Public Private Partnership in Health Care in India

PUBLIC PRIVATE PARTNERSHIP IN HEALTH CARE IN

INDIAPresenter: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 partiesPublic-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 OUT1. 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 INSURANCEExample: 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