PRIVATE PUBLIC PARTNERSHIP Dr Simon I. Beshir Consultant Cardiologist NAMIBIA HEART CENTRE Roman Catholic Hospital & Windhoek Central Hospital 8th December 2014 PRIVATE PUBLIC PARTNERSHIP PPP in HEALTHCARE

PPP in HEALTHCARE Introduction Overview of PPPs Views on PPPs Advantages and disadvantages PPPs in other countries Our Story Lessons learned

PPP in HEALTHCARE DEFINITIONS A Public-Private Partnership = contractual agreement between a public agency and a private sector entity. The resources of each sector (public and private) are shared in delivering a service or facility for the use of the general public. In addition to the sharing of resources, each party shares the potential risks and rewards in the delivery of the service and/or facility.

PPP in HEALTHCARE TYPES OF HEALTHCARE PPPs Outsourcing non-clinical support services Outsourcing clinical support services Outsourcing clinical services Private management of a public hospital Private financing, construction and operation of a public hospital

Potential Benefits of PPPs More incentives for private sector to perform New facilities available earlier Increased levels of efficiency and innovation Risks transferred to private sector Forward spending commitments known and able to be planned for

Potential Issues with PPPs PPP contracts can be very complex Results assessment is often subjective Public sector may be locked into contracts while health demands change PPPs may not gain the population’s trust

Many countries are adopting PPPs in Health Care

Hospital Facilities PPPs in the UK (DBFO): >60 new hospitals built All projects were delivered within the public sector budgets Estimated that PPP projects cost 17% less than public sector projects – a saving of $4 billion on a $22 billion programme – the equivalent of 25 hospitals PPPs have failed to win the people’s trust

Hospital services PPP in Spain First wave of 8 PPP (DBFO) contracts awarded in 2006 8th hospital: Valdemoro Hospital – includes Care Contract €72 million investment – awarded to Capio Care Contract includes full responsibility for local population 30 year concession – total value c. €1.3 billion

TB Control PPP in India Highest burden of TB worldwide State government contracted with NGO hospital to provide TB control services to 500,000 population Better outcomes than Control Comparison: Cost per patient 10% lower ($88) 21% more TB cases found 14% better treatment success rate Cost per successful treatment 14% lower ($118) Being extended across other parts of India (with ongoing independent evaluation)

OUR STORY – CARDIAC UNIT @ WCH NAMIBIA HEART CENTRE VISION Only 300-400 000 Namibians have a medical aid The remaining 2 million rely on state health care Some advanced methods of treating heart disease not available in Namibia (even at private facilities) LET’S DEVELOP A HEART UNIT (CENTRE) THAT WILL PROVIDE THE WORLD STANDARD OF CARDIAC CARE TO ALL NAMIBIANS !!!

OUR STORY – CARDIAC UNIT @ WCH NAMIBIA HEART CENTRE PREVIOUSLY Some patients with heart disease transferred to RSA or Kenya at a very high cost Most cardiac patients receive no or minimal therapy and faced suffering or death from heart failure, heart attacks or strokes

CARDIAC UNIT @ WINDHOEK CENTRAL HOSPITAL OUR STORY Established and inaugurated by H.E. President Hifikepunye Pohamba in August 2008 First step towards the national heart centre was made Some patients could receive heart treatment in Namibia OUR STORY

CARDIAC UNIT @ WINDHOEK CENTRAL HOSPITAL OUR STORY CARDIAC UNIT @ WINDHOEK CENTRAL HOSPITAL GREAT SUCCESS BUT STILL SOME PROBLEMS Lack of qualified staff (especially doctors) Inconsistent supplies of consumables > service interruptions Inconsistent funding of the service

OUR STORY – CARDIAC UNIT @ WCH GETTING A WELL QUALIFIED AND SKILLFULL DOCTORS State salaries for specialist physicians are below the levels of the trainees in the EU/UK/US Private physicians not keen to work at the state facilities (loss of income from private healthcare) BIG HURDLE ISSUE ……starting a new train is more difficult than jumping into a going one

Micro PPP CONCEPT OUR STORY – CARDIAC UNIT @ WCH Attract a highly qualified Consultants to work at the state hospital Allow them to conduct a limited private practice to supplement their income Set a performance standard for each consultant Define precisely the proportion of consultant ‘s time dedicated to the state unit

PUBLIC INVESTMENT OUR STORY – CARDIAC UNIT @ WCH Consultant salary as per the national public service pay rates Annual budget for the service provided + development

PUBLIC RETURN OUR STORY – CARDIAC UNIT @ WCH Increased number of patients using the service Newly introduced treatments Less (or no) patients sent for the expensive therapy abroad Increased patient satisfaction – high quality care in Namibia Training of the young Namibian doctors and nurses = knowledge & skill transfer to benefit larger number of patients in the future

