Public-Private Partnerships Public-Private Partnerships for Health Service Delivery in for Health Service Delivery in

Africa:Africa:

ThreeThree Myths to DestroyMyths to Destroy&&

We Can’t Continue We Can’t Continue Business as UsualBusiness as Usual

Tonia MarekTonia MarekLead Public Health Specialist, The World Lead Public Health Specialist, The World

BankBank

Cambridge, March 2006Cambridge, March 2006

The three mythsThe three myths

• Health is mainly financed by the Health is mainly financed by the public sectorpublic sector

Who finances health ?Who finances health ?

Proportion of health expenditures provided by the public and private sectors,

by countries' income level

0 20 40 60 80 100

Low income

Middle income

High income

% o

f to

tal

GD

P

exp

en

dit

ure

s

Public

Private

The three mythsThe three myths

• Health is mainly financed by the public Health is mainly financed by the public sectorsector

• The private sector is for the rich and the The private sector is for the rich and the public sector is for the poorpublic sector is for the poor

• The private sector is not very developed in The private sector is not very developed in AfricaAfrica

Who is the private sector Who is the private sector in Africa ?in Africa ?

• Formal private sector:Formal private sector:– Private for profit clinics, pharmacies, Private for profit clinics, pharmacies,

doctorsdoctors– NGOsNGOs

• Informal private sector:Informal private sector:– Informal drug vendorsInformal drug vendors– Traditional healersTraditional healers– Moon lighting workersMoon lighting workers

Existence of a large Existence of a large private sectorprivate sector

Ex. Tanzania (2000)Ex. Tanzania (2000)

PublicPublic PrivatePrivateDistrict hospitalsDistrict hospitals 81%81% 19%19%Specialized clinicsSpecialized clinics 74%74% 26%26%DispensariesDispensaries 68%68% 332%2%X ray unitsX ray units 30%30% 70%70%LaboratoriesLaboratories 10%10% 90%90%Other hosp.(not regional)Other hosp.(not regional) 7%7% 93%93%

Existence of a large Existence of a large private sectorprivate sector

ContinentContinent MDs working inMDs working inthe private the private

sectorsector------------------------------------------------------------------------------------------------------------------ASIAASIA (6 countries)(6 countries) 60%60%SUB-SAHARAN AFRICASUB-SAHARAN AFRICA(8 countries)(8 countries) 46%46%LATIN AMERICA & CARIBLATIN AMERICA & CARIB.(5 c.).(5 c.) 46%46%NORTH AFRICA & MIDDLE E. NORTH AFRICA & MIDDLE E. (7 c.)(7 c.) 35%35%

Existence of a large Existence of a large private sectorprivate sector

The private sector also delivers The private sector also delivers prevention servicesprevention services

Ex. Nouakchott, Mauritania:Ex. Nouakchott, Mauritania:

PublicPublic PrivatePrivateInfant consultationsInfant consultations 75%75% 25%25%Prenatal visitsPrenatal visits 75%75% 25%25%DeliveriesDeliveries 93%93% 9%9%

People are voting with People are voting with their feet....their feet....

To what extent is the To what extent is the private sector used private sector used by the poorby the poor when a child is sick ? when a child is sick ?

by the 20% poorestby the 20% poorest by the 20% by the 20%

richestrichest Malawi, 2000Malawi, 2000 74%74% 71%71%Mali, 1996Mali, 1996 69%69% 58%58%Niger, 1998Niger, 1998 59%59% 28%28%Cameroon, 1998Cameroon, 1998 44%44% 52%52%Benin, 2001Benin, 2001 41%41% 58%58%Guinea, 1999Guinea, 1999 38%38% 55%55%

What type of private What type of private sector people go to ?sector people go to ?

