1. 1 ` PUBLIC -PRIVATE PARTNERSHIP FOR HEALTH CARE DEVELOPMENT fi!LH fiajdfjss ixjO—kh i|yd rdcH yd fm!oa.,sl wxYhka fldgialrejka ùu by Dr A.K.S.B.DE Alwis Dr Luxman Edirisinghe

2. 2 Private & public mix (partnership) Government hospital rcfha frday, Contracting out by government.sjsiqus.; fiajd,nd.ekSug Paying wards of government f.jk jdgsgq Private hospitals mqoa.,sl frday,a Public rdcH Privat e mqoa.,sl Funding uq,H iemhqu Public rdcH Private mqoa., sl Production ksIamdokh

3. 3 Aims of the partnership iyfhda.S;djfha wruqK 1. Promote inter and intra-sectoral coordination and cooperation for health development. fi!LH ixjrAOkh i|yd jsjsO fCIa;% w;r iusnkaOSlrKh jrAOkh lsrSu 2. Mobilize more resources. jevsmqr iusm;a fhdod.ekSug 3. Reduce the service gaps. fiajd ysoeia wju lsrSug 4. Promote participation of community and other stakeholders m%cd iyNd.S;ajh jevs lsrSug 5. Ensure the equity and quality..=Kd;aul;djh yd idOdrk;ajh jevslsrSug 6. Reduce wastage of resources. iusm;a kdia;sh jevslsrSug

4. 4 There are many references to partnerships To ensure the delivery of comprehensive health service, which reduce the disease burden and promote health it is proposed - Rationalized health network,(that include allopathic & indigenous as well as public & private services mrsmQrAK fi!LH fiajdjla u.ska frda. ;;ajhlg uqyqK §ug mj;akd l%ufjsoh Yla;su;a lsrSu Strengthened public-private partnerships to enhance efficient health service delivery. fi!LH fiajd iemhSu ldrAAhlaIu lsrSu i|yd rdcH-fm!oa.,sl fiajd w;r iyfhda.S;dj kxjd,Su To empower communities towards more active participation in maintaining their health it is proposed to achieve fi!LH kxjd,Su i|yd m%cd iyNd.S;ajh iy;sl lsrSu Improved participation of civil society and non governmental organizations in promoting behavioral and life style changes cSjk rgdjka yd mqoa.,sl yeiSrSus rgdjka hym;a lrjSu i|yd isjs,a iudch iy rdcH fkdjk ixjsOdk iyNd.S lrjSu To strengthen stewardship and management function of the health system. fi!LH fiajd l<uKdlrk l%shdldrlus jevs oshqKq lsrSu Strengthened coordination and partnerships with other sectors (Strategic framework for health development in Sri Lanka,2004-2005\April 2003)

5. 5 Health care Priority areas of the Government rdcH fi!LH ixrÌKfha m%uqL;djhka E xpand access to curative health care services through hospitals and other providers at the district level to move their services more accessible in poor and rural areas. wvq jrm%ido,dNS ÿIalr m%foaYj, ck;dj i|yd fi!LH fiajdjka flfrys m%fõYhka osia;s%la uÜgñka mq,q,a lsrSu E xpand the services to meet the needs of specific groups such as elderly, victims of war, displaced people, and specific health problems such as occupational health, mental health, estate health etc… jhia.;jQjka, hqO mSä;hska iy wj;eka jQjka jeks úfYaIs; lKavdhï j, fi!LH wjYH;djka iy jD;a;Sh fi!LH, udkisl fi!LH iy j;= ck;djf.a fi!LH jeks úfYaIs;.eg,q ksrdlrKh lsrSu i|yd fi!LH fiajdjka mq,q,a lsrSu D evelopment of health promotion programs with specific emphasis on outreach through the schedule. fi!LH m%jrAOkh i|yd ÿria: jevigyka ilia lsrSu H ealth care financial options and partnerships fi!LH ixrÌKfha uQ,Huh úl,amhka iy odhl;ajhka H uman Resource Development. udkj iïm;a ixjO—Kh

