Muzaffarpur, Bihar: By noon daily, the reception area of Surya Clinic in Muzaffarpur district of Bihar begins to fill up. Patients admitted for gyanecological care are clothed in the blue robes of the hospital and ushered into clean rooms with freshly made beds.

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At the state-run primary health centre (PHC) in Bochahan block of Muzaffarpur, which also offers family planning services, disposable gloves are washed and re-used and rusted beds are covered with tattered mattresses.

Click here to view a slideshow on the contrast between public health centres and the new clinics coming up under public private partnerships in Bihar.

There are no sheets on the beds. Ratnesh Kumar, a clerk at the PHC, has an explanation for their absence.

“They get stained with blood and then the stains don’t wash off," he says. “So we prefer to not have sheets at all and save on the money we would spend to have them washed."

Better alternative: The number of sterilizations at Surya Clinic has increased rapidly despite the fact that it doesn’t offer any compensation for the procedure unlike the government’s cash incentive model. Priyanka Parashar/Mint

Not surprising, perhaps, that the PHC performed just 892 female sterilizations in 2009 compared with 29,208 carried out in Surya Clinic the same year.

Both the PHC and Surya Clinic don’t charge patients for the family planning services they provide. Yet the response they get by way of consumer satisfaction is a vast contrast.

Surya Clinic is a public-private partnership (PPP) under the National Rural Health Mission (NRHM), the programme launched in 2005 by the Congress-led United Progressive Alliance seeking to improve access to quality health care, especially to rural residents, the poor, women and children.

Under NRHM, for the first time, the Centre introduced health services at the primary level with the aim of reaching out to every block, or local administrative unit, in the country. The mission was to increase public expenditure on health, decentralise health programmes, give decision-making powers to the lowest point in the organisational pyramid and provide health care to all.

Human, financial and infrastructural capital on such a scale had not been invested in the country’s health sector earlier. Its implementation received a boost after the private sector was co-opted as a partner.

The experiment

Surya Clinic was started by an organisation called Janani that has been offering family planning services for a fee in Bihar and Jharkhand since 1996.

“After NRHM, the dynamics changed and we decided to stop conducting institutional deliveries because our core competence lay in family planning," said Ranjit Banerjee, general manager of Janani.

Thereafter, Janani’s clinic and its social marketing arm were merged; it created Surya Health Promoters (SHPs) to generate clients at the block level for the district clinics, which perform male and female sterilizations, abortions and offer contraception and counselling services. Its motto: “Let every child be wanted."

However, while the service improved vastly, Surya Clinic would charge for it. For example it would charge Rs1,000 for a sterilization. That is when the central government stepped in and formed an alliance with Surya Clinic under NRHM. The hospital stopped charging its patients and was instead paid Rs1,500 for every sterilization it performed.

The outcome was dramatic: The number of sterilizations rose from 2,382 in 2007-08 to 13,896 in 2008-09 and 29,208 at the end of January in 2009-10. And this despite the fact that a sterilization in a government facility would entitle a woman to Rs600 while no such compensation is paid at Surya Clinic.

From conducting 0.79% of the total sterilizations in Bihar in 2007-08, Janani at the end of January this year accounted for 13.6% of the surgeries.

A success story

The key to its success has been the combination of the government’s financial support through the NRHM and the service delivery capability of the non-profit agency. While state funding ensured free services to the rural population, it also enabled Janani to expand the SHP network.

“NRHM opened up the entry of private sector in partnership for health care delivery. Janani has been able to go to the district level, unlike any other non-government organisation," said Shejo Bose, programme director at Janani.

This may be because Janani’s model mirrors the government’s perspective in rural health care, but excels it in terms of delivery, particularly with respect to outreach. Like the government, Janani too has a clinic in almost every district, each run by a district manager.

To generate clients Janani takes recourse to SHPs, while the government model depends on so-called accredited social health activist, or ASHA, who brings in the patients. Although both follow a cash incentive model, SHPs have been far more effective. At the same time, the government model has built up huge arrears in terms of incentives promised to patients.

Under NRHM, for every institutional delivery, the client is paid Rs1,400. A sum of Rs600 goes to the ASHA. In Raghopur block, a sum of nearly Rs20 lakh has still not been paid out. “There are at least 100 cases who haven’t received this incentive payment," says Pawan Kumar, accountant at the PHC.

“Money not reaching the people on time is one big problem. We are trying to expedite it," says Sanjay Kumar, mission director (NRHM), State Health Society, Bihar. Kumar is now exploring the possibility of evolving a PPP model for timely payment of the incentive money.

More importantly, the PPP model has for the first time offered a choice--even at the village level--to the people living in the 35 districts of Bihar and Jharkhand where Janani operates.

Maniya Devi, 35, a resident of Hajipur, Vaishali, has nine children. Despite being aware of the fact that she could have had her sterilization performed in a government hospital and received monetary compensation, she opted for Surya Clinic.

“I don’t care about the money," she says, lying on her bed at the Surya Clinic in Hajipur block of Vaishali district. “Here, everything is clean and nice. The government facilities are dirty, ill-equipped and not very pleasant."