P UBLIC P RIVATE P ARTNERSHIP IN H EALTH C ARE IN I NDIA Presenter: Dr. Reshma Moderator: Dr. Subodh...
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Transcript of P UBLIC P RIVATE P ARTNERSHIP IN H EALTH C ARE IN I NDIA Presenter: Dr. Reshma Moderator: Dr. Subodh...
PUBLIC PRIVATE PARTNERSHIP IN HEALTH CARE IN
INDIA
Presenter:Dr. ReshmaModerator: Dr. Subodh S Gupta
FRAMEWORK
Concept of public private partnership
Need of public private partnership Objectives of PPP Principles of PPP Models of PPP Existing PPP in Health sector Challenges faced in
operationalization
CONCEPT OF PUBLIC PRIVATE PARTNERSHIP
“Public” would define Government or organizations functioning under State budgets, “Private” would be Profit/Non-profit/Voluntary sector and “Partnership” would mean a collaborative effort and reciprocal relationship between two parties
Public-Private Partnerships (PPP) are collaborative efforts, between private and public sectors, with identified partnership structures, shared objectives, and specified performance indicators for delivery of health services
NEED OF PUBLIC PRIVATE PARTNERSHIP
Source: National Health Accounts Report 2004-05 of MOHFW/GOI.(With Provisional Estimates from 2005-06 to 2008-09)
Source: Pearson M, Impact and Expenditure Review, Part II Policy issues. DFID, 2002
NEED OF PUBLIC PRIVATE PARTNERSHIP
OBJECTIVES OF PUBLIC PRIVATE PARTNERSHIPS
Improving quality, accessibility, availability, acceptability and efficiency
Exchange of skills and expertise between the public and private sector
Mobilization of additional resources. Strengthening existing health system Widening the range of services and number
of services providers. Universal coverage and equity for primary
health care
PRINCIPLES OF PPP
Set up common goals and objectives Joint decision-making process Relative equality between partners Accountability and responsibility set out for each
partner Understanding the strengths and weakness of the
partners among themselves A high level of trust and confidence Benefits to both the stakeholders
PRINCIPLES OF PPP
Monitoring and evaluation: (i) by government departments authorized to do so, based on a standardized scale (ii) by independent agencies/regulators based on a
standardized scale(iii) by department or independent agencies,
based on the simple criteria of pass and fail(iv) by department or independent agencies,
based on the feedback received from the beneficiaries.
SELECTION OF SERVICE PROVIDERS IN PPP
Competitive Bidding
Competitive Negotiation
Swiss Challenge Approach
PUBLIC-PRIVATE-PARTNERSHIP MODELS
Franchising Contracting out Contracting-in Social marketing Joint ventures Voucher schemes Involving professional associations Build, operate and transfer Running mobile health units Community based health insurance
FRANCHISING
Franchise is a business model where the franchiser grants exclusive rights to franchisees to conduct business in a prescribed manner over a specified period
The franchisees contribute resources of their own to set up a clinic and pay membership to franchiser
SOCIAL MARKETING
Application of marketing techniques to achieve a social objective.
Associated with expanding access to contraceptives and medicine
The trend is to increase the available products, including oral rehydration solution, IFA tablets and other health products to make marketing more self-sustaining.
Example: Janani in Bihar Social marketing and social franchise program in
Bihar It combines social marketing with a clinic-
based service delivery program and a franchisee program through which doctors in rural areas provide low-cost services.
Family planning and comprehensive abortion care through Surya Clinics.
Titli centres sells condoms, pills and pregnancy test kit
Supplies contraceptives to both rural and urban pharmacies and shops.
FRANCHISING AND SOCIAL MARKETING
CONTRACTING OUT
Contracting out refers to situation in which private providers receive a budget to provide services and manage a government health unit.
Identify those government health clinics that need to be contracted out
Vacancies for a long period, high absenteeism, and consistent low performance on all RCH indicators could be the critical criteria
EXAMPLE OF CONTRACTING OUT
1. Govt. of Karnataka, Narayana Hrudalaya hospital in Bangalore and Indian Space Research Organization initiated project called ‘Karnataka Integrated Tele-medicine and Tele-health Project’ , which is an on-line health-care initiatives in Karnataka.
