A consolidated fund

The government of Telangana reportedly decided to call for tenders to identify the service provider for operation and maintenance of 108 Emergency Responsive Services in the state. A committee has also been constituted for preparation of RFP document, floating tenders, processing finalisation and transition of services, etc.

When the former united AP government, a decade and a half ago, felt that lack of transportation was the main reason for non-utilisation of healthcare services for institutional deliveries, it initiated the Reproductive and Child Health Project to implement Rural Emergency Health Transport Services (REHTS) scheme in rural and tribal areas of the state in 2005. REHTS was part of the Indian government's National Rural Health Mission (NRHM) for providing integrated, comprehensive primary health care services. It was aimed at transporting pregnant women, infants, children below 12 years of age and any other cases in need of emergency health care services to the nearest hospital.

The scheme was piloted in four districts of Kadapa, Kurnool, Mahbubnagar, Nizamabad and the tribal areas of nine other districts in the year 2005. Initially, 122 ambulances were deployed under the scheme and were operationalised through NGOs as a Public-Private Partnership (PPP) concept.

In addition to REHTS, the government recognised Emergency Management and Research Institute (EMRI), a non-profit organisation established in April 2005, by Satyam Computer's Ramalinga Raju, as the State Level Nodal Agency, to provide comprehensive emergency response across the state, in PPP mode and signed first Memorandum of Understanding (MoU) on 2nd April 2005. EMRI on its own launched 70 ambulances funded by Raju, from August 2005 to June 2006 covering 50 towns of 25 million populations in the united AP state. A toll-free telephone number 108 was allotted by the government and the ambulance services became popular with this number.

State government having piloted the REHTS decided to expand to the remaining 18 (Rural) districts of the state by utilising services of EMRI as the State Level Nodal Agency and accordingly entrusted the responsibility of operationalising the balance of the 310 ambulances and signed the 2nd MoU on September 22, 2006. Formal launching took place on January 26, 2007. The earlier piloted districts were also handed over to EMRI.

The third MoU signed in October 2007 further strengthened the PPP. 122 more ambulances were added then. A revised MoU was signed between government and EMRI on May 5, 2008, and accordingly, the government committed to provide 150 more ambulances (later another 150 ambulances). As far as the financial commitments were concerned, during the financial year 2008-09, out of the direct operating cost of Rs 1,18,420, an amount of Rs 1,12,499 towards its 95 per cent share per ambulance per month was provided to EMRI. Later this figure was subjected to changes. In due course, more and more ambulances were added as and when needed and the arrangement between the government and EMRI was Public-Private Partnership but not a tender process initially.

EMRI later expanded its services to several states like Gujarat, Madhya Pradesh, Karnataka, Himachal Pradesh, Meghalaya, Tamil Nadu, Assam, Uttarakhand, Rajasthan, Goa, etc. Almost all states are covered now handled by either EMRI or others. Initially, in none of the states, the tender process was followed and everywhere it was based on an MoU.

National Health Systems Resource Centre (NHSRC) commissioned by the government of India observed that "EMRI was undoubtedly a historic landmark in the provision of health care in the nation. To its credit goes the achievement of bringing Emergency Medical Response on to the agenda of the nation. The tremendous gratitude and praise of the family members of the emergency victim for the timely arrival of this Angel of Mercy when heard in first person is most convincing and moving and makes the service very popular".

The great success of 108 had its roots in Public-Private Partnership concept. It is assumed that collaboration with the private sector in the form of PPP would improve equity, efficiency, accountability, quality, and accessibility of the entire health system. Advocates argue that the PPP can potentially gain from one another in the form of resources, technology, knowledge and skills, management practices, cost efficiency and so on. Provision of Emergency Response Services by EMRI is the best example of this.

There is no hard and fast rule that the governments have to follow in choosing a non-profit organisation to partner with it for providing services in PPP framework. Several analyses and studies, however, suggest that a competitive process of selecting the private partner for the PPP framework is less effective than an invited or negotiated partnership. While competing to win the deal, the private partner's primary concern is to quote less to become the lowest bidder whereas the government side officials' main concern would be to meet procedural requirements than meeting beneficiaries' needs. Tendering process in government is adapted to choose the lowest bidder. Though it is economical initially, the trend later would be an upward revision of costs and if the government disagrees, then the level of quality and effectiveness comes down.

Hence, either prior negotiations with the potential partner or a tender where eligibility conditions are tailor-made or the prior experience of the private partner to be used as a basis for choosing is ideal for the success of PPP. Public-Private Partnership is different from privatisation and the message has to go without ambiguity. A partnership is not meant to be a substitution for lesser provisioning of government resources nor an abdication of government responsibility but as a tool for augmenting services.
This entails a paradigm shift in the role of the government from the provision of services to partnering with a private non-governmental organisation in making available these services through a meaningful arrangement popularly known as Memorandum of Understanding (MoU).

108 emergency response services are the first of its kind Public-Private Partnership originated in the then united AP and in those days it was a role model for other states to replicate on the similar lines as in AP. The model sustained and has come to stay despite some occasional hiccups. 108 emergency response services are one of the most successful transformational institutions conceived and developed in the united AP state. The vision of EMRI is to provide leadership through a PPP framework to respond to emergency calls round the clock and save lives meeting global standards in Emergency Management, Research and Training.

Surprisingly, few persons associated with this model themselves are now demanding a tender process for operationalising the scheme instead of a PPP model. Whatever it might be, the most important thing is how best the government funds are channelised. The best way to channelise funds would be to create a Permanent "Health and Emergency Care Developmental Fund" by pooling NRHM, state government and private contributions from many but not from one single source either through the tender route or through PPP route. For such a huge scheme one single source means "dependence in uncertainty".

Such an arrangement may not require one single Private Partner or someone else through tender, but would certainly require management experts as CEO and in PPP mode. Let the PPP concept be dynamic and not static with the boundaries well defined. In the implementation of the scheme, let there be no wrong signals going to people. If the scheme fails, in future it would be difficult to bring it back again on track.

(The author is Chief PRO to Telangana CM and a former Consultant PPP, EMRI. The views expressed are strictly personal)