Public private partnerships (PPPs) have been embraced by successive Pakistani policymakers, as in other countries, as a means for improving healthcare. Pakistan boasts one of the largest private health sectors in the region, which can be leveraged to contribute towards sustainable development goals and mobilise domestic resources.

Private providers proliferated over time to fill the gap left by congested government hospitals or weakly functional government primary care services. According to data from the World Bank for 2014, more than 92 percent of clinics, 60 percent of registered laboratories and 40 percent of hospital beds are in the private health sector in Pakistan.

A later survey, the Pakistan Social and Living Standards Measurement in 2020, found that 58 percent of outpatient health consultations take place in formal private facilities. Meanwhile, 43 percent of births take place in formal private facilities, according to the Pakistan Demographic and Health survey of 2018.

Even after adjusting for unlicensed providers — colloquially called ‘quacks’ in South Asia — a large number of formal private practitioners remain. These predominantly comprise small-and-medium scale private clinics, laboratories and hospitals, which are the go-to option even for the poor and are embedded within the local community ecosystem.

Pakistan’s healthcare system already leans heavily on private clinics, labs and hospitals — but without clear direction towards public health targets. Public-private partnerships offer a real chance to bridge gaps and improve healthcare services

Additionally, a fast growing digital small-and-medium-enterprise (SME) sector and wide penetration of mobile networks in Pakistan provides an opportune market for digital health services and innovations.

Although often marginalised in national health policies and mistrusted by government counterparts, the private health sector — for better or worse — carries considerable responsibility for primary care, diagnostics, medical imaging, blood banks and supplementary hospital care in Pakistan which, if turned off, can cause the health system to collapse.

PREPPING FOR THE ‘NEW NORMAL’

Global experience shows that PPPs have been deployed to supplement government hospitals for specialist services, such as dialysis or cardiac surgeries, in middle-income countries without comprehensive national health insurance. PPPs fill the gaps for urban primary care in South Asian cities that typically have too few government clinics — they have served as a game-changer for early diagnosis of Hepatitis-C, helped establish new health facilities and run additional services within government facilities, and devised digital innovations to speed up cost-effective disease detection and intervention.

Although successive governments in Pakistan have acknowledged the role of PPPs in healthcare over the past two decades, this recognition has mainly resulted in isolated or ad-hoc projects rather than a coherent, strategic approach for the health sector.

A purposeful strategy built on local realities and building steering capacity is the foundation for impactful PPPs. But more than that, a meeting of minds across population health, management enterprise and finance is required to design viable models.

With declining foreign aid, the moment is now for countries to prepare for the “new normal” of developing greater self-reliance — PPPs can contribute to this new agenda.

CHARTING A COHESIVE DIRECTION

Aligning health PPPs with national health targets should logically be the starting point, yet this is seldom the case in most countries. As in other countries, health PPPs have proliferated as siloed initiatives in Pakistan, often disconnected from national health targets and interpreted differently by various stakeholders.

Tension and confusion often arise in framing of health PPPs, with many mistakenly equating it with privatisation. In contrast to privatisation, PPPs provide public sector resources for agreed pro-poor healthcare goals and retain public sector oversight on performance.

Similarly, health PPPs are also mistaken for grant-in-aid agreements set up to support philanthropic hospitals, but without being under-written by performance goals. Simply put, health PPPs involve a formal contractual agreement between the public and private sector to deliver mutually agreed goals, through jointly shared responsibilities and supported by an accountability framework. There is an implicit expectation of innovation and an understanding based on trust and cooperation. And there is an explicit mention of performance goals.

PPPs have been shaped under various motivations, ranging from establishing additional health infrastructure, digital healthcare transformation or expanding access to affordable healthcare. Stepping back is important to bring these together under a cohesive country strategy for health PPPs. Otherwise, even the best designed projects run the risk of appearing scattered and unsystematic.

The global momentum of universal health coverage (UHC) for accessible and affordable services provides the ideal direction under which to formulate a cohesive PPP strategy, integrating private enterprise and private providers within the national momentum.

