PUBLIC PRIVATE PARTNERSHIP IN HEALTH SECTOR: MODELS & THE

AGRA EXPERIENCE

Prof. Deoki NandanDirector

National Institute of Health & Family Welfare, New Delhi

Public Private Partnership in Health

Definition:Public-Private Partnership (PPP) is a collaborative effort, between private and public sector, with clearly identified partnership structures, shared objectives, and specified performance indicators for delivery of a set of health services (MOHFW,GOI)

Objectives of Public Private Partnership in Health

Improving access to essential services

Improving the quality of services available

Exchange of expertise

Mobilize additional resources for activities

Improve efficiency

Better Management of Health services

Increasing scope and scale of services

Increasing community ownership of programs.

Ensuring optimal utilization of govt. investment and infrastructure

The Benefits of PPP are

Economies of Scale

Utilising Existing Capacity

Create Synergy

Targeting the Poor

Flexibility in Action

Resource Mobilisation

Technical Upgradation

Better Services BETTER HEALTH

ECONOMIES OF SCALE

UTILISING EXISTING CAPACITY

CREATE SYNERGY

TARGETING THE POOR

FLEXIBILITY IN ACTION

RESOURCE MOBILISATION

TECHNICAL UPGRADATION

BETTER SERVICES

Models of Public Private Partnerships in Health

1. Social Franchising 2. Branded Clinics 3. Contracting 4. Social Marketing5. Build, Operate and

Transfer 6. Joint Venture 7. Voucher System 8. Donations from

individuals

9. Partnerships with Social Clubs and Groups (e.g. Rotary Club)

10. Involvement of Corporate sector

11. Partnership with Professional Associations

12. Capacity Building of Private Providers

13. Autonomous Institutions

14. Mobile Health Vans 15. Health Insurance

Social Franchising

“ A franchise is a contractual relationship between the

franchiser and franchisee in which the franchiser

offers or is obliged to maintain a continuing interest

in the business of the franchisee in such areas as

know-how and training; wherein the franchisee

operates under a common trade-name, format and/

or procedure owned and controlled by the franchiser

and in which the franchisee has or will make a

substantial capital investment in his business from

his own resources”

-International Franchise Association

The Merrygold Network (USAID, SIFPSA & HLFPPT), Uttar

Pradesh

Provides high quality MCH services at affordable prices.

Network comprises of seventy - 20-bed Merrygold Hospitals, 350 - Merrysilver clinics and 10,500 - Merrytarang Ayush partners.

The franchisees of this network are being provided training, marketing and quality assurance support

Challenges

• Controlling Quality of Services

• Positioning on Price/ Quality – Trade off between Social goals and Provider Satisfaction

• Understanding motivation of Clients for Accessing Services

Social Franchising - Criteria for Initiation

Revitalising present Government structure is slow

Resources required to expand public health infrastructure is enormous.

High demand but poor supply from government health institutions

Availability of vast network of private hospitals in places needed

When objective is to improve access to services on immediate basis.

Improve quality standards of private sector and provide high quality care at affordable prices

Branded Clinics

Chain of Clinics – Same Organisation

Cater to better-off clients – Market Segmentation

More Income More

Sustainable

Eg. Butterfly clinics, titli centres in Bihar,MP

Example With the support of States, an NGO Janani set

up a network of more than 21,000 Titli (butterfly) centres and more than 500 Surya (sun) clinics in Bihar, Jharkhand and Madhya Pradesh.

Surya clinics are referral clinics run by formally qualified, state-registered doctors in the towns.

Titli centres are situated in villages and run by RHPs who have been trained to provide family planning counselling and sell non-clinical contraceptives.

