dr deoki nandan
TRANSCRIPT
PUBLIC PRIVATE PARTNERSHIP IN HEALTH SECTOR: MODELS & THE
AGRA EXPERIENCE
Prof. Deoki NandanDirector
National Institute of Health & Family Welfare, New Delhi
Public Private Partnership in Health
Definition:Public-Private Partnership (PPP) is a collaborative effort, between private and public sector, with clearly identified partnership structures, shared objectives, and specified performance indicators for delivery of a set of health services (MOHFW,GOI)
Objectives of Public Private Partnership in Health
Improving access to essential services
Improving the quality of services available
Exchange of expertise
Mobilize additional resources for activities
Improve efficiency
Better Management of Health services
Increasing scope and scale of services
Increasing community ownership of programs.
Ensuring optimal utilization of govt. investment and infrastructure
The Benefits of PPP are
Economies of Scale
Utilising Existing Capacity
Create Synergy
Targeting the Poor
Flexibility in Action
Resource Mobilisation
Technical Upgradation
Better Services BETTER HEALTH
ECONOMIES OF SCALE
UTILISING EXISTING CAPACITY
CREATE SYNERGY
TARGETING THE POOR
FLEXIBILITY IN ACTION
RESOURCE MOBILISATION
TECHNICAL UPGRADATION
BETTER SERVICES
Models of Public Private Partnerships in Health
1. Social Franchising 2. Branded Clinics 3. Contracting 4. Social Marketing5. Build, Operate and
Transfer 6. Joint Venture 7. Voucher System 8. Donations from
individuals
9. Partnerships with Social Clubs and Groups (e.g. Rotary Club)
10. Involvement of Corporate sector
11. Partnership with Professional Associations
12. Capacity Building of Private Providers
13. Autonomous Institutions
14. Mobile Health Vans 15. Health Insurance
Social Franchising
“ A franchise is a contractual relationship between the
franchiser and franchisee in which the franchiser
offers or is obliged to maintain a continuing interest
in the business of the franchisee in such areas as
know-how and training; wherein the franchisee
operates under a common trade-name, format and/
or procedure owned and controlled by the franchiser
and in which the franchisee has or will make a
substantial capital investment in his business from
his own resources”
-International Franchise Association
The Merrygold Network (USAID, SIFPSA & HLFPPT), Uttar
Pradesh
Provides high quality MCH services at affordable prices.
Network comprises of seventy - 20-bed Merrygold Hospitals, 350 - Merrysilver clinics and 10,500 - Merrytarang Ayush partners.
The franchisees of this network are being provided training, marketing and quality assurance support
Challenges
• Controlling Quality of Services
• Positioning on Price/ Quality – Trade off between Social goals and Provider Satisfaction
• Understanding motivation of Clients for Accessing Services
Social Franchising - Criteria for Initiation
Revitalising present Government structure is slow
Resources required to expand public health infrastructure is enormous.
High demand but poor supply from government health institutions
Availability of vast network of private hospitals in places needed
When objective is to improve access to services on immediate basis.
Improve quality standards of private sector and provide high quality care at affordable prices
Branded Clinics
Chain of Clinics – Same Organisation
Cater to better-off clients – Market Segmentation
More Income More
Sustainable
Eg. Butterfly clinics, titli centres in Bihar,MP
Example With the support of States, an NGO Janani set
up a network of more than 21,000 Titli (butterfly) centres and more than 500 Surya (sun) clinics in Bihar, Jharkhand and Madhya Pradesh.
Surya clinics are referral clinics run by formally qualified, state-registered doctors in the towns.
Titli centres are situated in villages and run by RHPs who have been trained to provide family planning counselling and sell non-clinical contraceptives.
