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Public-Private Partnerships for Health Service Delivery in Africa: Three Myths to Destroy & We Cant Continue Business as Usual Tonia Marek Lead Public.

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Presentation on theme: "Public-Private Partnerships for Health Service Delivery in Africa: Three Myths to Destroy & We Cant Continue Business as Usual Tonia Marek Lead Public."— Presentation transcript:

1 Public-Private Partnerships for Health Service Delivery in Africa: Three Myths to Destroy & We Cant Continue Business as Usual Tonia Marek Lead Public Health Specialist, The World Bank Cambridge, March 2006

2 The three myths Health is mainly financed by the public sector Health is mainly financed by the public sector

3 Who finances health ?

4 The three myths Health is mainly financed by the public sector Health is mainly financed by the public sector The private sector is for the rich and the public sector is for the poor The private sector is for the rich and the public sector is for the poor The private sector is not very developed in Africa The private sector is not very developed in Africa

5 Who is the private sector in Africa ? Formal private sector: Formal private sector: –Private for profit clinics, pharmacies, doctors –NGOs Informal private sector: Informal private sector: –Informal drug vendors –Traditional healers –Moon lighting workers

6 Existence of a large private sector Ex. Tanzania (2000) PublicPrivate District hospitals81%19% Specialized clinics74%26% Dispensaries68%32% X ray units30%70% Laboratories10%90% Other hosp.(not regional) 7%93%

7 Existence of a large private sector ContinentMDs working in the private sector ASIA (6 countries) 60% SUB-SAHARAN AFRICA (8 countries) 46% LATIN AMERICA & CARIB.(5 c.) 46% NORTH AFRICA & MIDDLE E. (7 c.) 35%

8 Existence of a large private sector The private sector also delivers prevention services Ex. Nouakchott, Mauritania: PublicPrivate Infant consultations75%25% Prenatal visits75%25% Deliveries93% 9%

9 People are voting with their feet.... To what extent is the private sector used by the poor when a child is sick ? by the 20% poorest by the 20% richest Malawi, %71% by the 20% poorest by the 20% richest Malawi, %71% Mali, %58% Niger, %28% Cameroon, %52% Benin, %58% Guinea, %55%

10 What type of private sector people go to ? Malawi, 2000 of those who went to the private sector when their child was sick among the 20% among the 20% poorest richest 73%61% went to shops 15% 6% went to traditional healers 11%27% went to a private facility

11 Why do people choose not to go to the public sector ? Poor perceived quality of care Poor perceived quality of care

12 Quality of care in public and private sectors Quality of care in public and private sectors South Africa, study on clinics PublicPrivate -STIs diagnosed using the correct syndromic approach 68%85% syndromic approach 68%85% -Correct treatment of STIs 80%97%

13 Why do people choose not to go to the public sector ? Poor perceived quality of care Poor perceived quality of care Uneven availability of staff and drugs Uneven availability of staff and drugs

14 Operating hours per day in public and private facilities Operating hours per day in public and private facilitiesCambodia PublicPrivate N=27N=31 -Average weekday hours Average weekend hours

15 Why do people choose not to go to the public sector ? Poor perceived quality of care Poor perceived quality of care Uneven availability of staff and drugs Uneven availability of staff and drugs Not well received (especially if poor) Not well received (especially if poor)

16 Client satisfaction Private Sector Outperforms Public Sector (survey in India, Andra Pradesh, 2000) Andhra Pradesh (2000)

17 Why do people choose not to go to the public sector ? Poor perceived quality of care Poor perceived quality of care Uneven availability of staff and drugs Uneven availability of staff and drugs Not well received (especially if poor) Not well received (especially if poor) Parallel payments Parallel payments

18 Guineas 2 main public hospitals (MOH, GTZ study, 2003) OfficialAverage tariffpaid -External consultation 1,700 FG 6,500 FG -Hospitalized patient 22,000 FG225,000 FG

