ppp in healthcare- an indian perspective, world bank mooc, by saurav kumar das
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KEY HEALTHCARE CHALLENGES
Access to specialty healthcare, advanced diagnostics
86 hospital beds / 1000 population – heavily skewed, the metro areas (6% of population) account for 25% of hospital bedsTravel upwards of 90 km to access specialty careStrong private sector - 64% of all hospital beds, 80% of outpatients and 57% of inpatients receive treatment from private hospitals
Affordability and equity One of the world’s highest levels of private out-of-pocket financing
of medical expenses, at about 85 percent, with debilitating effects on the poor - 35% of hospitalized patients fall below the poverty line because of hospital expenses
Public spending on health has remained stagnant at around one percent of GDP (0.9%)
The poorest quintile of the population uses only one-tenth of the public (state) subsidies on health care while the richest quintile accesses 34 percent of these subsidies
Critical workforce shortages India is short of 600,000 Doctors; 1,000,000 nurses and 200,000
dental surgeons, only 0.9 doctors and 1.2 nurses for every 1,000 Indians
NEED OF PUBLIC PRIVATE PARTNERSHIP
Source: National Health Accounts Report 2004-05 of MOHFW/GOI. (With Provisional Estimates from 2005-06 to 2008-09)
PUBLIC
SECTOR
PRIVATE
SECTOR
Free Provision of Products and Services
Unsustainable for Government & Donors
Unsustainable for Consumers
Profit Maximization
Break Even
GOAL IS TO CREATE FINANCIALLY SUSTAINABLE SYSTEM
Develop strategies to utilize untapped
resources and strengths of the private sector
Reducing financial burden of government
expenditure
Reaching remote areas & target specific group
of populations
Improving efficiency through evolving new
management structures
CURRENT FOCUS OF PPP IN HEALTHCARE
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KEY RISKS & CONSTRAINTS
Payment delaysDifferences in Operating styles and trust level Local political interference Non-revision of contract clauses (Tariffs) Lack of capacity or willingness to supervise /
monitor / guide the projectNegative attitudinal orientation towards
private sector
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POLITICAL AND ADMINISTRATIVE COMMITMENTS
Half hearted government support for PPPTop officials are enthusiastic, but lower level
officials suspect PPP as ‘privatization’ or show disdain towards the private provider
Need for technical / managerial skills for designing, negotiating, implementing and monitoring PPP contracts
Develop institutional capacity at all levels
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CHALLENGES FOR PPPDefining and verifying beneficiaries (BPL
patients)- especially high cost servicesDefining Quality or Performance or Outcome
indicatorsEfficient Supervision and Monitoring
mechanismTimely revisions / updating of contractOmbudsman for dispute settlementClarity on setting user fee
Franchising & Social marketingContracting out & Contracting-inJoint venturesVoucher schemesRunning mobile health unitsCommunity based health insuranceInvolving professional associations
PUBLIC-PRIVATE-PARTNERSHIP MODELS IN
HEALTHCARE SECTOR
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. It intends to increase the available products, including oral rehydration solution, IFA tablets and other health products to make marketing more self-sustaining.
FRANCHISING & SOCIAL MARKETING
Janani social marketing and social franchise program
Non-profit organization that provides family planning and maternity care services in the states of Bihar, Jharkhand and Madhya Pradesh.
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 reproductive health services through Surya Clinics.
Titli centres sell condoms, pills and pregnancy test kit
EXAMPLE OF FRANCHISING AND
SOCIAL MARKETING
Contracting out: Refers to situation in which private providers receive a budget to provide services and manage a government health unit. Vacancies for a long period, high absenteeism,
and consistent low performance could be the critical criteria to identify those government health clinics that need to be contracted out
Contracting In: Hiring of one or more agencies or individuals to provide services.
CONTRACTING OUT & CONTRACTING IN
Example of contracting out:Sawai Man Singh Hospital in Jaipur has contracted
out the installation, operation and maintenance of CT-scan and MRI services to a private agency
The agency is paid monthly rent by the hospital and the agency has to render free services to 20% of the patients belonging to the poor socio-economic categories
Example of contracting in:Hiring of medical specialists for certain days of the
week in Primary Health Centers (PHC) or Community Health Centers CHC.
EXAMPLE OF CONTRACTING
Joint ventures are companies launched with equity participation of government and private sector.
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
The basic reason for establishing the partnership was to give super specialty health care at low cost to the people living below the Poverty Line.
