conducted during the months of September and October 2010 among organizations involved exclusively and actively in health education in Udaipur city, Rajasthan, India.

Study sample

The organizations were selected on the basis of following criteria: (1) Should come within the definition of private- public partnership. (2) Be exclusively and actively involved in health education activities. The organizations selected for the study were: (1) Narayan Sewa Sansthan, Trust, Udaipur, Rajasthan.(Health Museum) (2) Seva Mandir, Udaipur, Rajasthan. (Health Library) (3) Arth, Udaipur, Rajasthan,(NGO). (4) Department of Preventive and Social Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan. (Private Medical College) (5) Department of Preventive and Community Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan. (Private Dental College) (6) Department of Preventive and Community Dentistry, Darshan Dental College and Hospital, Udaipur, Rajasthan. (Private Dental College) All the personnel from the above institutions (those who were present at the time of the survey and those who were actively involved in health education) were selected for the survey.

Sampling tool

Ethical clearance

The ethical clearance was obtained from the ethical committee of Darshan Dental College and Hospital Loyara, Udaipur, Rajasthan, India.

Permission from consent authorities

Prior to study concern authorities were approached, explained the nature of the study and permission sought.

Informed consent

The written informed consent was obtained from the participants.

Proforma

The 21 item self designed structured questionnaire pertaining to current practices of private-public partnership (PPP) in health education (such as source of finance, beliefs about private-public partnership in relation to government sector, services for general public, collection of people oriented materials, delivery of information regarding oral health and promotion of use of library/museum) was used.

Pilot study and pretesting of questionnaire

The questionnaire was pretested in a pilot survey comprising of 06 (20%) participants. Kappa (k), weighted kappa (kw) were used to evaluate the test-retest reliability of the questionnaire and internal consistency was assessed by Cronbach's alpha (a) coefficients (k = 0.86), (kw = 0.9) (a = 0.78). Single trained interviewer described the purpose and process of the survey to the participants and gave standardized instructions for completing the questionnaire.

QUESTIONNAIRE DISTRIBUTION AND COLLECTION

The questionnaire was distributed among all the designated people in these organizations who were actively involved in provision of health education. The questionnaires were collected back by the following day. The questionnaires were checked for completeness and partially filled questionnaires were returned back to the study participants to complete it.

Data compilation and statistical analysis

The data was compiled systematically, transferred from a pre-coded proforma to a computer and a master table was prepared using Microsoft Excel 2007. Data was statistically computed by using simple descriptive statistics.

RESULTS

Out of total 54 personnel from 1 health museum, 1 health library, 1 NGO, 2 private dental colleges, 1 private medical college; 50 participants completed and returned the questionnaire resulting in a 93% response rate.

Table 1 shows the knowledge about private-public partnership, finance and funding of projects. Majority [42 (84%)] of participants reported that their institution and organization is a type of PPP. Seventeen (34%) of participants had long-term loans (restricted to large, corporate, non-profit organizations) as the source of finance for their PPP. In the present study, 37 (74%) of participants have currently have or had in the past, a well-defined or longstanding relationship, with a non health sciences library or other agency to provide consumers with health information. Majority [25 (67.5%)] of participants reported that these health projects/programs were supported through funding by each partner followed by grant fund [17 (45.9%)].

Table 1

Knowledge about private-public partnership, finance and funding of projects

Table 2 shows the beliefs about private-public partnership in relation to government sectors. In the present study, 35 (70%) of participants reported that they had knowledge about Government Organization providing health education. Majority [49 (98%)] of participants believe that private-public partnership is better than government initiatives. While 46 (92%) of participants believe that private sector is intrinsically superior at delivering goods and services.

Table 2

Beliefs about private-public partnership in relation to Government sector

Table 3 shows the target group in health education by private-public partnership. All [50 (100%)] of participants had reported that their institution/Organization provide services to general public. Only 15 (30%) of participants had reported that they have a written reference policy that outlines services they will provide the general public.