19 The private sector faces the same problems as the public sector The private sector faces the same problems as the public sector % failure of content of chloroquine tablets in 7 african countries, % of samples (WHO, 2003) District hospital:70% Vendor/shop:50% Health center:46% Teaching hospital:44% Pharmacy:43% An example of solution: Kenyas CFW Shops franchise operates over 40 essential drug outlets

20 The private sector faces the same problems as the public sector The private sector faces the same problems as the public sector Quality of care: Kampala, Uganda 164 private health facilities surveyed 81% of simple malaria cases 64% of pneumonia cases not treated correctly by the facilities which treated those cases

21 The private sector faces the same problems as the public sector The private sector faces the same problems as the public sector Two examples of solution: training and franchise Kenyas Medical Research institute training of shop keepers in 2-4 days workshops>> went from 7% to 65% of children given the right dose of anti-malarials Top-Reseau Madagascar is a reproductive health franchise with 17 private clinics and several private MDs in the network to address sexually transmitted infections in particular (since 2001)>> went from 50 to 90% of Top Reseau doctors who accurately treat STI symptoms

22 Types of PPP Contracting Contracting Franchising Franchising Concessions Concessions Leasing Leasing Vouchers Vouchers

23 Contracting Of Governement with NGOs, local associations, Private for Profit sector Of Governement with NGOs, local associations, Private for Profit sector Of Health Mutuals or Health Insurances with public or private service deliverers Of Health Mutuals or Health Insurances with public or private service deliverers

24 Contracting Experience in Hyderabad Mahavir Trust began TB DOTS in 1995 with outreach to private providers Mahavir Trust began TB DOTS in 1995 with outreach to private providers Expanded in 1998 to 500,000 population not covered by public sector Expanded in 1998 to 500,000 population not covered by public sector MOU – MOH provides drugs, lab supplies, training, Mahavir provides staff, overhead MOU – MOH provides drugs, lab supplies, training, Mahavir provides staff, overhead Compared to Osmaina, similar sized area run by public sector Compared to Osmaina, similar sized area run by public sector Independent assessment of records & costs Independent assessment of records & costs

25 Results in Hyderabad, India ParameterNGOMOH No.of TB cases detected per year Treatment success rate (%) 94%80% Total cost per successfully treated patient ($US) $118$138 Total cost per patient treated $88$98

26 PPP pitfalls to avoid: inefficiency of public-private alliances Contracts with NGOs (ex. of the Dominican Republic): - sole source is the norm, no competition - most didnt describe the services which the NGO must provide and none had specific objectives - none includes an incentive or disincentive system; - 84% of contracts dont have a clear definition of the costs - 70% dont establish who will monitor the contract - more than 30% dont mention the contracts duration

27 Towards Better PPP The Legal Framework The Legal Framework The Norms The Norms The Procedures The Procedures The Institutions The Institutions

28 The Legal Framework for Contracting A General Health Law : A General Health Law : -establishes the MOH as the rector agency - Agreements will be signed with public entities who receive public funds - requires accreditation for all, public as well as private, health service providers A Social Security Law : A Social Security Law : - establishes the necessity for the public sector to contract and buy services from the private sector

29 The Legal Framework for Contracting A Social Security Law : Sets a pre-paid modality where services will be bought by the State which will refer to the private sector a certain quantity of patients who belong to the Subsidized regimen, so that the patients receive services without additional costs. This can end an era of subsidies to the private sector without asking for results.

30 The Norms for Contracting Presidential Decree allows the provincial health officer to contract services Presidential Decree allows the provincial health officer to contract services Norms of Accreditation for NGOs which provide health services Norms of Accreditation for NGOs which provide health services

31 The Procedures for Contracting Pilot operations and other operations: Pilot operations and other operations: Manuals, types of contracts, of payment mechanisms, of incentives…. Manuals, types of contracts, of payment mechanisms, of incentives….

