Greetings from

National Institute of Health and Family Welfare,Munirka, New Delhi-110067

Prof. Deoki Nandan, Doctor Honoris Causa-Odessa State Medical University, MD, FAMS, FIAPSM, FIPHA, FISCD

Director(director@nihfw.org, www.nihfw.org)

&NIHFW FAMILY MEMBERS

PRIVATE SECTOR IN NRHM

& URBAN HEALTH

TASK FORCE

Dominance of the private sector

• 82% OPDs (many by unqualified doctors)

• 58% inpatients

• 40% of institutional deliveries

• All the domiciliary deliveries (TBAs)

Perceived disadvantages of the public sector

• Interminable wait in dirty surroundings• Hordes of patients• All medicines and all tests not available• Doctors attend to more that 100

patients/OPD (Avg. 1 min/patient)• 30% patients have to pay bribes/influence

doctors to attend to them well/on priority

State of the private health sector• 20 years ago private sector dominated by

solo practitionerssmall nursing homes and hospitals

• Many charitable trusts/religious organizationsdelivering exemplary quality of health careservices

• As medicine increasingly driven by technology,such smaller organizations not able to competewith large corporations – five star hospitals withforeign trained doctors

State of the private health sectorWorld Bank Report:• Private sector dominates health care • Inadequate legislations and failure to enforce

regulations are contributing to poor quality of medical services.

• No laws regulating geographical distribution of health & Type of technology to be made available

Kerala Govt 1994:• This state govt. has no control over private

hospitals/ nursing homes functioning in this stateat present as there is no legislation now for thispurpose.

State of the private health sector• 40% sell property /borrow for treatment

• Suspicion that unnecessary tests & surgical procedures are performed

• IMA consistently opposes any kind of regulation.

• Few actions against doctors violating code of ethics by MCI

• Maharashtra Medical Council unable to produce record of actions taken against erring doctors

• Substandard, understaffed Medical Colleges not having own hospital recognized

State of the private health sector Report of committee set up by the High Court

• Majority of nursing homes are substandard, most being housed in tiny flatlets (some under 200 square feet in area)

• one-seventh of them are in sheds or lofts in slums

• 77% do not have scrub rooms

• less than one-third have qualified nurses

• some have operating theatres less than 5 sq m in area

• some do not disinfect the operating theatre more than once a week, some every three days and hardly any after each operation

State of the private health sector• none of the nursing homes dispose biomedical waste

correctly

• a majority of them claim to be maternity homes, but only one-third have labour rooms

• 38% of wards and 50% of beds are dirty and poorly lit

• none of the nursing homes keep records of notifiable diseases, and only 10% record births and deaths

• hardly any nursing homes display their licences prominently.

HOWEVER• Some private establishments offer excellent quality at

high prices (S. Chakarborty IIM Lucknow)

State of the private health sectorWHO Bulletin 2005 Prata

• Private sector delivery of PH care poorly regulated.

• Poor spend a greater proportion of their income on health care leading to financial burden

• Private sector not structured to assure quality or affordability of health care

Strategies to improve health care services :

• Health seeking behavior of various Socio Economic Status so poor can be protected and served appropriately

• Regulation & enforcement can improve private sector

Regulations(R. BHAT IIM A)

• Expansion of private sector has forcedpassage of regulations to promote qualityof care and protect consumers

These are:

• Drugs• Medical practices• Health facilities

Laws , Acts and Standards

• Blood Bank Policy • Biomedical Waste Management• PNDT act• Consumer Protection Act• Nursing Home Registration Act • IPHA Standards• Bureau of Indian Standards• National Accreditation Board for testing and calibration of

laboratories under Ministry of Science and Technology• National Accreditation Board for Health & Hospital

Administration.

Suggestions

• Impose greater social accountability of private providers

• Making a certain proportion of private services available to the poor.

• Geographical distribution of health services

• Exploring the potential of franchising

BLOCKLEVEL

HOSPITAL

30-40 Villages

Strengthen Ambulance/transport ServicesIncrease availability of NursesProvide TelephonesEncourage fixed day clinics

AmbulanceTelephone

Obstetric/Surgical MedicalEmergencies 24 X 7

Round the Clock Services;

BLOCK LEVEL HEALTH OFFICE –--------------- Accountant

CLUSTER OF GPs – PHC LEVEL

3 Staff Nurses; 1 LHV for 4-5 SHCs;Ambulance/hired vehicle; Fixed Day MCH/Immunization

Clinics; Telephone; MO i/c; Ayush Doctor;Emergencies that can be handled by Nurses – 24 X 7;

Round the Clock Services; Drugs; TB / Malaria etc. tests

GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL

Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages;Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic1000

Popu lation VILLAGE LEVEL – ASHA, AWW, VH & SC

1 ASHA, AWWs in every village; Village Health DayDrug Kit, Referral chains

100,000 Population

100 Villages

5-6 Villages

Accredit private providers for public health goals

Health Manager

Store Keeper

NRHM – ILLUSTRATIVE STRUCTURE

NRHM – 5 MAIN APPROACHES

COMMUNITIZE

1. Hospital ManagementCommittee/ PRIs at all levels

2. Untied grants to community/PRI Bodies

3. Funds, functions &functionaries to local

community organizations4. Decentralized planning,

Village Health &Sanitation

Committees

IMPROVEDMANAGEMENT

THROUGH CAPACITY

1. Block & District HealthOffice with management skills2. NGOs in capacity building

3. NHSRC / SHSRC / DRG / BRG4. Continuous skill development

support

FLEXIBLE FINANCING

1. Untied grants to public health 2. NGO sector for public

Health goals3. NGOs as implementers4. Risk Pooling – money

follows patient5. More resources for

more reformsINNOVATION IN

HUMAN RESOURCEMANAGEMENT

1. More Nurses – localResident criteria

2. 24 X 7 emergencies byNurses at PHC

3. 24 x 7 medical emergencyat CHC

MONITOR,PROGRESS &STANDARDS

1. Setting IPHS Standards2. Facility Surveys

3. Independent MonitoringCommittees at

Block, District & Statelevels

Private Sector and NRHMStrategies

(a) Core Strategies

• Promoting non – profit sector particularly in under served areas

(b) Supplementary Strategies• Regulation of Private Sector including the informal rural

