The Right for Health & Private Public Partnership in care delivery

Issues to be considered by policy makersSDU‐UK&I Spring Conference

16th & 17th June 2012

Dr Ibrahim M Abdel Rahim

UN Declaration of Human Rights

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Article 25

1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services …

2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection

WHO Constitution - Declaration of Principles

The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.

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WHO constitution first signed 1948 Please take note of definition of

health

WHO Constitution - Declaration of Principles.

Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.

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How to make

governments

accountable?

WHO Constitution - Declaration of Principles.

Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger.

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How to assure global health security

ALMA ATA DECLARATION

The existing of gross inequality in the health status of the people particularly between developed and developing countries, as well as within countries (advantaged and poor segments), is politically, socially and economically unacceptable and is, therefore, of common concern to all countries.

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Almata PHC Declaration 1978 . How

close are we to The health for

all goal?

HEALTH SYSTEM CONCEPTUAL FRAMEWORK

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Leadership & governance

Health workforce

Financing

SYSTEM BUILDING BLOCKS

Health

Responsiveness

Financial protection

GOALS OF HEALTH SYSTEM

Coverage

Provider performance

Info

rmat

ion

Sup

port

Equity

Health technology

Ser

vice

Del

iver

y

Efficiency

Quality & Safety

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Irrespective of the Financial arrangement or the mode of care delivery

Equity

in Access to Health

Affordable cost

Quality of Care &Responsiveness

Population

Good Health

outcomes

These are the goals of national health delivery system

Definitions

The Public health delivery sector: defined as all health facilities owned, controlled and financed by various levels and agencies of government.

The private delivery sector is a residual category not under the direct control of the government

Within the private sector itself, additional classification: The private for profit and private not for profit, faced-based organization, traditional & non-traditional, etc.

Partnership: “a relationship based upon agreements, reflecting mutual responsibilities in furtherance of shared benefits.”1

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Status of private care delivery in the EMR region?

Has established role in infrastructure development, pharmaceutical and non clinical services.

Role in care delivery reached sky rocketing rates in recent past (more 70% of ambulatory care in some EMR countries).

Some of the reasons include poorly funded and managed public delivery systems providing poor quality care, population growth and marketing practices … etc

Most of the delivery modalities are unregulated individual vendors (including dual practice) and small inpatients faculties with limited capacity.

PPP may offer an opportunity and a leverage to streamline, regulate and positively engages Private Sector.

While performance of each sector depends on context & varies case by case yet: Public vs. Private comparison

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Provider Public Private

Advantage • Improvement in overall health of population drives growth and expansion strategy

• Potential for economy of scale to be realized both within a unit as generally facilities are large and across units due to extensive network

• More equitable in outlook

• Efficiency in management and operations with a thrust towards employing technology and latest best practices

• Increased access in areas of operation and availability of round the clock service

• Increased flexibility and responsiveness

Areas of concern

• Bureaucratic management hampers the system from realizing complete potential

• Inflexibility and Sluggish in taking corrective decisions/ measures

• Customer satisfaction and quality reception is low (issues in responsiveness)

• Financial sustainability without government support restricts expansion into all regions

• Quality of service can suffer in areas of low competition and lack of regulation

• High costs exclude large sections of the poor population

Key types of public private partnerships and collaboration in health sector

Contracting out: (activities

supported from Public funds)

• Service delivery contracts

• Management contracts

• Construction, maintenance, &

equipment contracts

• Hybrid contracts (e.g., large IT

infrastructure or service)

• Leases of facilities/assets

Concessions( activities on

new inputs from private partner)- Government guarantees/other

fiscal incentives (loans)

- Other Government incentives Land prices , taxes, amenities

• Private Financing Initiatives

• Other types, typically without

government guarantees, i.e.- Divestiture/privatization

- Free entry

- Other (e.g. provisions for health saving accounts)

Sample benefits:

• Efficiency

• Quality

• Cost- and risk-sharing

• Improve access

Prerequisites for PPP to aligned with interests & goals of health/social sectors

Adherence to Legal and regulatory frameworks

Transparency and Accountability

Partnership built on well founded Public policies (no policy without a policy dialogue)

Commitment to the notion of “Public Goods“

Mutual Understanding of terms & obligations

Sharing of Resources, risks and benefits

Respond to Consumers and Community needs & expectations

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Due to understandable differences in interests, goals and approaches to work, the results from PPP are not always rosy:

“In 2008, the Ontario Auditor General concluded that the

Ontario government could have saved $50 million in the

Brampton Civic Hospital P3 project if a public

procurement process had been chosen. The Auditor

General called for the costs and benefits of all feasible

procurement alternatives to be evaluated before entering

into a P3, and value-for-money assessments should

have relevant and clear criteria.” brief on PPP by British Columbia Government

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Health care delivery, The Market & Health Financing:

Health is a commodity whose value could not be easily monetized (estimated in monetary terms) or traded.

Health care is an imperfect field for market forces or mechanisms to work. “i.e asymmetric information exist between consumer & provider” “market failure”

Occurrence of liability “ill health” is unpredictable and when it occurs is unevenly distributed.

A wide based (universal) system for pooling risks and resources is needed for attainment of socially & ethically acceptable health and financial outcomes.

Pre-paid systems of financing are necessary for equitable access while out of pocket payments at point of service delivery lead to unacceptable consequences.

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Health policies should target reducing out-of-pocket expenditure

Push some households into poverty

Reduce expenditures on other basic needs

May cause households

to forgo seeking health care and suffer illness

Risk of financial

catastrophe

Out-of-pocket health

expenditure

Each year Millions suffer financial ruin when they use health services are the world

Due to absence or inadequacy of social health protection systems:

Globally around 150 million suffer severe financial hardship each year.

100 million are pushed into poverty because they must pay out-of-pocket at the time they receive health care.

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Risk of severe financial hardship and impoverishment drops substantially with out-of-pocket spending less than 20% of total cost of care

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

<10% 10-20% 20-30% 30-40% 40-50% 50-60% 60-70% 70%<

Financial CatastropheImpoverished

Share of out-of-pocket spending on health care

Source: WHO, Health Financing Policy unit database, unpublished

19

020

40

60

80

10

0

AFG

PAK

YEM

DJI

SDN

EGY

SYR

IRQ

MAR

JOR

TUN

IRN

LBN

LBY

OMN

SAU

BHR

KWT

ARE

QAT

EMR Share of out-of-pocket expenditure (%) in – 2010

Per capita total healthexpenditure (US$) – 2010

Source: W

HO

NH

A W

ebsite

0 200

400

600

800

1000

1200

1400

PAL

SudanSuda

n

HealthCare Financing Reform & Universal Health Coverage

A World Health Assembly Resolution in 2005 urged countries to develop their health financing systems to: Ensure all people have access to needed services without

the risk of financial hardship linked to paying for care. Aspiration to attain UHC was in WHO's constitutions of 1948; in

the Alma-Ata declaration of 1978

The way forward is in adopting policies based on population right for health, equity in health through committment to universal coverage and health care delivery based on primary health care

Thank you

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Chart to be used

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