Unpacking the politics and publicness of healthcare public-private partnerships: case studies from municipal hospitals in Maharashtra state, India
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Abstract
Introduction: Public-private partnerships (PPPs) have become a preferred global policy in healthcare. In India, PPPs have gained momentum over the past two decades but remain contentious. Most Indian research focuses on PPPs in primary rural healthcare. This study examines clinical and diagnostic PPPs in secondary and tertiary public hospitals in urban Maharashtra, analysing public-private relationships, decision-making processes, functionality, challenges, and their impact on health service delivery.
Methods: An exploratory, qualitative multiple-case study approach was employed. Forty hospital-based PPP projects active between 2017 and 2023 were mapped, and six diverse projects were selected for detailed case studies. Data collection included 25 qualitative interviews with stakeholders, review of technical documents, and a comparison of rates for 20 health services between PPPs and public hospitals. The study applied principal-agent theory to analyse public-private relationships and assessed PPP performance using the publicness criteria developed by David MacDonald and Greg Ruiters.
Results: The study revealed significant challenges in PPPs, including politicisation, lack of transparency, and governance inefficiencies. Local political influence often prioritised commercial interests over public health goals, with bureaucratic support addressing issues like doctor shortages and budget constraint. Decision-making for public hospitals was confined to municipal levels, with no involvement from the state health department. Of the 40 PPPs, 24 involved for-profit agencies and contracts lasting 10 to 30 years. Monitoring mechanisms were inadequate, leading to issues like non-compliance with contracts, underqualified staff, and inconsistent service delivery. Despite adequate resources, many projects had low utilisation rates. While some projects improved access, their services remained unaffordable for marginalised populations, with prices 3 to 15 times higher than those in public hospitals.
Conclusion: Addressing a critical knowledge gap, this study offers empirical insights into hospital-based clinical and diagnostic PPPs in municipal settings in India. Theoretically, PPPs can improve healthcare access by leveraging the private sector, however, structural reforms, robust governance frameworks, effective monitoring, and stricter regulation are critical to improving PPP performance in public interest. The study emphasizes the importance of strengthening the public health system to ensure comprehensive and equitable healthcare, raising concerns about the long-term viability of PPPs in addressing the complex challenges of urban healthcare.
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