ppp in health
TRANSCRIPT
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Public Private Partnership in Health Service Delivery
Digvijay TrivediMBA (HR), MA(Eco.) PGDCPM, PGDRD
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Public Private Partnership
An arrangement
Provide public servicesINVESTMENTS AND/OR MANAGEMENT
Fixed duration
Allocation of risk
Performance
PRE-DETERMINED STANDARDS
Measurable Indicators Entity
Government
Private
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Setting the tone…..
A quick introduction to Public-Private Partnership.mp4
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WHY PARTNER WITH THE PRIVATE SECTOR?
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Omnipresence of Private Sector
• 93% of all hospitals• 64% of all beds• 80% doctors• 80% of OP and • 57% of IP ….are in the Pvt. Sector(World Bank 2001)• Estimated at Rs. 1,56,000 Cr. in 2012 +Rs. 39,000Cr. for health insurance(NCMH 2005)
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Share of Pvt. Sector- Non- Hospitalized care (60th NSS-2004)
Andhra Bihar Gujarat Himachal Karnataka MP Orissa Punjab Rajasthan Uttrakhand UP W.Bengal0
102030405060708090
100
79
95
79
32
66
77
49
84
56
8290
818089
82
14
8477
46
82
47
65
8780
Rural Urban
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Share of Pvt. Sector- Hospitalized care (60th NSS-2004)
Andhra Biha
r
Gujarat
Himach
al
Karna
taka
M.Prad
eshOris
saPu
njab
Rajasth
an
Uttarak
...
U.Prad
esh
W.Benga
lInd
ia
73
86
69
22
60
42
21
71
48
57
73
21
5864
7974
11
71
52
27
74
36
66 69
35
62
Rural Urban
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Implications
>80% of health expenditure is out-of-pocket
(World Bank 2011)
Debilitating Effects on the poor: Liquidation of assets, indebtedness. 40% of hospitalized & 2% in the country every year end up BPL
(World Bank, 2001)
Compounded by poor regulation of private sector
14%
86%
Out of pocket expenditure in health
Government Expenditure Out of pocket expenditure
Source: www.data.worldbank.org
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Private sector is needed because...
India needs an additional7,50,000 beds5,20,000 doctors
Overall investment Rs 1,50,000 Cr.
80% likely to come from the private sector (NMCH,2005)
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PPP Approach
PPP approach
• Attract private investments Goal• Lack of Budgetary Resources• Need to improve efficiency in service delivery
Need
Private Sector contribution for: Public Sector contribution limited to:
Financial investmentsBest Management practicesEfficiency in service deliveryEfficient use of capital resources
Providing institutional commitmentProject Development Selection of Developer Viability gap funding (VGF), if any
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PPP MODELS & TYPES
Not all interactions between the Government and Private sector are PPPs
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Putting the projects on “shelf”
ProjectPreparation
PartnershipManagement
ProjectIdentification
Viability Structuring Do-ability ProcurementStrategy
Bid ProcessManagement
OperationsManagement
Identification/Assessment
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Financing vs Delivery: Public vs Private modes
Public Provision Private Provision
Public Financing Public Hospitals
Voucher
Contracting
Insurance
Private Financing
User Fee Hospital Autonomy Private Hospitals
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Common PPP Models
• Contracting (‘in’ and ‘out’)• Joint Ventures• Build/ Rehabilitate, Operate, Transfer • Health Financing (Vouchers, CBHI, Illness fund) • Mobile Health Units• Franchising• Social Marketing• Technology demos (e.g. Telemedicine)• Public-Private Mix
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Core Principles of Partnership
True partnerships entails
• Relative Equality between partners
• Mutual Commitment to Public Health objectives
• Benefits for the Stakeholders
• Autonomy for each partner
• Shared decision-making and accountability
• Equitable Returns / Outcomes
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PPP Models in Practice
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Demand side Financing- Voucher Scheme
Voucher Scheme, ANC, PNC Institutional Deliveries
Primarily for poor
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Demand side Financing- “चि�रंजीवी, यशस्वि�वनी”
Chiranjeevi Yojana, Gujarat
Institutional deliveries through private obstetricians and gynecologists
Scheme is primarily for women from poor families, with prior ANCs from a govt. hospital
Yeshasvini Health Insurance SchemeKarnataka
Hospitalization and care for more than 1600 surgeries
Only for the members of farmers’ co-operatives and their dependents
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Social Franchising
Social Franchising, ANC, PNC Institutional Deliveries
Primarily for poor
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Ambulance Service
Ambulance service ANC, PNC Institutional Deliveries, sick child, Emergency services etc.
