Public-private partnership to make healthcare is an initiative to reach out to the unreached, accessible, accountable and affordable for vulnerable sections of society Private Public Partnership (PPP) is not a very recent concept but of late it has gained momentum throughout the world. Initially, it was limited to the finance sector but gradually it was found of much use in infrastructure sector like telecom, roads and later on this concept emerged as a useful tool for services sector also. The overwhelming presence of the private sector in healthcare, estimates indicate 93 per cent of hospitals as private, the state governments have been looking up to involve the private sector in the health domain by creating partnership to cater to the growing needs of the population. PPP has carved a niche for itself in the healthcare sector also. This happened due to resource constraints in the public sector of governments across the world. It is often misunderstood as a substitute for public health services but in fact it complements it. The very concept of PPP in the healthcare sector, as stated by WHO in 1999, is a "means to bring together a set of actors for the common goal of improving the health of the population based on mutually agreeable roles and principles." In fact, PPP in the healthcare sector entails reciprocal obligations and mutual accountability, voluntary or contractual relationships, the sharing of investment and operational risks and joint responsibility for design and execution. Last month, a conference was held by Technopak Leadership Forum (TLF) in New Delhi on "Accessible Healthcare - A Reality Check" to discuss the problems of accountability, accessibility and affordability to chalk out tangible steps. As discussed in the forum, the lackadaisical attitude of the health sector indeed calls for a reality check. However, emphasis was laid on the PPP model for a simple reason - it ensures sustainability of programmes by enhancing the skills and capacities of local organizations and by increasing the public accessibility to unique expertise and core competencies of the private sector, it expands the reach of interventions by accessing target populations and it facilitates scaling up of proven and cost-effective interventions. Due to the incapabilities of our public sector in delivering quality healthcare and the extortionist mentality of the private sector, neither of the two can alone operate in the best interest of the health system, which again calls for PPP. India rules the roost when it comes to private out-of-pocket expenditure on health, which has a debilitating effect on the poor. Chronic illness and hospitalization often lead to selling of assets or borrowing - 40 per cent of hospitalized people either borrow money or sell their assets to meet their medical expenditure and 35 per cent of them lie below the poverty line (BPL). This exorbitant expense further pushes 2.2 per cent people below the poverty line every year. Approximately 29 per cent India's population is BPL, and is supposed to avail of the free health services provided by the public sector. The inequities in the health system are worse, as can be seen in the disclosure that public spending on health is stagnant at around 0.9 per cent of GDP as compared to the global average of 5.5 per cent. Even the public subsidy on health doesn't prove beneficial. Ironically, the ground reality is that the deprived quintile accesses only one-tenth of the public subsidies on healthcare but the affluent ones usurp 34 per cent! That is why the collaboration of both the sectors is vital to fortify the healthcare sector because public sector does not deliver and the private sector gorges on profits only. The government also has various healthcare schemes for poor indigent people living below the poverty line like Rashtriya Arogya Nidhi and the health minister's discretionary grant -still, very few could be benefitted by these schemes despite the fact that a sizeable budget is allocated for this. At present there are 16 partnership projects, five are urban-specific and others are in rural and tribal regions. Some PPPs are simple contracts relating to diet and laundry while some complex partnerships involve stakeholders. Although most of the projects are specific to a certain geographical area, but some are replicated in the entire state like Yeshavini scheme in Karnataka and Arogya Raksha scheme in Andhra Pradesh. The oldest of them is Karuna Trust (since 1996) which manages primary health centres in Karnataka. In Gujarat, Dr Amarjit Singh, principal secretary (FW) and commissioner health, medical services and medical education, almost brought a revolution by his Chiranjeevi scheme in health system making it more equitable, accessible, accountable, transparent and cost-effective. It engages private doctors for deliveries, which has strikingly lowered the maternal mortality rate (MMR) and infant mortality rate (IMR) in Gujarat. The PPP model, though very effective, has some drawbacks like use of illegitimate or unethical means to maximize profit or lack of interest in sharing clinical information etc. Partnership with NGOs can lead to poor quality care and untrained staff. The boons of PPP outweigh its banes, but the million-dollar question is: why, in spite of such achievements by the PPP-modelled scheme, is it still an issue? Dr Amarjit Singh reveals, "There is a huge amount of distrust between the public and private sector." In this scenario, there is a requirement to narrow this abysmal chasm between both the sectors. Until and unless it is bridged, seeing life at the end of the tunnel is tough, if not impossible! A /paradigm shift is needed.