Malawi, 2000Malawi, 2000of those who went to the private sector of those who went to the private sector

when their child was sickwhen their child was sick

among the 20% among the 20% among the 20% among the 20% poorestpoorest richest richest

73%73% 61%61% went to shopswent to shops

15%15% 6% 6% went to traditional healerswent to traditional healers

11%11% 27%27% went to a private facilitywent to a private facility

Why do people choose not Why do people choose not to go to the to go to the publicpublic

sector ?sector ?

• Poor perceived quality of carePoor perceived quality of care

Quality of care in public and Quality of care in public and private sectorsprivate sectors

South Africa, study on clinicsSouth Africa, study on clinics

PublicPublicPrivatePrivate

-STIs diagnosed using the correct-STIs diagnosed using the correct

syndromic approachsyndromic approach 68%68% 85%85%

-Correct treatment of STIs-Correct treatment of STIs 80%80% 97%97%

Why do people choose not Why do people choose not to go to the to go to the publicpublic

sector ?sector ?

• Poor perceived quality of carePoor perceived quality of care

• Uneven availability of staff and drugsUneven availability of staff and drugs

Operating hours per day in public Operating hours per day in public and private facilitiesand private facilities

CambodiaCambodia

PublicPublicPrivatePrivate

N=27N=27 N=31N=31

-Average weekday hours-Average weekday hours 6.66.6 11.311.3

-Average weekend hours-Average weekend hours 0.00.0 11.711.7

Why do people choose not Why do people choose not to go to the to go to the publicpublic

sector ?sector ?

• Poor perceived quality of care Poor perceived quality of care • Uneven availability of staff and drugsUneven availability of staff and drugs

• Not well received (especially if poor)Not well received (especially if poor)

0 10 20 30 40 50

Waiting time

Doctor’s manner

Doctor’s skills

Nurse’s manner

Nurse’s skills

Explanation of care

Overall visit

Percent Satisfied or Very Satisfied

Public Private

Client satisfactionPrivate Sector Outperforms Public Sector

(survey in India, Andra Pradesh, 2000)

Andhra Pradesh (2000)

Why do people choose not Why do people choose not to go to the to go to the publicpublic

sector ?sector ?

• Poor perceived quality of care Poor perceived quality of care • Uneven availability of staff and drugsUneven availability of staff and drugs

• Not well received (especially if poor)Not well received (especially if poor)

• Parallel paymentsParallel payments

Parallel paymentsParallel payments

Guinea’s 2 main public hospitalsGuinea’s 2 main public hospitals(MOH, GTZ study, 2003)(MOH, GTZ study, 2003)

OfficialOfficial AverageAverage

tarifftariff paidpaid

-External consultation-External consultation 1,700 FG1,700 FG 6,500 FG 6,500 FG

-Hospitalized patient-Hospitalized patient 22,000 FG22,000 FG 225,000 FG225,000 FG

The private sector faces the same The private sector faces the same problems as the public sectorproblems as the public sector

% failure of content of chloroquine tablets in 7 african % failure of content of chloroquine tablets in 7 african countries, countries,

% of % of samples (WHO, 2003)samples (WHO, 2003)

District hospital:District hospital: 70%70%Vendor/shop:Vendor/shop: 50%50%Health center:Health center: 46%46%Teaching hospital:Teaching hospital: 44%44%Pharmacy:Pharmacy: 43%43%

An example of solution: Kenya’s CFW Shops franchise An example of solution: Kenya’s CFW Shops franchise operates over 40 essential drug outletsoperates over 40 essential drug outlets

The private sector faces the The private sector faces the same problems as the public same problems as the public

sectorsector

Quality of care: Kampala, Uganda Quality of care: Kampala, Uganda 164 164 privateprivate health facilities health facilities

surveyedsurveyed

81% of simple malaria cases 81% of simple malaria cases 64% of pneumonia cases64% of pneumonia cases

not treated correctly by the not treated correctly by the facilities which treated those casesfacilities which treated those cases

The private sector faces the The private sector faces the same problems as the public same problems as the public

sectorsector

Two examples of solution: training and franchise Two examples of solution: training and franchise