32 The Institutions which contract Contracting units set up in the Social Security Institute and in the MOH Contracting units set up in the Social Security Institute and in the MOH Provincial health officers to monitor the implementation of pilot contracting Provincial health officers to monitor the implementation of pilot contracting

33 Types of PPP Contracting Contracting Franchising Franchising Concessions Concessions Leasing Leasing

34 Franchising (some examples) of Voluntary Counseling and Testing (S. Africas network of nurses) of Voluntary Counseling and Testing (S. Africas network of nurses) of reproductive health services (Pakistan Greenstar network of clinics; Kenyas KIMET network of service providers since 1996) of reproductive health services (Pakistan Greenstar network of clinics; Kenyas KIMET network of service providers since 1996) of drugs, condoms (Kenyas CFW, Indias Janani franchise with over 44,000 shops) of drugs, condoms (Kenyas CFW, Indias Janani franchise with over 44,000 shops) of Impregnated Mosquito Nets (Ghana) of Impregnated Mosquito Nets (Ghana)

35 Types of PPP Contracting Contracting Franchising Franchising Concessions Concessions Leasing Leasing

36 The myth: the private sector is not very developed in Africa Theres a large private sector in Africa Theres a large private sector in Africa People do use the private sector, especially the poor People do use the private sector, especially the poor The private sector has similar problems of quality as the public sector The private sector has similar problems of quality as the public sector There are examples of successfull PPP and pitfalls to avoid There are examples of successfull PPP and pitfalls to avoid

37 We cant continue business as usual THE WORLD BANK & THE PRIVATE SECTOR REVIEW OF 40 PROJECTS : 23% of projects with high PPP : 23% of projects with high PPP : 57% of projects with high PPP 33% of projects had no mention of private sector 33% of projects had no mention of private sector Successes: - NGOs/Communities in nutrition Successes: - NGOs/Communities in nutrition - Communities in reproductive health - Communities in reproductive health

38 We cant continue business as usual Adapting the World Bank for PPP Conduct systematic assessment of private sector in countries Conduct systematic assessment of private sector in countries Seek support from private sector expertise to help Banks staff Seek support from private sector expertise to help Banks staff Need for more Banks management commitment of the institution on PPP Need for more Banks management commitment of the institution on PPP Establish direct channels with private sector Establish direct channels with private sector Set up a PPP fund to complement operations Set up a PPP fund to complement operations Donor coordination to limit # of procedures Donor coordination to limit # of procedures

39 We cant continue business as usual: Adapting the public sector for PPP Strengthen the Role of the State to carry out its essential functions: Strengthen the Role of the State to carry out its essential functions: Policy setting Policy setting Resource generation Resource generation Health system financing Health system financing Regulation Regulation Quality control Quality control Monitoring Monitoring Information dissemination Information dissemination Strategic purchasing Strategic purchasing

40 We cant continue business as usual: Adapting the public sector for PPP Capacity enhancement of Government, decentralized bodies, for contracting through training, lessons learnt... Capacity enhancement of Government, decentralized bodies, for contracting through training, lessons learnt...

41 We cant continue business as usual: adapting the private sector for PPP Get organized to ease dialogue Get organized to ease dialogue Gain a place at the policy table Gain a place at the policy table

42 We cant continue business as usual: 5 points to keep in mind to promote PPP 1. Consider the whole health system, not just the public sector (quality of care, financing...) 2. Ensure that the organization adapts –public sector to have PPP focal persons, PPP procedures –private sector to get organized

43 We cant continue business as usual: 5 points to keep in mind to promote PPP 3. Expand Contracting: Given the results so far, contracting may make a real difference in achieving MDGs. 4. Evaluate: Evidence is good but not great. Debate on contracting should be decided by evidence 5. Apply Lessons Learnt on Process (ex. the art of contracting: - Autonomy for managers is important - Scale matters: large scale contracts likely save money, facilitate management, and allow better M&Ev. )

44 Resources on PPP (publications) (best practices) providers/stage2.htm (case studies) (purchasing) (health systems) (contracting) (provider network)

45 Resources on PPP Training


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