an innovative public-private partnership for rch focused healthcare to the urban poor dr hemant...
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An innovative public-private partnership
ForRCH focused healthcare to the urban
poorDr Hemant Kumar
MBBS; MBAConsultant – Health systems developmentSector Investment Program, Haryana
Swasth KutumbSwasth Kutumb
Problem statement
To provide affordable and accessible quality primary health care with a particular focus on RCH services - to the urban poor population in the state.
Absence of appropriate & affordable health providing infrastructure/ services for urban poor
Situation Analysis Health indices among the urban poor
are consistently worse as compared to the rural population in the state.
Situation Analysis - II
Utilization of public health facilities very poor – just 6% of all deliveries take place in public health institutions
Infrastructure set up cost very high – yet no guarantee of optimal utilization
State has a robust private health sector with significant spare capacity – more than 75% people use pvt sector.
Swasth Kutumb
Public Private Partnership model to provide quality healthcare to the urban poor.
Utilize the existing infrastructure and trained manpower in the private health sector.The government provides back up support, monitoring and regulatory mechanism.
Process of evolution of the project
MoHFW funds available for urban RCH projects.
Basic framework design in the dept of health
Wide ranging consultation with PHPs/IMA
Rapid urban survey to assess present health
seeking practices
Iterative meetings with GoI
External assessment by AFF
Beneficiaries
Urban poor in four district headquarters.
Includes the BPL population and families with a monthly income of less than four thousand per month.
An estimated 30% of the DHQ population would be covered.
Basic mechanism Identified Private Health Providers – PHPs
would be assigned a beneficiary population approximately 1500 families (7500 population).
These PHPs would be responsible for the provision of the entire range of primary healthcare services including outreach services in the community through health workers.
The focus would be on RCH related services
Payment StructureA total sum of Rupees one hundred per person per year would be payable to the PHP.Service offered Paymen
t by Govt
Payment by
beneficiary
Remark
OPD consultation Rs. 70 Rs. 5 First 5 visits are freeSpecialist consultation
Rs. 10 If available in-house
Basic medicines Rs. 20 Medicines other than those on the list to be purchased. PHP would make them available at fair price
Normal Delivery Rs 200 Includes all costs for medicines/consumables till the time the pt is discharged
Cesarean delivery
Rs 400
Referral Tpt. Rs 5 per km or a min of Rs 50
PHP setup Qualified medical personnel including a
General Practitioner, Gynecologist and Pediatrician with others specialists in-house/on call
In-house facilities in terms of OT, LR, facilities for NB resuscitation and Path Lab
Meeting basic standards of hygiene and service quality
Proximity to urban slum clusters
Sufficient spare capacity in both OPD and IPD
Government support & responsibilities
Providing free medicines/medical supplies under existing programs
Supply chain management support Referral services at District Hospital Promotion and awareness generation Monitoring, co-ordination and supervision Timely payment to PHP’s for their service
Key Success Factors
Monitoring
No misuse
Maintenance of service standards
Impact assessment
Stakeholder’s selection
Beneficiaries PHPs
NGO’s/ Co-ordinating agencies
Financials
Affordability Financial viability Value for money
Sustainability
IEC activities
Improving health seeking behaviour
Service Quality - Govt.
Support services Payment settlement Grievance handling
Service Quality - PHPs
Standards of services; availability & quality
KEY SUCCESS
FACTORS
Beneficiary selection
All the BPL population in the DHQ Survey of identified slum areas and
inclusion of all the families within the slum area.
District administration, department of health and NGOs aid in identification of beneficiaries.
PHP selection Applications invited detailing
infrastructure, manpower and present utilization levels.
The number of PHPs selected depends on the urban poor population identified
Proximity to a slum area is an important criteria.
Site visit and interview of the owner Signing of contract
Service Quality of PHPsImportant Issues
Timely & fair treatment to beneficiaries Availability of medical facilities/medicine Focus on preventive & outreach services Specialist & diagnostic facilities at fair
price Option of beneficiary to switch PHP Option of terminating contract Feedback from beneficiaries
Service Quality - Govt Ensuring free medicines/medical
supplies under National Health Programs
Availability of generic drugs at fair price
Timely payment to PHPs Back up referral services in place Minimized paper work Obtaining and acting on
beneficiaries feedback/grievance
Monitoring & Evaluation
Focus Areas Reduce/prevent the potential for
misuse of funds/supplies Service standards are maintained Beneficiaries are not exploited Tracking improvement through
performance indicators
M & E Proposed system
Family health booklets for beneficiaries Computerized tracking of all/most of the
transactions between the beneficiaries Sample verification of services provided Fund flow system with independent auditing Impact assessment survey Grievance redressal mechanism Record keeping by PHPs/Govt.
Family Health Booklet
ANC NoName – w/o
D.o.R
RegTM
LMP
TT 1 TT2
IFA
ANC VISITS
PNC No.1 2 3 4 5
Starting Date
D.o. last Delivery
Advised byDoc/ANM/
Self
Month for which OCP taken
Reason for discont Complaints//complications
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
ANC Details
OCP
Family Health BookletWeight ______B.P _________Diag.______________
Date_____________Presenting Complaints
O/EPrescribed Treatment –
Provided in-house
To be purchased
Doctor’s signature
District code :Service Provider code:
Sheet No :
Doctor/Staff Code:
Date of Visit :
•Computerization cost per transaction – 6 Paise
•Total characters=24
•Cost per service provider per year Rs. 500 approx
Sr.No.
Patient code(7)
Disease code(3)
Service code(3)
Likely cost of additional treatment to patient (4+4)
Specialty Referred(3)Medicine
Investigation
Swasth Kutumb service rendered sheet
Swasth Kutumb ANM service rendered sheet
S/N
Patient code
(7)
Service code (5)
Disease code(3)+3+3
Remark (3)
Appropriateness for beneficiaries
Easily accessible better health services at affordable costs
Arrangements for specialist and diagnostic services at fair price
PHPs to tie-up/provide in-house specialist, diagnostic service providers
Government financial support during initial stages
Appropriateness for PHPs
Low incremental costs Scope for additional income generation Attractive revenue cost analysis PHPs favorably inclined towards the
scheme Improved utilization of existing
infrastructure Fairly assured clientele base
Improved financial resource utilisation
Gradually reducing financial liability of the government
No capital cost towards infrastructure
No gestation period
Registration and actual services provided based payment
Reduced cost of providing services
Appropriateness for the government
Project Comparison: Public vs Private AFF estimates
* Assuming same number of patients treated in both the options
In the private option payment to PHPs for service delivery account for 80% of the total operating expenses
In the public option fixed staff costs account for 63%, drugs & Consumables for 28% of the total operating expenditure
Project Cost Comparison (205 PHPs vis-à-vis 40 CHCs)
Major Cost Head Private Option
(in lakhs)
Public Option
(in lakhs)
Capital expenditure (yr. 1)
- Infrastructure 19 5619 - Preparatory expenses 54 17
Revenue/operating expenditure (yr. 1-5) - Average per year * 1575 2018 - Cumulative for five year 7876 10091
Beneficiary selection Regulation of the private
sector / quality of care Systems for supply chain
management An independent coordinating
agency
Challenges
Only those who risk going too
far can possibly find out how far they can
go!!