Kenya’s Medical Research instituteKenya’s Medical Research institute training of shop keepers in training of shop keepers in 2-4 days workshops>> went from 7% to 65% of children 2-4 days workshops>> went from 7% to 65% of children given the right dose of anti-malarialsgiven the right dose of anti-malarials

Top-Reseau MadagascarTop-Reseau Madagascar is a reproductive health franchise is a reproductive health franchise with 17 private clinics and several private MDs in the with 17 private clinics and several private MDs in the network to address sexually transmitted infections in network to address sexually transmitted infections in particular (since 2001)>> went from 50 to 90% of particular (since 2001)>> went from 50 to 90% of Top Top ReseauReseau doctors who accurately treat STI symptoms doctors who accurately treat STI symptoms

Types of PPPTypes of PPP

•ContractingContracting

•FranchisingFranchising

•ConcessionsConcessions

•LeasingLeasing

•VouchersVouchers

0102030405060708090

1stQtr

2ndQtr

3rdQtr

4thQtr

EastWestNorth

ContractingContracting

• Of Governement with NGOs, local Of Governement with NGOs, local associations, Private for Profit associations, Private for Profit sectorsector

• Of Health Mutuals or Health Of Health Mutuals or Health Insurances with public or private Insurances with public or private service deliverersservice deliverers

Contracting Experience in Contracting Experience in HyderabadHyderabad• Mahavir Trust began TB DOTS in 1995 Mahavir Trust began TB DOTS in 1995

with outreach to private providerswith outreach to private providers

• Expanded in 1998 to 500,000 population Expanded in 1998 to 500,000 population not covered by public sectornot covered by public sector

• MOU – MOH provides drugs, lab supplies, MOU – MOH provides drugs, lab supplies, training, Mahavir provides staff, training, Mahavir provides staff, overhead overhead

• Compared to Osmaina, similar sized area Compared to Osmaina, similar sized area run by public sector run by public sector

• Independent assessment of records & Independent assessment of records & costscosts

Results in Hyderabad, Results in Hyderabad, IndiaIndia

ParameterParameter NGONGO MOHMOH

No.of TB cases detected No.of TB cases detected per year per year

563563 466466

Treatment success rate Treatment success rate (%) (%)

94%94% 80%80%

Total cost per Total cost per successfullysuccessfully treated patient ($US)treated patient ($US)

$118$118 $138$138

Total cost per patient Total cost per patient treated treated

$88$88 $98$98

PPP pitfalls to avoid: PPP pitfalls to avoid: inefficiency of public-private inefficiency of public-private

alliances alliances

Contracts with NGOs Contracts with NGOs (ex. of the Dominican Republic):(ex. of the Dominican Republic):

- sole source is the norm, no competitionsole source is the norm, no competition- most didn’t describe the services which the NGO most didn’t describe the services which the NGO

must provide and none had specific objectivesmust provide and none had specific objectives- none includes an incentive or disincentive system;none includes an incentive or disincentive system;- 84% of contracts don’t have a clear definition of the 84% of contracts don’t have a clear definition of the

costscosts- 70% don’t establish who will monitor the contract70% don’t establish who will monitor the contract- more than 30% don’t mention the contract’s durationmore than 30% don’t mention the contract’s duration

Towards Better PPPTowards Better PPP

• The Legal FrameworkThe Legal Framework

• The NormsThe Norms

• The ProceduresThe Procedures

• The InstitutionsThe Institutions

The Legal Framework for The Legal Framework for ContractingContracting

• A General Health LawA General Health Law : :-- establishes the MOH as the rector agencyestablishes the MOH as the rector agency- Agreements will be signed with public entities Agreements will be signed with public entities

who receive public funds who receive public funds - requires accreditation for all, public as well as requires accreditation for all, public as well as

private, health service providers private, health service providers

• A Social Security LawA Social Security Law : : - e- establishes stablishes the necessity for the public sector to the necessity for the public sector to

contract and buy services from the private sectorcontract and buy services from the private sector

The Legal Framework for The Legal Framework for ContractingContracting

A Social Security LawA Social Security Law : : Sets a pre-paid modality where services Sets a pre-paid modality where services

will be bought by the State which will will be bought by the State which will refer to the private sector a certain refer to the private sector a certain quantity of patients who belong to the quantity of patients who belong to the Subsidized regimen, so that the patients Subsidized regimen, so that the patients receive services without additional receive services without additional costs. costs.

