𝐂𝐚𝐧 𝐏𝐮𝐛𝐥𝐢𝐜-𝐏𝐫𝐢𝐯𝐚𝐭𝐞 𝐏𝐚𝐫𝐭𝐧𝐞𝐫𝐬𝐡𝐢𝐩𝐬 𝐁𝐫𝐢𝐝𝐠𝐞 𝐓𝐡𝐞 𝐆𝐚𝐩𝐬 𝐈𝐧 𝐇𝐞𝐚𝐥𝐭𝐡𝐜𝐚𝐫𝐞 𝐃𝐞𝐥𝐢𝐯𝐞𝐫𝐲?

…𝒏𝒂𝒕𝒊𝒐𝒏𝒂𝒍 𝒅𝒊𝒂𝒍𝒐𝒈𝒖𝒆 𝒆𝒙𝒂𝒎𝒊𝒏𝒆𝒔 𝒇𝒆𝒂𝒔𝒊𝒃𝒊𝒍𝒊𝒕𝒚 𝒐𝒇 𝑷𝑷𝑷𝒔 𝒊𝒏 𝒆𝒙𝒑𝒂𝒏𝒅𝒊𝒏𝒈 𝒂𝒄𝒄𝒆𝒔𝒔 𝒂𝒏𝒅 𝒊𝒎𝒑𝒓𝒐𝒗𝒊𝒏𝒈 𝒔𝒆𝒓𝒗𝒊𝒄𝒆 𝒒𝒖𝒂𝒍𝒊𝒕𝒚

By Yeshi Dolma

Amid growing strain on the national healthcare system, the feasibility of Public-Private Partnerships (PPPs) in delivering equitable, efficient, and sustainable health services took center stage at a recent workshop supported by the Asian Development Bank (ADB). The event brought together a wide cross-section of stakeholders to examine whether PPPs could offer practical solutions to longstanding challenges in the country’s health sector.

The country currently has 2,318 health workers, including 0.57 doctors and 2.12 nurses per 1,000 people- roughly one doctor for every 1,750 individuals. Each year, approximately 3.5 percent of doctors and 16.1 percent of nurses leave the workforce. Despite a network of 57 hospitals, 184 health centers, 52 sub-posts, and mobile health units serving remote areas, the system continues to face challenges such as staff shortages, low public health awareness, an inefficient referral process, and uneven access to services.

A PPP refers to a long-term contractual agreement between public and private entities in which both sectors share expertise, resources, risks, and benefits to deliver infrastructure or services. While the government remains responsible for public service delivery, the private sector may be engaged to manage certain operational components.
Sonam Zangpo, a nurse at the national referral hospital, said the health workforce is under pressure due to insufficient facilities and declining service quality. “The biggest challenge we face is the low quality of services and insufficient infrastructure,” he said, underlining the urgency for reform.

ADB representatives stressed that local context must guide the adoption of PPPs. “You need to know the challenges and why you need PPPs,” said an ADB spokesperson. “The reasons can range from service delivery gaps and infrastructure decay to innovation bottlenecks and cost inefficiencies.”

The spokesperson added that PPPs should not be viewed as an objective in themselves. “PPP is not an objective; it is a tool. It can help where governments want to focus on core clinical roles and let the private sector manage facility services, or where the public sector lacks teaching or clinical staff and the private sector can fill that void.”

One workshop participant cited an example from dialysis care to highlight service inequity. “Take dialysis as an example. Our commitment to equity means everyone should access care, but with only three dialysis centers nationwide, people in places like Trashigang face disadvantages compared to those in Mongar, who can access services more easily. This is where PPPs can help- bringing services to even two or three patients so no one is left behind. It may not be profitable, but the government would still bear the cost, and the private sector could be paid based on the services they provide. Saving even one life is invaluable and aligns with our national values.”

Another participant pointed to the need for cross-sector collaboration. “Health is not just the health sector’s job. Many factors- like tobacco, alcohol, diet, and exercise- are shaped by other sectors. That’s why all agencies must work together. Health is the foundation of a productive society, and its benefits extend across every sector. Therefore, the responsibility- and investment- must be shared collectively.”

ADB also outlined the governance requirements for PPPs to succeed, including clear contractual terms and payment systems linked to performance. “There are many layers,” the ADB spokesperson explained. “First is business sense, second is a fair contract with timely payments and performance-based monitoring- not excessive regulation. If that balance is achieved, the private sector will engage.”

However, concerns about unintended outcomes were also raised. One participant warned, “Volume-linked payment may not work if the private sector is involved, as they could make more by prescribing more. In one country, they had to put a price ceiling on cesarean sections because doctors were recommending them unnecessarily to earn more.”

In response, the ADB representative said that safeguards could be built into the model. “Yes, the private sector can overcharge, but there is a solution. General doctors can prescribe services. In PPP, private actors can’t do whatever they want because they are under contract with the government. That’s why drafting a strong contract is so important.”
The ADB also stressed that projects must be selected based on local priorities. “We can’t simply replicate models from other countries,” the spokesperson said. “Take a Day Care Center- it’s important, but is the private sector ready to handle it?”

To illustrate different PPP models, international examples were shared. In Uzbekistan, a ten-year dialysis PPP launched in 2019 expanded services across four clinics situated within government hospital compounds. The government guarantees a minimum patient volume and reimburses the private provider monthly to ensure financial sustainability.
In Mexico, a 25-year PPP project in Toluca and Tlalnepantla delivered dialysis, imaging, and laboratory services to around 20,000 people while reducing operational costs by 33 percent. In India, the Shillong Medical College was built and managed under a 99-year concession, creating new medical infrastructure and producing about 100 trained doctors each year.

However, some experiences also revealed challenges. In the United Kingdom, Private Finance Initiatives (PFIs) led to better maintenance and infrastructure but also higher costs due to the price of private equity and extended procurement timelines. Observers noted that these models sometimes suffered from limited government oversight and weak accountability mechanisms.

Regulatory interventions in other countries were cited as corrective measures. In Thailand, private hospitals were reported to charge up to 400 percent more for medical devices compared to public facilities. The government introduced caps on prices of items like CT scanners and pacemakers to limit excessive markups. In Japan, a biannual system for reviewing healthcare fees helped curb unnecessary procedures. A 35 percent reduction in MRI charges in 2002, for instance, followed a sharp rise in usage.

One participant summarized the workshop’s outcomes: “We have engaged in valuable discussions, drawn lessons from global examples, and explored how PPPs can be effectively applied in our context. This workshop made it clear that PPPs go beyond financing infrastructure- they are about enhancing service quality, fostering innovation, and reinforcing the health system as a whole. The insights gained here can now be shaped into actionable strategies as we move forward together toward a more inclusive, efficient, and resilient healthcare future.”

As the country considers the insights from the workshop, the future of PPPs will depend on balanced planning, realistic expectations, and robust regulatory oversight. If implemented with accountability and public interest at the core, such partnerships could contribute meaningfully to healthcare improvement. But success will rest not only on technical execution but on a shared commitment to health equity and sustainable collaboration between public and private actors.

The workshop concluded with calls to keep the dialogue active, ensuring that the public, private, and civil sectors continue to engage. The adoption of PPPs, if pursued, will require trust-building, strong legal frameworks, and long-term commitment to achieving universal health coverage.