In large, decentralised countries such as Pakistan, the starting point can be a national framework for health PPPs, under which provinces having a sizeable private healthcare sector can fashion a locally suited strategy. Budgetary planning, at least for the medium term, is equally important, to allow the strategy to be meaningfully implemented and can be the basis of crowdsourcing funding from the private sector.

ADDRESSING LOCAL HEALTH NEEDS

Earlier forms of health PPPs were driven by economic infrastructure policies to establish more healthcare facilities, based on collaborative financing.

Build-and-operate schemes were first introduced in the UK to expand National Healthcare Services (NHS) hospital capacity and address infrastructure gaps. Similar models were later adapted in the Gulf countries to reduce reliance on overseas treatment and promote medical tourism, and in India, through land-for-bed schemes that exchanged land grants for commitments to provide affordable hospital admissions. In Egypt, joint ventures with private laboratories helped expedite the diagnosis of hepatitis and chronic diseases.

Less practised in Pakistan, this offers a policy instrument to fill geographical gaps in health infrastructure, with negotiated agreements and by providing direction to the unbridled growth of the commercial private sector. A promising example is the revamping of children’s emergency care in Pakistan’s public sector hospitals seen in Sindh, Punjab, Balochistan and Azad Jammu and Kashmir.

Digital health, including artificial intelligence, is now the future of healthcare delivery, providing groundbreaking solutions that are quick, affordable and accessible for diagnosis and treatment.

Pakistan rapidly advanced digital health interventions during the Covid-19 pandemic, using them for health communication, workforce training, patient triage and hospital cross-referrals, supported by collaboration among societal partners. A promising example amongst many was a public sector university partnering with a digital start-up and female home-based doctors providing digital triage and telecall care to female patients. These are yet to be cohesively integrated in the post-pandemic time.

Additionally, transformative biotechnologies offer cost-effective home-based monitoring of lifelong chronic disease and early escalation for surgical interventions. The technologies rely on the private industry for prototype designs, digital platforms, analytics and information technology (IT) management, as well as public health direction for establishing new ventures.

Using private management to revitalise poor performing public sector hospitals and clinics has been another popular push for health PPPs. Pakistan stands out as a country with one of the largest examples of outsourcing the management of poorly performing governmental health facilities but, importantly, still supporting with government budgets to keep services free of charge for patients.

Popular with provincial and local governments as a solution to overcome slow-moving public-sector systems, evaluations in Pakistan have shown an increase in patient footfall at contracted health facilities, better staff availability, more medicines and technological innovations under private sector management.

In regional countries, PPPs are providing laboratory, pharmacy and radiology services within government health facilities and mobile clinics in underserved areas. Investing in government capacity for performance monitoring is important to look at value for money.

More recently, contractual partnerships with private polyclinics and general practitioner (GP) clinics to provide free or subsidised primary care is being tested out by middle-income countries such as Philippines, Egypt, Iran and Singapore, through domestic financing.

Long practised in Western economies as the basis for primary care, the engaging of qualified GPs can be vital in Pakistan’s context for early management of diseases, decongesting hospitals and preventing health insurance expenditure growing to unsustainable levels.

Previous GP initiatives in Pakistan have tended to target single diseases, often tuberculosis or family planning, but expansion towards integrated services is required to make a dent in hospitalisation.

Moreover, past models were designed and managed by international NGOs with donor agency funding, which is not a sustainable model and a major reason for the lack of scale-up. Pakistan must lead the design and oversight and contribute to the expense of GP partnerships, even if this means starting small and running with simpler models.

A promising innovation is the use of GP clinics by Punjab and Sindh’s immunisation programmes for vaccinating children in urban slums, which can be consolidated for integrated child health services.

CAPACITY, RESOURCES AND REFORMS

Steering of PPPs requires investment in capacity, identifying resources and linking with domestic health financing reforms. This requires not huge but strategically placed funds.