This can end an era of subsidies to the This can end an era of subsidies to the private sector without asking for results. private sector without asking for results.

The Norms for ContractingThe Norms for Contracting

• Presidential Decree allows the Presidential Decree allows the provincial health officer to contract provincial health officer to contract servicesservices

• Norms of Accreditation for NGOs Norms of Accreditation for NGOs which provide health services which provide health services

The Procedures for The Procedures for ContractingContracting

• Pilot operations and other Pilot operations and other operations:operations:

Manuals, types of contracts, of Manuals, types of contracts, of payment mechanisms, of payment mechanisms, of incentives….incentives….

The Institutions which The Institutions which contractcontract

• Contracting units set up in the Social Contracting units set up in the Social Security Institute and in the MOHSecurity Institute and in the MOH

• Provincial health officers to monitor Provincial health officers to monitor the implementation of pilot the implementation of pilot contractingcontracting

Types of PPP Types of PPP

•ContractingContracting

•FranchisingFranchising

•ConcessionsConcessions

•LeasingLeasing

0102030405060708090

1stQtr

2ndQtr

3rdQtr

4thQtr

EastWestNorth

Franchising Franchising (some examples)(some examples)

• of Voluntary Counseling and Testing of Voluntary Counseling and Testing (S. Africa’s network of nurses)(S. Africa’s network of nurses)

• of reproductive health servicesof reproductive health services (Pakistan Greenstar network of clinics; (Pakistan Greenstar network of clinics; Kenya’s KIMET network of service Kenya’s KIMET network of service providers since 1996)providers since 1996)

• of drugs, condoms of drugs, condoms (Kenya’s CFW, India’s (Kenya’s CFW, India’s Janani franchise with over 44,000 shops)Janani franchise with over 44,000 shops)

• of Impregnated Mosquito Nets of Impregnated Mosquito Nets (Ghana)(Ghana)

Types of PPP Types of PPP

•ContractingContracting

•FranchisingFranchising

•ConcessionsConcessions

•LeasingLeasing

0

10

2030

40

50

60

7080

90

1stQtr

2ndQtr

3rdQtr

4thQtr

EastWestNorth

The myth: the private sector is The myth: the private sector is not very developed in Africanot very developed in Africa

• There’s a large private sector in AfricaThere’s a large private sector in Africa

• People do use the private sector, especially People do use the private sector, especially the poorthe poor

• The private sector has similar problems of The private sector has similar problems of quality as the public sectorquality as the public sector

• There are examples of successfull PPP and There are examples of successfull PPP and pitfalls to avoid pitfalls to avoid

We can’t continue business as We can’t continue business as usualusual

THE WORLD BANK & THE PRIVATE SECTOR THE WORLD BANK & THE PRIVATE SECTOR REVIEW OF 40 PROJECTSREVIEW OF 40 PROJECTS

• 1994-98: 1994-98: 23% of projects with high PPP23% of projects with high PPP

1999-2003: 1999-2003: 57% of projects with high PPP57% of projects with high PPP

• 33% of projects had no mention of private 33% of projects had no mention of private sectorsector

• Successes: Successes: - NGOs/Communities in nutrition- NGOs/Communities in nutrition

- Communities in reproductive health- Communities in reproductive health

We can’t continue business as We can’t continue business as usualusual

Adapting the Adapting the World BankWorld Bank for PPP for PPP

• Conduct systematic assessment of private Conduct systematic assessment of private sector in countriessector in countries

