upgrading hospital through ppps in eastern cape province in south africa: a case study iain menzies...
TRANSCRIPT
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Upgrading hospital through PPPs in Eastern Cape province in South Africa: A case study
Iain Menzies
The World Bank
St. Petersburg- May 23, 2008
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Overview
• Introduction• An Eastern Cape Health
Perspective• 5 Myths / Realities• Health PPP’s in Eastern Cape• Hospital Co-location Projects• Lessons Learned
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An Eastern Cape Health Perspective
• History
– Three administrations– Lack of infrastructural maintenance– Provincial inequity– Access to health services– Inadequate budget
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An Eastern Cape Health Perspective (Cont.)
• Service Delivery Model
– 92 Hospitals– 714 Clinics and Health Centers– 25 Districts– 3 Regions– 7 Programmes– 9 CSC’s
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Introduction
• Strategic Plan– PPP– Staff recruitment and retention
• PGDP
• 2010
• Department of Public Works
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5 Myths / Realities
• PPPs are just another form of privatization
• Private Sector is the winner, and the public the loser (services, costs/budget, inequities, institutional capacity, unsolicited bids, etc.)
• Employees of the affected institutions will lose their jobs
• Users of the services will no longer be able to afford them
• No opportunities for local communities to participate in the economic spin-offs
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Co-location PPP’s
The model :
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Structure of Co-location PPP
• Private Party upgrades & maintains facility and provides non-core services;
• Public sector serves public patients (doctors, nursing & pharmaceuticals)
• Private party serves private patients in dedicated wards
• Each party has own exclusive use areas (eg. Theatres)
• Shared facilities for joint use (eg. Admissions)
• Cross servicing for some services at agreed charge per use (eg. Maternity)
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What does Department need?
• Upgrade existing hospital facilities to modern specifications;
• Improved medical equipment;
• On-going maintenance to keep to above at high standard;
• Provision of certain non-core services;
• Transfer of skills
• All = IMPROVED HEALTH FACILITIES FOR ALL
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Non-core Services Required
• Estate maintenance.
• Ground and gardens.
• Cleaning.
• Patient catering.
• Security.
• Waste control.
• Pest control.
• Utilities management (rates and services).
• Life-cycle asset management.
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Human Resource Impact
• Only non-clinical posts are to be affected
• Department position = no retrenchments
• Unions informed and support PPP process
• Looking for innovative solutions from partner
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What does Department offer?
• Right to establish co-located private hospital facilities on premises
• Unitary payment:– Fixed component;– Variable component; and– Profit share to Department
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Humansdorp District Hospital
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Background
• Maintenance backlogs – competing needs
• Population growth – more beds needed
• Private patients traveling to P.E. for services
• Tourist destinations of Jeffreys’ Bay – increased seasonal demands
• Shortage of Medical professionals
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Goals
• Improve hospital services for public patients by:
– improving the condition and maintenance of buildings, grounds and equipment
– improving the supply of water, electricity, gases
– improving patient management and/or clinical care
– Improving the hospital and info. Management syst’s
• Provide private hospital services for private patients who are presently inconvenienced by having to go outside the district for care
• Improve PHC services for HIV/AIDS and TB prevention and care..
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Goals (Cont.)
Assumptions:
• No differentiation between public and private patients when it came to clinical care.
• No negative impact on public sector labour.
• the hospital budget will increase or be maintained at necessary levels
• revenue should be taken in kind where possible.
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Benefits to Stakeholder
• for departments – PPPs must be an accessible, relevant, viable and beneficial service delivery option
• for the users of services – PPPs must result in accessible, affordable and safe services that meet acceptable quality standards
• for society – PPPs must promote goals such as social equity, economic empowerment, efficient utilisation of scarce resources, and protection of the environment
• for private parties – PPPs must be sufficiently rewarding in relation to the investment required and the risks undertaken.
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Why PPP?