Branded Clinics – Criteria for initiation Need to expand services rapidly Need to provide high visibility to
services available Offer a package of services
selected for the purpose Provide high quality services at
comparatively affordable prices
Contracting – Contracting-in and Contracting-out
Legally enforceable Contract
- Defined Set of healthcare services
- Quantity of services
- Quality of services
- Duration of Service Provisioning
Public Private
Contracting out State Govts. Has contracted out few PHCs
in Karnataka, Arunachal Pradesh to by Karuna Trust, VHAI
Subcentres in Uttarakhand to NGOs
Contracting in Human resources by almost all states
under NRHM -Radiology, drug stores etc.eg. SMS Hospital, Jaipur -Diet, cleaning, laundry etc. in almost all states
Contracting Out & InExamples
Criteria for initiating Contracting-
out
Difficult to manage government health units in remote and inaccessible areas
Utilization of services and performance levels are consistently low due to non-availability of staff
Aim is to put government health facilities to optimum use
Increase responsiveness of government health facilities to local needs through community involvement
Criteria for initiating Contracting-in Improve efficiency levels of
services provided Make management of services
more effective Conserve scarce resources by
cutting costs Try out innovative approaches to
improve efficiency and effectiveness
Voucher System/ Demand Side Financing
A voucher is a document that can be exchanged for defined goods or services as a token of payment (tied-cash).
Eg: AGRA, Hardwar
Voucher System – Criteria for Initiation
Improve access to services and provide choice Where costs act as a major barrier to services Existing public healthcare service delivery points
do not have provision for all types of services Inadequate knowledge about the value of services
(e.g. importance of antenatal care) Need to generate demand for healthcare services Possible to do regular monitoring for ensuring
quality standards Training of providers and network with the people
to ensure proper use of vouchers is possible
Donations From Individuals
Donations from rich philanthropists institutions
Need for simple and transparent mechanisms to encourage donations
Partnerships with Social Clubs and Groups
Social Clubs like Rotary Lions’
They have been proven to be useful in: Popularising reformed healthcare service
delivery outlets In communication campaigns Management of camps on a large scale Providing additional resources and
technical expertise Advocacy efforts
Involving the Corporate Sector
Organised Corporate Sector through CII FICCI
E.g. Indo-Gulf Fertilisers’ Health Initiative and recent Health Conclave by CIIAdoption of Villages for providing primary health care services – TVS -in Karnataka
Partnerships with Professional Associations
Expert Pool• IAPSM, IPHA
• FOGSI – Vande Matram scheme
• IMA – Aao Gaon Chalein
• TNAI
• Pharmacists Associations
Protocols/ Quality Assurance/
Accreditation
Mobile Health Vans
Already implemented in inaccessible areas
Comprehensive Health Services Fixed Journey Plans Public Sector contribution Medical
Officers and Medicines Private Sector for Purchase and
Management of Vans These vans are useful in:
Provide access to services people living in inaccessible terrain
Make services available at central location to reduce travel time and costs of clients
Under NRHM many states have introduced this scheme
Health Insurance
CGHS – Tie up with private hospitals
RSBY – Empanelled private hospitals
ESIS - Panel of private hospitals &
empanelment of private doctors
Initiating Public Private Partnerships in Health
Prioritizing needs
Evaluating and analyzing the ground realities
Selecting the appropriate model
Piloting the model
Evaluating the pilot
Scaling up
Initiating PPP in Health - Vital Components: STRAIGHT
Identifying the SCOPE of partnership Identifying the appropriate TARGET
POPULATION Selecting the RIGHT PARTNERS and the
RIGHT MODEL of PPP Ensuring ACCOUNTABILITY of private
providers Ensure active INVOLVEMENT of the
government GENERATE SUPPORT of all the key
stakeholders through IEC, advocacy and rapport building
HIGHLIGHT ACHIEVEMENTS of the partnerships
Build TRUST of all the partners and clients
Initiating Vouchers scheme for MCH care for BPL in Agra
The task was to bring government health sector,
private health care providers,NGOs
work together on one platformand
Policy makers To accept PPP in health as an
implementable issue
Key policy makers were:
State Government
Health Department Bureaucracy-Principal Secy M&H
Senior technocrats at state HQ
Existing Rules were……..
It cannot be done!
Principal viewpoints against scheme were…
Government-Why should we give government money to private providers?Private providers are profiteers, so why link with them? It has not been done before so how can we do it now?