Table 3

The target group in health education by private-public partnership

Table 4 shows practices of private-public partnership regarding their collection of health education materials. All 50 (100%) of participants reported that their Institution/Organization house a collection of people oriented materials and had plans to add more materials to their collection or expand their existing collection, in the near future. Majority of 35 (70%) participants reported that they have printed books in their collection followed by audio visual (AV) materials (slides, videos, audio cassettes) [22 (44%)]. 35 (70%) of participants will loan only pamphlets and broachers to the public.

Table 4

Collection of health education materials

Table 5 shows current practices of private-public partnership regarding delivery of information of oral health. In the present study, 34 (68%) of participants provide information about oral health. Among which 23 (67.6%) of participants covered topics related to oral cancer/harmful effects of tobacco. While 01 (2.9%) of participants had covered infant oral care and levels of prevention, respectively. Among the study participants, 18 (52.9%) of participants use Oral and Audio-Visual aids and 04 (11%) of participants performed skits to deliver information about oral health.

Table 5

Current practices of private-public partnership regarding delivery of information of oral health

Table 6 shows the current practices of private-public partnership regarding provision of feedback, periodic evaluation and promotion of use of library/museum. Among the study participants, 40 (80%) of participants had provision for feedback from the public, 23 (46%) of participants reported that their institution/Organization undergoes periodic evaluation, 30 (60%) of participants had their institution/Organization actively solicit or promote public use of their library/museum and 20 (66.6%) of participants had promoted the public use of their institution's/organization's library/museum through meeting with the various community groups.

Table 6

Provision of feedback, periodic evaluation and promotion of use of library/museum

DISCUSSION

Widdus urges one to view public-private partnerships as social experiments that are attempting to learn how to tackle intractable health problems in better ways.[2] In the present study, 08 (16%) of participants failed to recognize that their institution and organization is a type of PPP. This may be due to lack of awareness about PPP, and what types of organizations come under the definition of PPP.

To evaluate PPPs, it is important to understand the actual policy-making and implementation processes so as to maximize their health benefits. By building on these actions, collaborative efforts between the public and private sectors would yield added value.[12] In many countries, governments have managed to mobilize private investment to finance needed capital stock in utilities and other public services.[5] Financing determines the efficiency and effectiveness of a health care system. The nature of financing determines a system's structure and incentives, drives the behavior of different stakeholders, and ultimately the quality of outcomes.[7] In the present study, about 1/3rd [17 (34%)] of participants had long-term loans (restricted to large, corporate, non-profit organizations) as the source of finance for their PPP, which was followed by donations [15 (30%)]. In terms of health expenditure, National Health Account framework (NHA) reported that has central government (7.2%), state government (14.4%), and local government (2.2%), public sector banks (0.2%), NGO (90.3%) together spending about 1/4th of the total health expenditure.[13]

In the present study, 49 (98%) of participants believed that PPP is better than government initiatives and 46 (92%) of participants believed that private sector is intrinsically superior at delivering goods and services. The reason behind that may be due to belief that the constraints on government borrowing, and a reluctance to increase taxes or charges, projects such as new schools and hospitals could not go ahead at all without PPPs. The second key assertion is that PPPs are better because somehow they do not cost the public, or the public sector, anything. This myth takes various forms: The idea that the public – or the public authorities – do not have to pay for schools or hospitals developed by PPPs; the idea that the government or municipality will have more money left to spend on other services; and the idea that PPPs mean a reduction in borrowing. But in PPPs like hospitals or schools, the government pays for the cost of the PPP from taxation – by paying for the cost of construction, and then the cost of running the service. So, PPPs are paid for by the public sector in just the same way as projects carried out directly by public authorities. The final claim is that the private sector is more efficient in all areas than government and public sector employees. These assumptions are false. And empirical evidence shows that the private sector is not overall more efficient than the public sector.[14]

Only a handful of studies were found that report on policies and practices of health sciences libraries as a whole in providing access or service to the general public. In the mid-1970s, at the beginning of the consumer health movement, Jeuell and colleagues surveyed publicly and privately supported libraries associated with medical schools listed in the American Association of Medical Colleges Directory (1975-76) to determine whether they provided access and, primarily, reference service to the general public. At that time, they found more than 90% of respondents from both publicly supported and privately supported academic health sciences libraries provided access to some or all of the general public.[1516] In the present study, 50 (100%) of participants had reported that their institution/Organization provide services to the general public. Several years later, in an effort to understand public access policies of medical libraries better, Schell conducted a survey of the largest medical library in each state. This survey included both hospital and academic health sciences libraries. The then current Directory of Health Science Libraries in the United States was used to identify this sample. Schell found while 91% of respondents provided access to the public, only 20% provided the public with full service.[17]