A Public Private Partnership (PPP) was seen as providing the opportunity to revitalise, &
upgrade the district hospital, generate revenue from the private sector via shared services and
create additional beds within the district.
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Procurement process
• Advertised in 1999 for Expressions of Interest ( 3 responses received)
• TA’s appointed with Equity funding
• Pre- regulation 16
• ECDOH project officer appointed in October 2002.
• Concession agreement signed in June 2003.
• Site handed – over July 2003
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Project outputs
• Rehabilitation/Upgrading of existing public sector facilities including all electrical and mechanical items, building and services and decorative finishes : – 60 to 80 beds. 20 Maternity(16), 20 surgical(16), 24 Medical(20) and 16 Paediatrics(8).
• Build two new theatres, one each for each of the parties who will be responsible for equipping and managing their own theatre
• upgrade and reconfigure the Casualty / Outpatients Department for the public sector
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Outputs specified
• Construction of a 33 bed private facility on the public sector property – incl. 3 High-care beds.
• The Department and Private Party will have exclusive use areas, comprising the male, female, paediatric and maternity wards for the public sector and a new 33-bed facility for the private sector:
• the Department will provide birthing facilities to Private Party patients (including ante-natal, delivery and, if required , nursery accommodation for the babies) as well as serve private patients in the paediatric ward;
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Obligations
• The parties will jointly manage the administration facilities and catering services for the benefit of both parties
• Private party will be responsible for the facilities management for the Concession Period, including all:
– maintenance & repairs, – security, – gardening, – cleaning & domestic and – waste removal;
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REHABILITATION, UPGRADING & CONSTRUCTION
• Central block
– Building of a second theatre.– New CSSD– Laboratory.– New radiology department.– New casualty/OPD section – New Private Pharmacy and Dispensary
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REHABILITATION, UPGRADING & CONSTRUCTION (Cont.)
• West wing (surgical and maternity wards).
– Upgrading and renovations.– Expanding maternity section with 8 beds.– Upgraded reception area.
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REHABILITATION, UPGRADING & CONSTRUCTION (Cont.)
• East wing (medical and paediatric wards)
– Upgrading and renovations– Renovations to kitchen
• Private ward (Isivivana hospital)
– Thirty bed private wing with a 3 bed high care unit.
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REHABILITATION, UPGRADING & CONSTRUCTION (Cont.)
Other areas
• New roads, parking areas and gas bank.
• Renovations and upgrading of different out buildings to accommodate a laundry sorting area, refuge area, workshop, medical waste holding area, general stores and ring road.
• New pharmacy and ARV clinic outside the PPP (ECDOH funds).
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Terms of Concession Agreement
• Period
– 20 yrs plus construction period
• Maintain for period and hand back
• Share in profits
• Agreement was signed on June 2003
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Lessons learned
• Project Management
– Responsibility for the project cannot be abdicated – Dedicated Project champion
– Dedicated Functional team with team leaders
– Must project manage the TA’s and assist/facilitate data collection
– Project Officer must have project management skills and advanced influencing/negotiation skills
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Lessons (Cont.)
• Project Management (Cont.)
– Project mix must be methodical and painstakingly precise
– Ensure that everyone in the room has the same understanding – repetition and reinforcement
– Functional teams must have detailed brief and progress must be followed up – must meet regularly
– Project definition must be clear
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Lessons learned (Cont.)
• Buy-in
– Must ensure political and top management buy-in
– Must mainstream PPP to ensure adequate funding to deal with pressures
– Must ensure that labor is brought on board at an appropriate time
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Lessons (Cont.)
• Communication– Regular communication on progress
– PPP’s driven from the Head Office SCM Units – set-up a PPP unit with strong financial and contract management competencies
– Local Project Manager / Hospital Manager
– JMC
– EMC
– Good relationships during negotiations and beyond
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Lessons (Cont.)
• Policy
– Non-core services vs clinical services
– Policy imperatives – District hospitals L1 services
– Procurement phase – feasibility processes
• Land
– Heritage
– Ownership