For best practice, health PPPs must be locally moulded, while drawing on international guiding principles. Keeping the design simple, focused and practical has been seen to work well in developing countries. Importing complex, legalistic PPP models from Western countries with stringent rules of business from donor agencies often fail in the less developed systems of the Global South, adding red tape instead of improving service delivery.

At the same time, developing databases of private healthcare markets, identifying and countering risks for each type of PPPs, devising clear responsibilities and mutual benefits, managing conflicts of interest and maintaining dialogue are foundational practices learnt from PPPs of Organisation of Economic Co-operation and Development (OECD) countries. Digital reporting from PPPs has been a game-changer in many countries, to keep PPPs on track for performance and course correction.

AVOIDING THE USUAL PITFALLS

Choosing where not to engage is equally important. A useful point is to start with elimination. For example, de-prioritise geographies where private facilities duplicate existing public sector hospitals and clinics. Avoid PPP contracts with private clinics and hospitals maintained by government doctors, to prevent perverse interests of unwarranted patient referrals to private healthcare. Ensure those sitting on PPP advisory committees are not beneficiaries of PPP agreements.

It is important to separate the management of PPPs from the usual business of managing healthcare services. While health ministries and departments should provide the strategic direction and performance framework, the management of PPPs must be set-up up at arm’s length from health directorates, to counter conflicts of interest and ensure the right expertise. Pakistan has invested in PPP nodes, authorities and foundations, but these remain under-resourced and require blended skills of public health, business acumen and financing.

Partnerships are built on dialogues. Steering of PPPs must require attitudinal shifts. Territorial antagonism to private providers is common in mid-level public sector staff and private sector involvement taken as an implicit failure of the public sector. Establishing dialogue platforms to understand viewpoints, aligning interests and co-design workable models is vital.

But dialogue with the smaller private providers can also be very challenging as these are numerous, fragmented and lack formal representation. Positive examples are seen in countries in Africa and Southeast Asia, where smaller private providers were re-organised into associations to provide a dialogue interface for health PPPs.

PPPs require careful balancing. Giving too much of a freehand to the private sector within PPPs results in private providers running on with their own agendas rather than delivering on public sector goals. However, too much control can stifle innovation, which is the hallmark of the private sector, and drives away private partners from PPP initiatives.

In Pakistan as elsewhere, PPPs in healthcare have sometimes gone too far in one direction or the other. Bringing in voices beyond just the government and private companies, such as patient advocates, local communities and think tanks, helps keep PPPs focused on healthcare as a public good, not just a commercial deal.

Finally, PPPs for healthcare are built on domestic resources, not on international donor aid. Aid is useful to provide catalytic support and technical assistance, but mobilising sustainable resources falls to the lot of governments. Public sector financing priorities in Pakistan are heavily tilted toward high-end hospital care, with much less spending for frontline primary care management and early diagnostics to counter disease progression.

More efficient allocation of public sector funding, bonds to attract private sector investment in healthcare, tapping into healthcare industry resources and crowd-funding discrete projects can mobilise private sector funds. And an emphasis on ‘resourcing’ rather than cash financing widens opportunities for contribution from the private sector in the shape of staff, space, expertise and digital platforms.

The time is now for governments to embed PPPs as part of transformative domestic healthcare reforms. Aid systems have abruptly undergone a change. But the change was anyways to come in the not-too-distant future, with the economic transition of Pakistan to a middle-income country. It is time to bring the divergent private health sector to work more closely with public sector counterparts for societal goals.

Clear direction, open dialogue, reliable data, and strategic resourcing are essential to maximise the impact of PPPs in the rapidly evolving global aid landscape. The starting points must be primary care, diagnostics, digital healthcare, patient transportation networks and selective specialty services to supplement public hospitals.

Can we get there? Yes, we can — with evidence, persistence and inclusive engagement.

The writer is a global health academic based at University College London in the UK

Published in Dawn, EOS, May 11th, 2025