In their 1988 publication, Landwirth and colleagues,[18] offered several suggestions for maintaining the balance between meeting the needs of the general public and fulfilling their obligation to their primary clientele, including scheduling hours around primary users needs, setting reference guidelines to ensure that primary users receive top priority, implementing charges for certain services beyond basic level reference assistance, and placing increased emphasis on training library staff in providing reference assistance. They also suggested that those academic medical libraries without written reference services guidelines were vulnerable and in danger of letting outside demand overshadow the university's obligation to its primary clientele. In the present study, only 15 (30%) of participants has a written reference policy that outlines services you will provide the general public. And, all 15 (100%) participants had general public included in their mission statement.

Pertaining to the type of health education materials, 50 (100%) of participants reported that their Institution/Organization house a collection of people oriented materials and had plans to add more materials to their collection or expand their existing collection, in the near future. In a survey of a health science library, Hollander SM,[19] reported that a significant number of surveyed libraries (44.4% private and 36.5% public) housed a collection of consumer-oriented resources. Almost half of the libraries (48.6% private and 44.3% public) indicated they planned to add consumer materials to an existing collection or develop a consumer health collection in the near future.

Circulation practices were also examined. In a survey, Hollander SM reported that 35 (61.4%) and 5 (13.9%) institution/library circulated print books to the public.[19] In the present study, 35 (70%) of participants will loan only pamphlets and broachers to the public. Twenty five (50%) and 10 (20%) will loan printed books and AV materials to the public.

According to Malamborg R et al. most PPPs are currently poorly regulated as developing countries do not have the resources to monitor the quality of health services provided.[20] Buse and Waxman state that an organization should draw lessons from its own experience of partnership and develop indicators of success.[21] In the present study, 23 (46%) of participants reported that their institution/organization undergoes periodic evaluation.

The data of present study revealed that 34 (68%) of participants were providing information about oral health. Among which 23 (67.6%) of participants covered topics related to oral cancer/harmful effects of tobacco. Eighteen (52.9%) of participants use Oral and Audio-Visual aids. Over the past two decades, health information has expanded exponentially.[19] A new development started, around 1900 where popular health education was given by visual means.[22] In the present study, one organization had even adopted a newer innovative technique; the health education train to deliver the information to general people.

In the mid-l980s, Paterson conducted a review of the literature to determine the level and type of health information available to the lay person and urged all libraries to take a more active role in providing health information to the general public. In her report, she stated, “Medical libraries do not encourage public use of their collections and usually refer questions to the public library”.[23] While the vast majority 30 (60%) of participants had reported that their institution/Organization actively solicit or promote public use of their library/museum. 20 (66.6%) of participants had promoted the public use of their institution's/organization's library/museum through meeting with the various community groups. In the survey done by Hollander SM, it was reported that promotion was accomplished in a number of ways. Almost all encourage public and other libraries to refer patrons to them; two-thirds encourage affiliated health professionals to refer patients to them; and half meet with community groups, advertise their services, work with patient education committees, offer workshops or seminars, or promote use of their library via a web page.[19]

The present study was an attempt to comprehensively survey the current practices of private-public partnership (PPP) in health education in Udaipur city, Rajasthan, India. Comparison of the present study with other data groups is difficult due to the paucity of literature/availability of similar studies.

CONCLUSIONS

The importance of education cannot be overemphasized. Education participates critically in building individual endowments and abilities, and it drives social and economic development at the national level. Health education encompasses all strategies and activities, which are meant of the attainment of better health status of the people. The results of the present study revealed that most of PPP were involved in delivering health education mostly concentrated on general health. Only few of them were involved in delivering oral health education. Majority of them housed printed books and AV materials in their collection. One organization had even adopted an innovative health education train to deliver information to the health information-seeking public. Implementation requires long-term commitment. There is the need to continue these efforts in future prospects of involvement of PPP in health education.