Branded Clinics – Criteria for initiation Need to expand services rapidly Need to provide high visibility to

services available Offer a package of services

selected for the purpose Provide high quality services at

comparatively affordable prices

Contracting – Contracting-in and Contracting-out

Legally enforceable Contract

- Defined Set of healthcare services

- Quantity of services

- Quality of services

- Duration of Service Provisioning

Public Private

Contracting out State Govts. Has contracted out few PHCs

in Karnataka, Arunachal Pradesh to by Karuna Trust, VHAI

Subcentres in Uttarakhand to NGOs

Contracting in Human resources by almost all states

under NRHM -Radiology, drug stores etc.eg. SMS Hospital, Jaipur -Diet, cleaning, laundry etc. in almost all states

Contracting Out & InExamples

Criteria for initiating Contracting-

out

Difficult to manage government health units in remote and inaccessible areas

Utilization of services and performance levels are consistently low due to non-availability of staff

Aim is to put government health facilities to optimum use

Increase responsiveness of government health facilities to local needs through community involvement

Criteria for initiating Contracting-in Improve efficiency levels of

services provided Make management of services

more effective Conserve scarce resources by

cutting costs Try out innovative approaches to

improve efficiency and effectiveness

Voucher System/ Demand Side Financing

A voucher is a document that can be exchanged for defined goods or services as a token of payment (tied-cash).

Eg: AGRA, Hardwar

Voucher System – Criteria for Initiation

Improve access to services and provide choice Where costs act as a major barrier to services Existing public healthcare service delivery points

do not have provision for all types of services Inadequate knowledge about the value of services

(e.g. importance of antenatal care) Need to generate demand for healthcare services Possible to do regular monitoring for ensuring

quality standards Training of providers and network with the people

to ensure proper use of vouchers is possible

Donations From Individuals

Donations from rich philanthropists institutions

Need for simple and transparent mechanisms to encourage donations

Partnerships with Social Clubs and Groups

Social Clubs like Rotary Lions’

They have been proven to be useful in: Popularising reformed healthcare service

delivery outlets In communication campaigns Management of camps on a large scale Providing additional resources and

technical expertise Advocacy efforts

Involving the Corporate Sector

Organised Corporate Sector through CII FICCI

E.g. Indo-Gulf Fertilisers’ Health Initiative and recent Health Conclave by CIIAdoption of Villages for providing primary health care services – TVS -in Karnataka

Partnerships with Professional Associations

Expert Pool• IAPSM, IPHA

• FOGSI – Vande Matram scheme

• IMA – Aao Gaon Chalein

• TNAI

• Pharmacists Associations

Protocols/ Quality Assurance/

Accreditation

Mobile Health Vans

Already implemented in inaccessible areas

Comprehensive Health Services Fixed Journey Plans Public Sector contribution Medical

Officers and Medicines Private Sector for Purchase and

Management of Vans These vans are useful in:

Provide access to services people living in inaccessible terrain

Make services available at central location to reduce travel time and costs of clients

Under NRHM many states have introduced this scheme

Health Insurance

CGHS – Tie up with private hospitals

RSBY – Empanelled private hospitals

ESIS - Panel of private hospitals &

empanelment of private doctors

Initiating Public Private Partnerships in Health

Prioritizing needs

Evaluating and analyzing the ground realities

Selecting the appropriate model

Piloting the model

Evaluating the pilot

Scaling up

Initiating PPP in Health - Vital Components: STRAIGHT

Identifying the SCOPE of partnership Identifying the appropriate TARGET

POPULATION Selecting the RIGHT PARTNERS and the

RIGHT MODEL of PPP Ensuring ACCOUNTABILITY of private

providers Ensure active INVOLVEMENT of the

government GENERATE SUPPORT of all the key

stakeholders through IEC, advocacy and rapport building

HIGHLIGHT ACHIEVEMENTS of the partnerships

Build TRUST of all the partners and clients

Initiating Vouchers scheme for MCH care for BPL in Agra

The task was to bring government health sector,

private health care providers,NGOs

work together on one platformand

Policy makers To accept PPP in health as an

implementable issue

Key policy makers were:

State Government

Health Department Bureaucracy-Principal Secy M&H

Senior technocrats at state HQ

Existing Rules were……..

It cannot be done!

Principal viewpoints against scheme were…

Government-Why should we give government money to private providers?Private providers are profiteers, so why link with them? It has not been done before so how can we do it now?