practitioners to ensure availability of quality service to citizens at reasonable cost

• Promotion of PPP for achieving public health goals

• Effective and viable risk pooling and social health insurance to provide health security to the poor by ensuring accessible, affordable, accountable & good quality hospital care

Plan of ActionComponent (H): PPP for Public Health Goals, including regulation of private sector

• Since 75% of health services are being currently provided by the private sector, there is a need to refine regulation

• Regulation to be transparent and accountable• Reform of regulatory bodies/creation where

necessary• District Institutional mechanism for Mission must

have representation of private sector

Plan of Action cont.

• Need to develop guidelines for PPP inhealth sector. Identifying areas ofpartnership, which are need based,thematic and geographic

• Public sector to play the lead role indefining the framework and sustaining thepartnership

• Management plan for PPP initiatives: atDistrict/State and National levels

EXISTING SCENARIO OF PPP in NRHM• MOHFW evolved guidelines for PPP in National Health

Programmes like RNTCP, NBCP, NLEP, RCH, IDSP etc.• Under the RCH II several initiatives proposed to

strengthen social-franchising initiatives• Contractual appointments and hiring of PPs• Handing over the mgmt. of public sector health facilities• Pvt. Sector/ industry providing health care to tribals• Contracting services in diet &catering, laundry, security

and IEC Programmes.• GOI constituted a Technical Advisory Group, consisting

of officials of GOI, development partners and otherstakeholders to conceptualize strategies.

PPP IN THE HEALTH SECTOR• Contracting in-government hires individual on a

temporary basis to provide services

• Contracting out- government pays outsideindividual to mange a specific function

• Subsidies-government gives funds to privategroups to provide specific services

• Leasing or rentals-government offers the useof its facilities to a private organization

• Privatization-government gives or sells a publichealth facility to a private group

POTENTIAL AREAS FOR PARTNERSHIP• Services, disease control and surveillance,

diagnostics and medicines.

• Infrastructure

• Health manpower

• Behaviour change communication

• Capacity building including training andsystems development.

• Managerial service and auxiliary activitiesof the health sector

Models for Partnership• Contracting :Contracting out, Contracting-in• Franchising: Partial franchising, Full

franchising & Branded clinics• Social marketing• Joint ventures• Voucher schemes• Hospital autonomy• Partnership with corporate sector/

industrial houses

Models for Partnership cont.• Involving professional associations• Build, operate and transfer• Donation & philanthropic contributions• Involvement of social groups• Partnership with co-operative societies• Partnership for capacity building• Partnership with non-profit community-based

organizations• Running mobile health units• Community based health insurance

Urban Health Task ForceMOHFW to document the best practices,

lessons learnt and experiences of PPP for

• better planning & implementation of

programmes on health of the urban poor

• sharing the same with States and other

stakeholders to enable them to effectively

initiate and implement PPP

Involving NGOS• NGOs to be involved in the planning and

implementation of the urban healthprojects.

• Situational analysis identification andmapping of slums

• Management of urban health centres• Supporting outreach clinics and linkage of

service with slum community• Community organization, identifying and

training link workers &IEC/BCC activities

Public Private PartnershipA. In cities where first tier public health infrastructure

available:partnership with NGOs for enhancing utilization ofexisting services through identification and training LinkVolunteers, and IEC/BCC activities

B. In cities where no public sector first tier facility available:Entire first tier service delivery contracted out through partnership.

C. PPs could be engaged on part-time basis for 1st & 2nd

tier facilities.

D. 2nd tier services ( laparoscopic tubal ligation and no-scalpel vasectomy ) and diagnostic services may beoutsourced on reimbursement basis.

Mechanisms for PPPSpecific requirements for evolving appropriate PPPs at the state and district levels :

• Guidelines on ‘How-to’ develop partnerships.�• Sample ToR and MoU

• � Screening criteria for selection of appropriate partners

• � Protocols for enabling and ensuring proper quality ofcare at the facility

• Financial mechanisms and fund flow

Possible areas of partnerships • Providing PH care services – mgmt of 1st tier health facilities

• Provision of 24 hour maternity services

• Sterilization services and mobilization of male partners

• Diagnostics

• Identification, training of Link Volunteers for BCC

• Referral transport facility

• Contracting out of vulnerable areas for all services

• Independent evaluations

• Mapping of slums and facilities and Situational Analysis of the city

Possible partners in urban areas • Professional associations (e.g. IMA, IAP,

FOGSI etc.)

• � NGOs and Charitable Organizations

• � CBOs and Self Help Groups etc.

• � Charitable Hospitals

• � Health practitioners and Nursing Homes

• � Medical Colleges

• � Corporate sector

Thank you

YOU ARE MOST WELCOME TO INDIA