Health department Technocrats-We give services for free! why should they get money for it We will lose our constituency and control on public health
Private health care providers-Government is corrupt, we will not work with them
Key supporters were
NONE
Except the funding agency
How we progressed
Signals
We compiled a data bank on
• Existing health indicators in the district
• Comparative cost of treatment to patients in Govt. vs Private sector
• Percentages of un-served BPL patients in the state
• Comparative reach of private sector
• Increasing inclination of population towards private health care
Consultation and Formulation
Step-1
• Called on the key government representatives to share data
• Discussed successful models to remove doubts
• Discussed the pro poor spectrum of this scheme
• Shared experiences from the other states/developing countries
• Tried to convince that this is cost effective
Step-2
• Called a consultative meeting of all stakeholders at AgraThis included- Bureaucrats, Senior government officials,Nursing home Associations, IMA, Nursing council, Civil Society reps, Senior reform advocates and subject specialists
• Had discussions, did documentation, developed models and presented findings to government with a draft plan recommendation
Aggression
• Followed up with fostering pressure groups inside state bureaucracy. Also aggressively advocated with senior technocrats in health directorate
• Sent the proposal to Government for ratification
• Confronted objections through evidence in hand
Mechanism Proposed was…
SN MEDICAL COLLEGE AGRA WITH REPRESENTATION OF
GOVT,NGOs,NURSING HOMES ANDDISTRICT ADMINISTRATION AS VOUCHER MANAGER
NGOs AS DISTRIBUTORS AND MOBILIZING PARTY
SELECT 5-10 BED NURSING HOMES AS SERVICE PROVIDERS
Government said no to SNMC as voucher managersAnd proposed CMO in place to retain controlWe said OK
Government asked: at what cost NHs Will give servicesWe said cheap and not more than RGI figures
Government asked about NH accreditation criteriaWe said that we will develop
Government asked the spread of Pvt facilities in AgraWe said we will survey
WE REDEVELOPED THE MANAGEMENT STRUCTURE WITH CMO AS LEAD
WE SURVEYED AND MAPPED NHs in AGRA IN 3 MONTH
WE NEGOTIATED COSTS WITH NHs IN JOINT CONSULTATIONS AND REACHED THE BEST RATES IN INDIA IN 1 MONTH
WE DEVELOPED ACCREDITATION CRITERIA FOR 5-10 BED NHs IN 2 MONTHS
WE DEVELOPED FIELD DEFINITIONS OF ALL MCH CLINICAL SERVICES TO ENSURE UNIFORM STANDARDS AND QUALITYIN 2 MONTHS
State bureaucracy was now happy because they were leading the expansion
Nursing homes were happy on the proposed fund dispersal mechanism (advances ) and assured increase in patient numbers
Health technocrats were happy that they retained power
Politicians were happy as the scheme reaching their poor electorate
NGOs were happy on services they could do in the areas they work
Implementation
THE PROPOSAL WAS SENT TO CHIEF SECRETARY FOR RATIFICATION BY CABINET
AND WAS IMPLEMENTED!!!!!!!!
:
• 3 months later a review was done and additional grants were provided on field requirements, including refresher trainings on clinical field definitions
• Medical audits for quality assurance, financial audits for transparency conducted after 6 months
• Additional NHs contacted and accredited
• Scheme expanded to two more Districts (One by UPHSDP)
• PPP is now an official government policy for all sectors in UP
Evaluation & Feedback
PPP is Likely Democracy
- For the People- By the People-Of the People
PPP For People
Framework for Developing Problem Profile of Partners Process of Building a partnership Profit – Mutual Benefit Phase – start small & build Proliferate –Grow, Expand, &
Sustain Priorities & Preferred group
Framework for Developing PPP Policing – Mechanism of Monitoring
& Transparency Politics – Governance,
Administration, People’s audit Protection/proof: A security system Price: A cost share in terms of
money/kind
Framework for Developing
Professional Network Platform Prize:
Acknowledgement/recognition
PPP is a required PUNCH
Thank You