The Govt. of Karnataka has provided land, hospital building and staff quarters as well as roads, power, water and infrastructure.
Apollo provided fully qualified, experienced and competent medical facilities for operating the hospital.
JOINT VENTURES
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 initiative in Karnataka.
Tele-diagnosis and consultation in cardiac care and specialist care. Free diagnosis, medicines and treatment for BPL patients
EXAMPLE OF JOINT VENTURE
A voucher is a document that can be
exchanged for defined services as a token of
payment
The government offers vouchers at subsidized
rates to below poverty line people
Packages can be bought, used when required
and ensures privacy for the client.
VOUCHER SYSTEM
Chiranjeevi Yojna :
Concept A voucher system for the Below Poverty Line maternity
population to enable them to avail of private obstetricians in Gujarat
Design The Government deliberated the scheme with SEWA, the
acclaimed NGO and the Federation of Obstetric and Gynecological Society of India (FOGSI), the professional organization representing practitioners of obstetrics and gynecology in India, to devise a package rate for a delivery.
The package included the weighted average of rates of a normal delivery, complicated delivery, caesarian section, travel reimbursement to mother and the accompanying trained birth attendant etc.
A pilot project was conducted in five of the most backward districts empanelling almost three-fourth of those districts’ private obstetricians
EXAMPLE OF VOUCHER SYSTEM
Innovation The doctors were paid a sum of Rs. 15000 in advance at
signing of an MoU, unlike most PPPs where payment comes in months after the service has been delivered. This advance amount was to be topped up after a certain amount of deliveries. Hence, the government always paid for service in advance to gain credibility with the doctors
Results Between January 2007 and January 2010, about 4,35,047
safe deliveries were carried out by 768 obstetricians. These represented roughly 55-60% of the total deliveries by
the Gujarat BPL population in this period. Over 26 months of the scheme, each doctor earned on an
average almost Rs.10 lakh, which is a fair amount of marginal income.
Each pregnant woman, on the other hand, paid INR 654 on an average as costs of medicines for the child and herself
CHIRANJEEVI YOJNA:
Vans go to identified central points on fixed days and provide primary health services to a cluster of villages.
Vehicle, medical equipments, medicine are provided by govt. and primary health care services are provided by NGOs
Bihar adopted the MMU scheme under the name “Arogya Rath” in 2009 with three private providers – Spake Systems, Jagran Solutions and Jain Studios . The units provide primary health care services free of cost to people in underserved areas of the state
Madhya Pradesh adopted the scheme under the name “Deen Dayal Chalit Aspatal Yojana”
RUNNING MOBILE HEALTH UNITS
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
Provides 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
Rashtriya Swasthya Bima Yojna (RSBY)
AAROGYASRI COMMUNITY HEALTH INSURANCE SCHEME
Unique community health insurance programme through the Aarogyasri Health Care Trust
The trust defines premium package, treatment protocols, empanelment criteria
A private insurance company/ Third-Party Administrator (TPA), selected through competitive bid process , to administer patient enrolment, hospital empanelment, claims management, risk coverage
Network hospitals, both public and private – strong response by private hospitals to invest/move to district and sub-districts
Professional associations such as Indian Medical Association, Gynaecologists federation, nurses associations
Extended help in launching new programmes such as Vande Mataram SchemeScheme of social franchising: Involving the
interested private practitioners to popularize contraceptives like oral pills, emergency contraceptives and life saving Oral Rehydration Salt (ORS) packets etc.
Government facilities will be shared with the private doctors on cost basis (e.g. X ray machines, laboratory investigations).
INVOLVING PROFESSIONAL ASSOCIATIONS
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 patients to hospitalGovt. benefits as DOTS medicines are not
wasted
PARTNERSHIP BETWEEN THE GOVERNMENT AND THE NON PROFIT SECTOR
Partnerships in Healthcare: A Public Private Perspective, CII-Hosmac Whitepaper, 2010
Public Private Partnerships for Healthcare in India, IFC White Paper
Issues in Health, Public Private Partnership, Ramesh Bhat (December, 2010) Economic and Political Weekly Paper
Public and Private Roles in Health: Theory and Financing Patterns, Philip Musgrove (July, 1996). HNP
Public-Private Partnerships & Collaboration in the Healthcare Sector, Irina A. Nikolic and Harold Maikisch (October, 2006). HNP
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