Guide to Developing Health Care Partnerships with India’s States

By Maya Iskandarani, Jonathan Gonzalez-Smith & Kartikeya Singh —

School health program run by Trinity Care Foundation in Karnataka, India. Trinity Care Foundation | CSR Projects in India’s flickr photostream, used under a creative commons license.

In a landslide victory, Narendra Modi’s Bharatiya Janata Party (BJP) captured a majority in India’s Parliament and catapulted Modi to a second term as prime minister. During Modi’s first term, India unveiled a new National Health Policy in 2017 in addition to Ayushman Bharat, a national health insurance plan. These ambitious policies, coupled with Modi’s reelection and significant parliamentary support, indicate health will remain a priority in the foreseeable future. However, state governments will shoulder much of the responsibility for enacting these reforms and Modi’s return to power will likely continue India’s recent trend towards state-led policy development and decentralized public spending  – including healthcare. With this shift in responsibility, states will need significant support to address outstanding health challenges, including severe workforce shortages and capacity gaps, rising incidence of Non-Communicable Diseases (NCDs), and stubbornly high maternal and child mortality rates. External actors seeking to advance India’s health goals will therefore find many state governments a willing — and essential — partner in collaboration.

Working with the public sector is often critical to the success of healthcare projects.  It allows organizations to leverage existing healthcare infrastructure, broaden reach, and access new revenue streams. Each state presents unique challenges for effective collaboration, however. To  map the steps to partnership with Indian states, Duke University’s Innovations in Healthcare and the Center for Strategic and International Studies (CSIS) launched the Indian State Health Innovation Partnership Project in 2017.

In the first phase of the project, we interviewed healthcare leaders across India’s public and private sectors to identify ripe opportunities for state collaboration. The report Indian State Priorities for Health Innovation Partnerships summarizes our findings. Subsequently, we sought to identify factors that enable or hinder successful partnerships. We interviewed 20 stakeholders from multinational organizations, small to medium social enterprises, private health systems, and U.S. universities who have successfully partnered with Indian state governments. Drawing from the experiences of these institutions, the report provides specific recommendations for successful state collaboration:

  1. Be wary of a complex, often slow bureaucratic process. Healthcare governance in India is split across many state and national institutions, making it difficult to identify where to start to build a partnership. Although some states are pursuing reforms to streamline this process, collaborators should expect to secure many layers of approval before their projects can move forward. To accelerate this, organizations should: continuously engage with the right national institutions; target key state- and district-level officials; partner with well-connected, knowledgeable local advocates; and decide what makes a state a good collaborator.


  1. Be sensitive to political environments. Given India’s high political turnover, it is important to strategically align outreach efforts with election schedules; proactively reach out to new administrations; keep projects flexible with or resilient against political trends; not to contract with states during election periods (it is illegal); and be aware of political alignment between state and central governments since this affects states’ access to public resources.


  1. Regardless of an administration’s political composition, be ready to show your chops to obtain funding. Prospective collaborators should learn state priorities, reading state ministries’ requests for proposals (RFPs); develop a convincing project pitch for relevant public officials; and show evidence of success in areas that officials value, such as cost-effectiveness, scalability, and patient outcomes.


  1. Plan in advance for funding delays and inconsistency. Create a line item in your organization’s budget for working capital; diversify sources of capital; or operate as a third-party vendor or subcontractor for the government.


  1. Improve your odds of project approval and consistent aid. Make an effort to understand state-specific tendering processes; use the Government eMarketplace to showcase goods and services for procurement; and seek inclusion in Programme Implementation Plans (PIP), states’ annual strategies for implementing national health programs.

Joint public-private health ventures are no simple feat, but can present high returns. Modi’s reelection and its implications for health spending in India make it all the more vital to understand the challenges of state-level collaboration. Experience is the best teacher, and the lessons of organizations with records of success in partnering with Indian states simplify the process for prospective collaborators.

Ms. Maya Iskandarani is pursuing a Bachelor of Science in Biology at Duke University and she previously worked at the Duke Margolis Center for Health Policy researching health care innovations for universal health coverage.

Mr. Jonathan Gonzalez-Smith, M.P.a.F.F., is a Research Associate at Duke University’s Robert J. Margolis, MD, Center for Health Policy.

Dr. Kartikeya Singh is deputy director and senior fellow of the Wadhwani Chair in U.S.-India Policy Studies and senior fellow with the Energy & National Security Program at CSIS. Follow him on twitter @KartikeyaSingh.

Kartikeya Singh

Kartikeya Singh

Dr. Kartikeya Singh is deputy director and senior fellow of the Wadhwani Chair in U.S.-India Policy Studies at CSIS.


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