The provision of public services

Public private partnership programmes in the education sector, such as adopt-a-school schemes, remain ad hoc

The Punjab government has decided to use the Public Private Partnerships (PPPs) model in an effort to improve its abysmal performance in the health sector. The provincial government seems confident that the decision will enable relevant private sector entities, including NGOs and private health care providers, to step up and ensure that better healthcare services become available to the citizenry without placing a financial burden on them. Compelled by similar motives, the Khyber-Pakhtunkhwa government has also been testing the outsourcing management model for health facilities in five districts. The Sindh government is also following suit.

Trying to use PPPs to improve the delivery of basic public services, such as health, education and sanitation is not unique to Pakistan. Many other countries have also been encouraged to engage with the private sector to improve social services. The growing strain of servicing their debts and meeting other major costs, such as government expenditure and defence and security needs, often leaves developing countries with little fiscal space to cater to the basic needs of the people. PPPs have thus gained increasing favour as the means to address versatile development needs, ranging from securing funding for mega infrastructure projects, to using them to improve health or education outcomes.

International financial institutions like the World Bank have endorsed the potential of PPPs as a valuable development tool, which can harness private sector financing, technical know-how and management expertise, for improving the quality of infrastructure and social services, at a lower cost. However, civil society organisations remain sceptical of the ability of PPPs, particularly in the undertaking of public works. The extent to which governments should count on the willingness of the private sector to go beyond its profit motive and act in support of sustainable development outcomes is thus debatable.

Critics of the World Bank argue that in many developing countries, development projects have adopted PPPs not for efficiency reasons, but to circumvent budget constraints. There is no sufficient evidence to confirm that private health care providers are more responsive to public needs, or even more effective than the public sector. PPP-based water privatisation schemes have been aborted in countries such as Bolivia and Tanzania. Oxfam International’s recent research points out that no low or middle-income country in Asia has achieved universal or near-universal access to health care without relying solely or predominantly on tax-funded public delivery.

Most PPP programmes in the education sector in Pakistan, such as adopt-a-school schemes, remain ad hoc, and thus show insufficient potential for systemic impact in addressing the fundamental challenges of universalising educational access, improving the overall quality of education or addressing regional disparities in educational outcomes.

The World Bank does not discount the role of the public sector, but it largely envisions this role to be confined to regulation, rather than the direct provision of services. Regulating private providers is, however, a rather messy task in practice. The Punjab government has, for example, stated it will continue to own the physical health facilities it hands over to private entities for management purposes, and these private entities will remain accountable to the government for overseeing the quality of health care being delivered. The provincial government wants to retain responsibility for allocating funds for medicines, salaries and to make decisions about transfers and postings of doctors and other staff. The above-mentioned fears concerning the impact of private sector providers being able to improve access and quality of care to poor patients will be further exacerbated if the government remains reluctant to relinquish control over hiring and firing of medical and other staff at public health facilities, and medicine provision, which are in fact major problems when it comes to public health care performance. Given this current situation, the use of PPPs to improve health outcomes in Punjab or other provinces may not be able to deliver the encouraging outcomes they are promising.

Published in The Express Tribune, October 23^rd, 2015.

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