PRIVATE INVESTMENT OUR STORY – CARDIAC UNIT @ WCH The time spent at the state hospital = loss of income in private practice (far exceeding the state salary) Know How Unit management (ownership)

PRIVATE RETURN OUR STORY – CARDIAC UNIT @ WCH Opportunity to define and to develop a national heart service Opportunity to introduce advanced methods and treatments . . i.e. personal growth, prestige, experience Ability to earn extra income from the limited private practice

2012 - SERVICE ASSESSMENT BUDGET BASE OUR STORY – CARDIAC UNIT @ WCH Performance analysis of the Cardiac Unit (2012) No of patients treated ( outpatients, operations, etc) annually Portfolio of treatment methods (CABG, stents, pacemakers) Costing analysis of the Cardiac Unit (2012) Salaries (doctors, nurses, technical staff) Capital costs (equipment) Consumables used for the procedures BUDGET BASE

VISION & GOALS – 5 YEAR PLAN NAMIBIA Approx. 2,000,000 population (state patients) vs UK/EU/US PERFORMANCE STANDARDS number of cardiac procedures per million population annually = NUMBER OF CARDIAC PROCEDURES TO BE DONE IN NAMIBIA

IMPLANTING PACEMAKERS & OTHER DEVICES OUR STORY – CARDIAC UNIT @ WCH IMPLANTING PACEMAKERS & OTHER DEVICES

OPENING THE BLOCK HEART ARTERIES WITH BALLOONS & STENTS

OUR STORY – CARDIAC UNIT @ WCH PERFORMING OPEN HEART OPERATIONS SUCH AS BYPASS SURGERY or VALVE REPLACEMENT

OUR STORY – CARDIAC UNIT @ WCH

INNOVATION & DEVELOPMENT VISION & GOALS – 5 YEAR PLAN INNOVATION & DEVELOPMENT New treatment methods Clinical research Clinical data management system

VISION & GOALS – 5 YEAR PLAN New treatment methods RENAL DENERVATION THERAPY TO TREAT HIGH BLOOD PRESSURE

VISION & GOALS – 5 YEAR PLAN ROBUST DATA MANAGEMENT SYSTEM

VISION & GOALS – 5 YEAR PLAN

VISION & GOALS – 5 YEAR PLAN

ANNUAL BUDGETTING PROCESS ACTIVITY REPORT FOR THE PREVIOUS 10 MONTHS PROPOSED FURTHER DEVELOPMENT/EXPANSION UPDATED COST PER ITEM PROPOSED BUDGET FOR THE COMING YEAR WITH MOTIVATIONS & JUSTIFICATIONS FINANCE DEPT. OF MHSS EVALUATION FINAL BUDGET SUMBITTED TO MOF NEW BUDGET RELEASED USUALLY IN APRIL/MAY

PAYMENT MECHANISM A SINGLE SUPPLIER OF THE CARDIAC UNIT SELECTED BY A TENDER Responsible for all the supplies for the Unit Single point of contact for the clinicians Bulk purchases – good pricing – good value for money Deadlines and clinical support stipulated in the contract AN ANNUAL VOLUME OF SUPPLIES ESTIMATE BASED ON PREVIOUS YEAR ACTIVITY + PROPOSED EXPANSION QUARTERLY REQUESTS SUBMITTED BY THE UNIT LEAD TO THE SUPPLIER VIA THE HOSPITAL MANAGEMENT WHEN APPROVED THE SUPPLIES DELIVERED TO THE CENTRAL CLINICAL STORES & INSPECTED FOR COMPLETNESS SUBSEQUENTLY PAYMENT RELEASED TO THE SUPPLIER

PRIVATE PARTY RESPONSIBILITY Clinical leadership of the Cardiac Unit Staff training Unit management Performing complex cardiac procedures Training of the junior medical & nursing staff Setting up goals and targets for the unit Putting together the annual activity report of the unit Bringing innovation and new developments Budget proposal – justfication.

GOVERNMENT RESPONSIBILITY Unit funding (staff salaries, annual budget) Analysis of the annual activity report Review and justification of the proposed budget Supervision of the unit ( via senior hospital management)

CARDIAC UNIT @ WCH - OUTCOMES

LESSONS LEARNED The Vision & Realistic Goals are essential Micro-PPP can achieve Macro-RESULTS Open minded approach - don’t let a stupid rule to stop a good project Robust data collection is necessary to avoid abuse of public money Key players must be selected well !

THE FUTURE OPTIONS Continue the current system = micro PPP National Heart Service – Country Wide Project = true PPP Outsourcing of the Cardiac service fully to a private facility for a fixed fee per patient Reverting back to a full state based care

Thank You