Primarily for poor
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Mobile Medicare Units
Uttaranchal Mobile Health and Research Clinic
Clinical & Radio diagnostics through health camps, lab tests
Free to all BPL cardholders
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Contracting Out
SMS Hospital Jaipur Rajasthan
Radiological (CT/MRI Scan) Diagnostics
Free for all BPL Patients; Subsidized rate for others
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Build, Operate, Transfer
Karuna Trust, Karnataka
Management of PHCs and sub-centers; 24-hrs clinical services
Free services- diagnosis, consultation, treatment and drugs
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Contracting in
Karnataka Integrated Tele-medicine & Tele-health, Chamrajnagar
Tele-diagnosis and consultation in cardiac care and specialist care
Free diagnosis, medicines and treatment for the BPL patients
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EMERGING MODELS
• Regional Diagnostic Centres- Hub/Spoke
•Medicity
• Co-location of Specialty services
• District Hospital + Medical College (Hub)
• Franchised /Accredited Health Units
• Private surgical teams
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Key Lessons & Challenges in PPP: Indian Experience
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Political and Administrative Commitment
• Half hearted support for PPP
• Policy makers enthusiastic but lack of positive outlook
amongst implementors
•Misunderstood as ‘privatization’
• Lack of Trust on both sides
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Institutional Capacity
• Requirement for technical/ managerial skills for designing, negotiating, implementing and monitoring PPP contracts
• Lack of institutional capacity at all levels, including oversight role
• Administrative framework and readiness to meet requirements
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Policy and Institutional Framework
• Lack of policy driven strategy
• Lack of information on Private sector thus poor regulatory leverage
•No institutional structures to manage PPP contracts
•Non functional specialized PPP cell
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Diversity and Complexity of Private Sector
• Private sector is diverse; Predominantly individualistic
(owner operated units) and in both recognized and
unrecognized systems of medicine;
• Diversity of tariffs, thus complicating information on cost
vs tariff and tariff negotiations
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Risks
•Private partner- Non-timely release of funds; Fear of
enquiry
•Government- unsuccessful/ failed contract leading to
lack of services – patients suffer, resources wasted
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Few Constraints
• Payment delays
• Personality styles and trust level
• Local political interference / political flip-flaps
• Lack of capacity or willingness to supervise / monitor / guide the project
• Perceptual and attitudinal orientation to private sector
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Limitations in Contract Features
• Defining & verifying beneficiaries (BPL patients)- especially high cost services
• Defining Quality or Performance or Outcome indicators
• Supervision and Monitoring mechanism
• Timely revisions / updating of contract
• Ombudsman for dispute settlement
• Clarity on user fee
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Enabling Environment
• Successful partnerships are contextual• Enabling conditions include
• leadership from both partners • prior consultations• relational / trust based contracting• pilot testing• timely payment• periodic review and amendments / revision of contract• specific performance indicators
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Conclusion
• Public-private partnership (PPP) is not privatization
• Government continues to play a key role
• Requires high degree of institutional capacity
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Contd…
• It does help in benefiting the poor. • It is one of the pragmatic options for health service delivery, but
not an alternative to public delivery or better governance.
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THANK YOU