Don’t Forget the Government

“Forget the government.”

I heard this from a number of friends in Nepal in the immediate aftermath of the earthquakes that devastated the country this spring, and I have heard it almost every day since, as the country has transitioned into rebuilding.

While Nepal has largely disappeared from the news, the country’s unmet needs are ever present; monsoon season continues, and cold winter months approach. It needs an estimated $6.66 billion dollars to rebuild its agriculture and education sectors, the health care sector (which I am most closely connected to), and others. And in Nepal—as in the other countries of which I am deeply familiar, the United States and India—the theme of “government” as some sort of monolithic, inept, corrupt, or outright destructive entity is common.

Yet the “governments” in each of these democracies of varying birthdates (the United States in 1789, India in 1950, and Nepal in 2008) are far from monolithic. While the same tax revenues largely fund the Home Ministry, the Ministry of Health and Population, and the Army in Nepal, for example, these agencies have dramatically different organizational cultures and management systems. This variability is an inherent strength of democratic governments.

What’s more, there is a way for governments to prepare more fully for unexpected disasters, and also improve their work when they are not in crisis mode. One solution lies in strong public-private partnerships (PPPs)—in which various government organizations come together with private businesses and nonprofits toward a common goal.

PPPs are responding to an all-too-common cycle, where the public sector is ravaged by years of under-funding and poor management, and the private sector providers attempt to fill the gap. The problem with this cycle is that those providers tend to be fee-for-service and unregulated. In healthcare in particular, the point-of-care fee-for-service revenue model leaves substantial gaps in care for certain populations. The for-profit private sector also tends to fail public health intervention efforts that do not have the right incentives to pursue fee-for-service arrangements. During outbreaks like Ebola in West Africa, situations such as the worldwide spread of H1N1, and disasters like the Haiti and Nepal earthquakes, these gaps lead to an inability to provide the public with basic health protections.

Enter PPPs.

Our nonprofit health care company, Possible, works to improve governance within Nepal’s public health care sector. (SSIR has previously covered aspects of our work.) The approach we take is a PPP model which aims to build more adaptive, responsive, accountable public health care systems. In doing so, we hope to create a paradigm in which citizens no longer have to say “forget the government.” We strive to break the cycle by leveraging public sector financing, supplies, and facilities under private nonprofit management. The approach blends the access and scale of the public sector, the customer orientation and management practices of the private sector, and innovation of philanthropists and academics.

We have seen this approach work with health care. We have also seen similar efforts work effectively in other sectors. In the Netherlands, for example, government develops education policy, but education management is decentralized at the school level. The results are some of the highest test results and enrollment rates in the world. Some low-income countries have caught on as well.  Uganda, for example, was the first country in sub-Saharan Africa to introduce universal education, and government went on to form alliances with private schools to deliver that education. Research argues for an increase in PPP’s there.

Integration, Accountability, and Efficiency

Whether in health care, education, or infrastructure, the key to a PPP’s success lies in three main characteristics: integration, accountability, and efficiency. Here, we break down our model along those lines, in the hope that other sectors can also benefit from what we’ve learned:

Integration is being able to leverage flexible, private management while preserving any public service as a public good. Disasters such as earthquakes and epidemics lay bare systems that lack sufficient public investment or fail to reach all communities of a country. Achieving the right balance means getting out in front of the curve by building rich, personal, and institutional relationships between governments and private providers when no crisis is present. In the health care sector, even as we deliver chronic care over the course of patients’ and families’ lifetimes, we are working together to mitigate and prepare for the risks of disasters and epidemics at a district level. There is no substitute for national-level coordination and regulation, particularly of public health; but at the district, local, or regional level, we believe that core health-care-to-public-health functions can be delivered on a public-private partnership.

Accountability means ensuring that people—whether patients, students, or employees—have both the channels of grievances via a democratic government and the feedback mechanisms of the provider. Possible provides the government with the opportunity to operate as a hub of research and innovation. We have begun to serve this role on some of the policy-to-implementation issues facing the country, including community health worker professionalization, electronic medical records, supply tracking, quality improvement initiatives, household surveillance, and national health insurance.

Efficiency means putting public resources to optimal social good use. In Nepal, with the flexibility of our PPP, we’ve been able to innovate around human resource and supply-chain management to improve upon typically challenged government health care systems. We’ve rolled out the public sector’s first electronic medical record initiative, and digitized supply chain systems and human resource management. We’ve also put to use lean tools such as Asana (a web-based project management application) to improve efficiency and accountability of managers—a capacity that is particularly weak among government health care managers in Nepal.

The tragedy of natural disasters and outbreaks is that they come unannounced and truly test the resilience of where they strike. Should another earthquake hit Nepal, another tsunami form in the Indian Ocean, or another Ebola epidemic breakout in West Africa, countries should have PPP in place across multiple sectors so that their citizens, rather than declare, “Forget the government,” can say, “Let’s work with the government and find a solution.”

Read more stories by Duncan Maru.