6. 6 Policy Issue : m%;sm;a;suh.eg,qj Strengthening of public - private partnership in development of health care delivery system in NWP of Sri Lanka. jhT m<df;a fi!LH ;;ajh kxjd,Su i|yd rdcH yd mqoa.,sl wxY j, iyfhda.S;djh Yla;su;a lsrSu Policy Vision : Harmonious Public Private- partnership contributing to highest possible level of health for the people of NWP jhT m<df;a ck;djg b;du;au by, ugsgfus fi!LH fiajdjla,nd §u i|yd rdcH iy mqoa.,sl wxY j, ukd odhlFjh iy;sl lsrSu Policy Mission : To strengthen public -private- partnership in health care delivery fi!LH fiajdj i|yd rdcH iy mqoa.,sl wxY j, iyfhda.S;dj,n§u Policy Goal : To ensure the private sector participation in health care provision in NWP. jhT m<df;a fi!LH fiajdj iemhSfus§ mqoa.,sl wxYfha odhlFjh,nd.ekSu

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8. 8 – Internal factors Health care provision in essentially needs multi-sectoral collaboration. Health care provision in essentially needs multi-sectoral collaboration. fi!LH fiajd iemhSu i|yd w;HjYH f,ig jsjsO fCI;% j, odhlFjh u; mokus jSu fi!LH fiajd iemhSu i|yd w;HjYH f,ig jsjsO fCI;% j, odhlFjh u; mokus jSu To reduce rising cost in health care provision. To reduce rising cost in health care provision. jevsjk fi!LH fiajd jshou md<kh lsrSu jevsjk fi!LH fiajd jshou md<kh lsrSu To ensure the quality assurance in health care provision. To ensure the quality assurance in health care provision. fiajd iemhSfus.=Kd;aul ;;ajh wdrlaId lsrSug wjYH jSu fiajd iemhSfus.=Kd;aul ;;ajh wdrlaId lsrSug wjYH jSu To ensure accessibility in health care provision. To ensure accessibility in health care provision. fi!LH fiajdj,nd.ekSug we;s yelshdj iy;sl lsrSu fi!LH fiajdj,nd.ekSug we;s yelshdj iy;sl lsrSu To ensure the cost effectiveness of health strategies. To ensure the cost effectiveness of health strategies. fi!LH Wmdh udrA. j, M,odhs;djh iqrlaIs; lsrSu i|yd fi!LH Wmdh udrA. j, M,odhs;djh iqrlaIs; lsrSu i|yd To ensure stakeholder participation in health policy implementation. To ensure stakeholder participation in health policy implementation. fi!LH m%;sm;a;s l%shd;aul lsrSfuS§ jsjsO mdrAYjlrejkaf.a iyNd.SFjh iy;sl lsrSug wjYH jSu fi!LH m%;sm;a;s l%shd;aul lsrSfuS§ jsjsO mdrAYjlrejkaf.a iyNd.SFjh iy;sl lsrSug wjYH jSu To resource sharing for better service delivery. To resource sharing for better service delivery. hym;a fiajdjka iemhSu i|yd iusm;a ksis whqrska fhdod.ekSug wjYH jSu hym;a fiajdjka iemhSu i|yd iusm;a ksis whqrska fhdod.ekSug wjYH jSu To achieve national health objectives. To achieve national health objectives. cd;sl fi!LH wruqK lrd,.d jSug cd;sl fi!LH wruqK lrd,.d jSug

9. 9 Evidence from international health agencies cd;Hka;r fi!LH ixjsOdk j,ska,efnk idÌs WHO policy direction focuses on six priority areas, f,dal fi!LH ixúOdkfha ih jeoEreï m%uqL;djhka Health sector reform & health system development. fi!LH m%;sixialrKh iy ixjO_kh fi!LH m%;sixialrKh iy ixjO_kh Communicable diseases control. fndajk frda. md,kh Promoting healthy life styles & reducing environmental risk factors, fi!LH iïmkak cSjk rgd m%jO_kh iy mdrsirsl wjOdku wju lsrSu Integrating health services to enhance efficiency & effectiveness. ldrAhÌu;djh iy M,odhs;djh jeä lsrSu i|yd fi!LH fiajdjka wka;rA.%yKh lsrsu ldrAhÌu;djh iy M,odhs;djh jeä lsrSu i|yd fi!LH fiajdjka wka;rA.%yKh lsrsu Emergency preparedness & response. yosis wjia:djka i|yd iQodkïùu iy m%;spdr oelaùu yosis wjia:djka i|yd iQodkïùu iy m%;spdr oelaùu Partnership & coordination. iyfhda.S;djh iy iïnkaO;djh