Tele-diagnosis and consultation in cardiac care and specialist care. Free diagnosis, medicines and treatment for BPL patients
EXAMPLE OF CONTRACTING OUT
2. SMS Hospital has contracted out the installation, operation and maintenance of CT-scan and MRI services to a private agency
Free services to 20% of the patients belonging to the poor socio-economic categories
CONTRACTING IN
Hiring of one or more agencies or individuals to provide services.
Example : Hiring of medical specialists for certain days of the week in PHC or CHC.
JOINT VENTURE COMPANIES
Joint venture companies are companies launched with equity participation of government and private sector.
Joint venture companies, in most cases have not succeeded due to lack of understanding and trust between partners
JOINT VENTURE COMPANIES
Example: The Rajiv Gandhi Super-specialty Hospital in Raichur Karnataka is a joint venture of Govt. of Karnataka and Apollo hospitals Group, with financial support from OPEC (Organization of Petroleum Exporting Countries)
VOUCHER SYSTEM
A voucher is a document that can be exchanged for defined services as a token of payment
Package can be bought, used when required and ensures privacy for the client.
Example: Chiranjeevi Yojna in Gujarat
BUILD, OPERATE AND TRANSFER
BOT models are highly successful in infrastructure development sector
Financing of projects by government, subsidized land at prime locations
These models are useful to establish large hospitals and ensure quality services at reasonable rates to poor people
RUNNING MOBILE HEALTH UNITS
Vans go to identified central points on fixed days and provide primary health services to a cluster of villages.
Vehicle, medical equipments, medicine will be provided by govt. and primary health care services will be provided by NGOs
4 Mobile medical unit for Gadchiroli, 3 each for Gondia and Nandurbar and one each for remaining 30 districts in the state.
Bihar adopted the scheme under the name “Arogya Rath” & in Madhya Pradesh under the name “Deen Dayal Chalit Aspatal Yojana”
COMMUNITY BASED HEALTH INSURANCE
Government pays health insurance premium for families below poverty line. These families in turn are insured against expenses on health and hospitalization, up to a certain amount.
Community members pay a minimum insurance premium per month and get insured against certain level of health expenditure
Community based schemes ensure that local needs and expectations of people are met
COMMUNITY BASED HEALTH INSURANCE
Example: Rashtriya Swasthya Bima Yojna (RSBY) Provide protection to BPL households Beneficiaries are entitled to get up to Rs.
30,000/- per year Beneficiaries need to pay only Rs. 30/- as
registration fee while Central and State Government pays premium to the insurer selected by State Government on basis of a competitive bidding.
COMMUNITY BASED HEALTH INSURANCE
Example: Karuna Trust in collaboration
with National Health Insurance Company and Government of Karnataka
Improve access and utilization of health services
INVOLVING PROFESSIONAL ASSOCIATIONS
Professional associations such as Indian Medical Association, Gynaecologists federation, nurses associations
Technical skills and expertise to provide advice on matters such as setting standard protocols, quality assurance systems and accreditation
Extended help in launching new programmes such as Vande Mataram Scheme
EXISTING PPP SCENARIO IN INDIA
• Partnership between the government and the profit sector
• Partnership between the government and the non profit sector
PARTNERSHIP BETWEEN THE GOVERNMENT AND THE PROFIT SECTOR
Government of Andhra Pradesh has initiated Arogya Raksha Scheme in collaboration with New India Assurance Company and with private clinics.
It is an insurance scheme fully funded by government.
It provides hospitalization benefits and personal accident benefits to citizens below the poverty line
The government paid an insurance premium of Rs. 75 per family to insurance company
Public/private DOTS model established on pilot basis in Hyderabad at Mahavir Trust Hospital
Mahavir Trust Hospital acts as a coordinator and intermediary between govt. and private medical practitioners
PMPs refer TB suspected patient to hospital Govt. benefit as DOTS medicine are not
wasted Mahavir Trust Hospital also benefited as
their service cure patient
PARTNERSHIP BETWEEN THE GOVERNMENT AND THE NON PROFIT SECTOR
CASE STUDIES: CHIRANJEEVI YOJNA SCHEME
Launched in Gujarat 2005 Aim: Improve access of poor families (BPL) to institutional delivery Form of partnership: Voucher scheme
to involve private providers in delivering maternity care
Reasons for contracting: High maternal mortality, low institutional delivery, involving large groups of private practitioners
Financing: NRHM and state budget
CASE STUDIES: CHIRANJEEVI YOJNA SCHEME CONT..
