The Telangana government, according to media reports, has decided to invite tenders to identify the service provider for operation and maintenance of 108 Emergency Responsive Services in the State. A committee has been constituted for preparation of RFP, floating tenders, finalisation of service provider and transition of services, among others.
When the then united Andhra Pradesh government, a decade-and-a-half ago, felt that a 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 the Rural Emergency Health Transport Services (REHTS) scheme in rural and tribal areas in 2005. REHTS was part of GoI’s National Rural Health Mission (NRHM) for providing integrated, comprehensive primary healthcare services. It was aimed at transporting pregnant women, infants, children below 12 years and any other cases in need of emergency healthcare 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. Initially, 122 ambulances were deployed and were operationalised through NGOs as a public-private partnership (PPP) concept.
The government also recognised Emergency Management and Research Institute (EMRI), a non-profit organisation established in April 2005, by erstwhile Satyam Computers founder Ramalinga Raju as the nodal agency to provide comprehensive emergency response across the State, in PPP mode and signed an MoU on April 2, 2005. EMRI launched 70 ambulances, funded by Raju, from August 2005 to June 2006 covering 50 towns. A toll-free telephone number 108 was allotted by the government and the ambulance services became popular with this number.
The State government having piloted the REHTS decided to expand to the remaining 18 (rural) districts by utilising the services of EMRI and, accordingly, entrusted the responsibility of operationalising the balance 310 ambulances. The second MoU was signed on September 22, 2006. The earlier piloted districts were also handed over to the EMRI.
The third MoU signed in October 2007 further strengthened the PPP. A revised MoU was signed between the government and EMRI on May 5, 2008, and accordingly the government committed to provide 150 more ambulances and later another 150 ambulances. During the financial year 2008-09, of the direct operational cost of Rs 1.18 lakh, an amount of Rs 1.12 lakh towards its 95% share per ambulance per month was provided to EMRI. The arrangement between the government and EMRI was PPP 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 and Goa. Initially, in none of the States, tender was followed and it was based on an MoU.
The National Health Systems Resource Centre observed that, “EMRI was undoubtedly a historic landmark in the provision of healthcare 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”.
Partnership with Private
The great success of 108 had its roots in PPP. 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 such a partnership can potentially gain from one another in the form of resources, technology, knowledge and skills, management practices, cost efficiency and so on.
There is no hard and fast rule that governments have to follow in choosing a non-profit organisation to partner with them for providing services in PPP mode. 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’s main concern would be to meet procedural requirements than meeting beneficiaries’ needs. Though it is economical initially, the trend later would be 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 is ideal for the success of PPP. The PPP mode is different from privatisation and the message has to go out without ambiguity.
Partnership is not meant to be a substitution for lesser provisioning of government resources nor an abdication of government responsibility but a tool for augmenting the services. This entails a paradigm shift in the role of the government from 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.
No Single Source
The 108 emergency response services are the first of its kind PPP originated in the then united AP and in those days, it was a role model for other States. They are one of the most successful transformational institutions conceived and developed in the united AP. The vision of EMRI is to provide leadership through PPP to respond to emergency calls round-the-clock and save lives meeting global standards in Emergency Management, Research and Training.
Surprisingly, a few people associated with this model are now demanding a tender process for operationalising the scheme instead of the PPP model. Whatever it might be, the most important thing is how best the government funds are channelised. The best way to channelise the funds would be to create a permanent ‘Health and Emergency Care Developmental Fund’ by pooling NRHM, State government and private contributions either through the tender route or through PPP. For such a huge scheme, one single source means ‘dependence in uncertainty’.
Such an arrangement would require management experts as CEO and in PPP mode. Let the PPP concept be dynamic and not static with boundaries well-defined. In the implementation of the scheme, let no wrong signal go to the people.
(The author is former consultant PPP, EMRI)