Health department Technocrats-We give services for free! why should they get money for it We will lose our constituency and control on public health

Private health care providers-Government is corrupt, we will not work with them

Key supporters were

NONE

Except the funding agency

How we progressed

Signals

We compiled a data bank on

• Existing health indicators in the district

• Comparative cost of treatment to patients in Govt. vs Private sector

• Percentages of un-served BPL patients in the state

• Comparative reach of private sector

• Increasing inclination of population towards private health care

Consultation and Formulation

Step-1

• Called on the key government representatives to share data

• Discussed successful models to remove doubts

• Discussed the pro poor spectrum of this scheme

• Shared experiences from the other states/developing countries

• Tried to convince that this is cost effective

Step-2

• Called a consultative meeting of all stakeholders at AgraThis included- Bureaucrats, Senior government officials,Nursing home Associations, IMA, Nursing council, Civil Society reps, Senior reform advocates and subject specialists

• Had discussions, did documentation, developed models and presented findings to government with a draft plan recommendation

Aggression

• Followed up with fostering pressure groups inside state bureaucracy. Also aggressively advocated with senior technocrats in health directorate

• Sent the proposal to Government for ratification

• Confronted objections through evidence in hand

Mechanism Proposed was…

SN MEDICAL COLLEGE AGRA WITH REPRESENTATION OF

GOVT,NGOs,NURSING HOMES ANDDISTRICT ADMINISTRATION AS VOUCHER MANAGER

NGOs AS DISTRIBUTORS AND MOBILIZING PARTY

SELECT 5-10 BED NURSING HOMES AS SERVICE PROVIDERS

Government said no to SNMC as voucher managersAnd proposed CMO in place to retain controlWe said OK

Government asked: at what cost NHs Will give servicesWe said cheap and not more than RGI figures

Government asked about NH accreditation criteriaWe said that we will develop

Government asked the spread of Pvt facilities in AgraWe said we will survey

WE REDEVELOPED THE MANAGEMENT STRUCTURE WITH CMO AS LEAD

WE SURVEYED AND MAPPED NHs in AGRA IN 3 MONTH

WE NEGOTIATED COSTS WITH NHs IN JOINT CONSULTATIONS AND REACHED THE BEST RATES IN INDIA IN 1 MONTH

WE DEVELOPED ACCREDITATION CRITERIA FOR 5-10 BED NHs IN 2 MONTHS

WE DEVELOPED FIELD DEFINITIONS OF ALL MCH CLINICAL SERVICES TO ENSURE UNIFORM STANDARDS AND QUALITYIN 2 MONTHS

State bureaucracy was now happy because they were leading the expansion

Nursing homes were happy on the proposed fund dispersal mechanism (advances ) and assured increase in patient numbers

Health technocrats were happy that they retained power

Politicians were happy as the scheme reaching their poor electorate

NGOs were happy on services they could do in the areas they work

Implementation

THE PROPOSAL WAS SENT TO CHIEF SECRETARY FOR RATIFICATION BY CABINET

AND WAS IMPLEMENTED!!!!!!!!

:

• 3 months later a review was done and additional grants were provided on field requirements, including refresher trainings on clinical field definitions

• Medical audits for quality assurance, financial audits for transparency conducted after 6 months

• Additional NHs contacted and accredited

• Scheme expanded to two more Districts (One by UPHSDP)

• PPP is now an official government policy for all sectors in UP

Evaluation & Feedback

PPP is Likely Democracy

- For the People- By the People-Of the People

PPP For People

Framework for Developing Problem Profile of Partners Process of Building a partnership Profit – Mutual Benefit Phase – start small & build Proliferate –Grow, Expand, &

Sustain Priorities & Preferred group

Framework for Developing PPP Policing – Mechanism of Monitoring

& Transparency Politics – Governance,

Administration, People’s audit Protection/proof: A security system Price: A cost share in terms of

money/kind

Framework for Developing

Professional Network Platform Prize:

Acknowledgement/recognition

PPP is a required PUNCH

Thank You