• Seek support from private sector expertise Seek support from private sector expertise to help Bank’s staffto help Bank’s staff

• Need for more Bank’s management Need for more Bank’s management commitment of the institution on PPPcommitment of the institution on PPP

• Establish direct channels with private sectorEstablish direct channels with private sector

• Set up a PPP fund to complement operationsSet up a PPP fund to complement operations

• Donor coordination to limit # of proceduresDonor coordination to limit # of procedures

We can’t continue business as We can’t continue business as usual:usual:

Adapting the Adapting the public sectorpublic sector for for PPPPPP

• Strengthen the Role of the State to carry Strengthen the Role of the State to carry out its essential functions:out its essential functions: Policy settingPolicy setting Resource generationResource generation Health system financingHealth system financing RegulationRegulation Quality controlQuality control MonitoringMonitoring Information disseminationInformation dissemination Strategic purchasingStrategic purchasing

We can’t continue business as We can’t continue business as usual:usual:

Adapting the Adapting the public sectorpublic sector for for PPPPPP

• Capacity enhancementCapacity enhancement of of Government, decentralized bodies, Government, decentralized bodies, for contracting through training, for contracting through training, lessons learnt...lessons learnt...

We can’t continue business as We can’t continue business as usual: usual:

adapting the adapting the private sectorprivate sector for for PPPPPP

• Get organized to ease dialogueGet organized to ease dialogue

• Gain a place at the policy tableGain a place at the policy table

We can’t continue business as usual:We can’t continue business as usual:5 points to keep in mind to promote 5 points to keep in mind to promote

PPPPPP

1.1.Consider the whole health Consider the whole health systemsystem, , not just the public sectornot just the public sector (quality of care, financing...)(quality of care, financing...)

2.2.Ensure that the organization Ensure that the organization adaptsadapts– public sector to have PPP focal persons, public sector to have PPP focal persons,

PPP procedures PPP procedures – private sector to get organizedprivate sector to get organized

We can’t continue business as We can’t continue business as usual:usual:

5 points to keep in mind to promote 5 points to keep in mind to promote PPPPPP

3.3. Expand ContractingExpand Contracting: Given the results so : Given the results so far, contracting may make a real difference far, contracting may make a real difference in achieving MDGs. in achieving MDGs.

4.4. EvaluateEvaluate: Evidence is good but not great. : Evidence is good but not great. Debate on contracting should be decided by Debate on contracting should be decided by evidence evidence

5.5. Apply Lessons Learnt on ProcessApply Lessons Learnt on Process (ex. the (ex. the art of contracting:art of contracting:

- Autonomy Autonomy for managers is important for managers is important

- Scale matters: Scale matters: large scale contracts likely save money, large scale contracts likely save money, facilitate management, and allow better M&Ev. )facilitate management, and allow better M&Ev. )

Resources on PPPResources on PPP

www.msh.org www.msh.org (publications)(publications)www.opus.co.tt/ihsdwww.opus.co.tt/ihsd

www.advanceafrica.org www.advanceafrica.org (best (best practices)practices)

www.idd.bham.ac.uk/service-providers/www.idd.bham.ac.uk/service-providers/stage2.htm stage2.htm (case studies) (case studies)

www.ihsd.org www.ihsd.org (purchasing)(purchasing)www.worldbank.org/hsd www.worldbank.org/hsd (health systems)(health systems)

www.nigi.org www.nigi.org (contracting)(contracting)www.cmsproject.com www.cmsproject.com (provider network)(provider network)

Resources on PPPResources on PPPTrainingTraining

www.hsph.harvard.edu/ihsg/ihsg.htmlwww.hsph.harvard.edu/ihsg/ihsg.html

www.worldbank.org/wbi/healthflagshipwww.worldbank.org/wbi/healthflagship

www.ncppp.org/training/ncppp.htmlwww.ncppp.org/training/ncppp.html