Implementation problems:• Inadequate awareness among private providers about the scheme benefits• Shortage of specialists• Uniform service package impedes handling of high-risk cases• Monitoring quality of Care Challenges: • With no system of cross checking BPL, the scheme now runs the
risk of processing bogus and fraudulent claims.• According to facility survey conducted under RCH II, at least two
of the districts do not have essential obstetric care services. • None of the private providers were aware of the fact that one
pre-delivery visit and an investigation is part of the Chiranjeevi package.
CASE STUDIES: MOTHER NGO SCHEME
Mother nongovernmental organization scheme was initiated as a centrally sponsored scheme within RCH I.
Under RCH II, the scheme was decentralized with greater involvement of states in selection and monitoring.
Goal: Provision of RCH care to underserved regions.
Form of partnership: Contracting out to nongovernmental organizations to work in underserved areas
CASE STUDIES: MOTHER NGO SCHEME
Reasons for contracting: Limited capacity of government to deal with smaller NGOs, increasing the capacity of these organizations to expand RCH services in the community
Funding: Government of India under NRHM
Target group: Women of reproductive age
CASE STUDIES: MOTHER NGO SCHEME
o Implementation problems: • Capacity of stakeholders a major constraint• Procedural delay in Selection and
disbursement of funds• Insufficient credibility and trust among
stakeholders• Inadequate monitoring Implementation of mother NGO scheme is
based on national guidelines, with no consideration of local capacity
CASE STUDIES: ANDHRA PRADESH URBAN HEALTH CENTRE SCHEME
Government of Andhra Pradesh initiated the scheme in 2000
Goal: Provide basic primary health care and family welfare services to urban poor living in slums
Form of partnership: Contracting out urban health centres to nongovernmental organizations
Reasons for contracting: Expanding primary health care services in urban areas through NGO Financing: Initially funded by Indian Population Programme VIII and then taken up by the State
CASE STUDIES: ANDHRA PRADESH URBAN HEALTH CENTRE SCHEME
CONT.. Implementation problems: • No incentive for NGOs to participate• Inadequate incentive for urban health centre
staffs• Delay in disbursement of funds• Urban health centres not equipped to handle changing scenario
CHALLENGES FACED IN OPERATIONALIZATION
True partnerships in sense of equality amongst partners, mutual commitment to goals, shared decision making and risk taking are rare.
Absence of representation of the beneficiary in the process
Lack of effective governance mechanisms for accountability
Non transparent mechanisms Lack of Institutional Capacity to design,
contract, monitor PPPs Payment Delay Local political interference
HLEG RECOMMENDATION TO ENSURE SUCCESSFUL PPP
Adequately synchronize the public and private sectors by plugging existing gaps in health systems policy documents
Enable government functionaries to structure, regulate and monitor PPPs
Adherence of PPPs to national health programme protocols
REFERENCES
Report of the PPP sub-group on social sector. Government of India. Planning Commission 2004. Accessed at URL: http://www.planningcommission.nic.in Draft report on recommendation of task force on public private partnership for the 11th plan. Accessed at URL: http://www.planningcommission.nic.in Public Private Partnership in health sector. Uttarakhand – A success story. Edited by- Sumit
Barua.Uttarakhand PPP cell. Government of Uttarakhand, Deaprtment of Planning. Published by: Government of India - Department of Economic Affairs, Ministry of Finance in collaboration with Asian Development Bank Institute
WHO. Public–Private Partnerships: Managing contracting arrangements to strengthen the Reproductive and Child Health Programme in India. Lessons and implications from three case studies. Ahmedabad: WHO; 2007
High Level Expert Group Report on Universal Health Coverage for India. New Delhi: Planning Commission of India; 2011
Health Finance Indicators. National Health Profile 2010. Accessed at URL: http://www.cbhidghs.nic.in Care for health market innovation. Janani 1998. Available from:
http://healthmarketinnovations.org/program/janani The Indian express. Chiranjeevi scheme failed to deliver: CAG report 2011. Available from:
http://www.indianexpress.com/news/chiranjeevi-scheme-failed-to-deliver-cag-report/769645/
NRHM. Mobile medical unit. Operational Guidelines for NGO. National Rural Health Mission, State Health Society, Mumbai. Available from: nrhm/guidemmu.pdf
Rashtriya Swasthya Bima Yojana. Health and Family Welfare Department 2012. Available from: http://rsbygujarat.org/about_rsby.html