10. 10 Financial Evidence uQ,Huh idOl Cost of Health : fi!LH fiajdfõ nerlï In 1994 World Bank assured that basic package for health should be US$ 13 per person (WB,1994). The Sri Lankan government has been spending around US$ 10 (Annual Health Bulletine,2000). If Sri Lanka wants to subsidize the health system, the following new challenges should be addressed Y%S,xld rch fi!LH iqNidOkh iemhSfïoS uqyqKoshhq;= kj wNsfhda. 1.Increasing elderly populations jeäjk jeäysá ck.yKh 2.NCD fnda fkdjk frda. 3.HIV/AIDS tps whs jS tavsia 4.Unfinished work in communicable diseases & malnutrition ksu fkdjQ fndajk frda. iy ukaofmdaIKh ms<sn| lghq;= 5.Dengue fvx.= frda.h 1991 § uQ,sl fi!LH fiajdjla iemhSu i|yd rgla jsiska wju jYfhka we fvd,rA 15la tla mqoa.,hl= i|yd jirlg jeh l, hq;= nj m%ldY lrk,§ tfy;a tu ld,fha§ Y%S,xldj ta i|yd jeh lrkq,enqfjs we fvd,rA 10ls ^cd;sl fi!LH m%ldYh 2005&

11. 11 This shows that public expenditure for health could rise from about 20 Billion Rupees in 2003 to between 70 & 173 billion Rupees in 2015. ta wkqj 2003È ns,shk 20la jq rdcH jshou 2015§ ns,shk 70-173 olajd jkq we; Source: Sri Lanka Health Financing Scenarios, 2000 to 2015 Y%S,xldfjs rdcH wxYfha fi!LH i|yd jshou 1996- 2015

12. 12 Source: National health Accounts-2002

13. 13 fkajdisl frda.S fiajd idhksl mqkre;a:dmk fiajd wdOdrl fiajd T!IO yd iemhSus ^ndysr frda.S& frda. ksjdrK yd m%cd fi!LH fiajd fi!LH mrsmd,kh l<uKdlrKh iuia: rdcH fi!LH jshous 1997 cd;sl fi!LH uq,H m%ldYh 2002

14. 14 Source: National health Accounts-2002

15. 15 fkajdisl frda.S fiajd idhksl mqkre;a:dmk fiajd wdOdrl fiajd T!IO yd iemhSus ^ndysr frda.S& frda. ksjdrK yd m%cd fi!LH fiajd fi!LH mrsmd,kh l<uKdlrKh iuia: rdcH fkdjk fi!LH jshous 1997 cd;sl fi!LH uq,H m%ldYh 2002

16. 16 rdcH jshous j, m<d;a wkqj fjkialus

17. 17 1999 – 1999 jir j, fi!LH wdfhdack

18. 18 rdPHfm!oa.,sl Pd;sl iuia:h Pd;sl fi!LH jshou Funding of national health expenditure 50%50% 3.4% of DGP-o< Pd;sl ksIamdokfha mqoa.,fhl= f,i Pd;sl fi!LH jshoï Wmfhda.s;djh Use of national health expenditure 51%49% 3.4% of DGP -o< Pd;sl ksIamdokfha mqoa.,fhl= ioyd frday,a fiajdj Hospital Services uq,H iemhqu Funding87%13% 1.4% of DGP-o< Pd;sl ksIamdokfha mqoa.,fhl= ioyd weoka ixLHdj Bed available 96%4% 3.0 per 1000 capita - mqoa.,fhl= ioyd fkajdisl frda.ska Inpatient admissions 96%4% 19.4 pre 100 capita -mqoa.,fhl= ioyd ndysr frda.s fiajdj frdy,a fkdjk fiajdj 26%74% 2.8% of DGP-o< Pd;sl ksIamdokfha mqoa.,fhl= ioyd frdy,a fkdjk fjk;a fiajd 27%73% Ndysr frda.s meusKsu 48%52% 3.9 per capita -mqoa.,fhl= ioyd Pd;sl fi!LH uq,H m%ldYh-2000 National Health Accounts

19. 19 Total Expenditure on Health at Current Market Prices, 1990-99 1990199119921993199419951996199719981999 Total public sources (Rs. Billion) 5.65.57.16.98.410.812.51417.719.2 Total private sources (Rs. Billion) 5.66.37.58.39.811.512.614.316.920 Total national expenditures (Rs. Billion) 11.211.714.615.318.222.325.128.434.639.2 Source: National health Accounts-2002 iuia: rdcH iy fm!oa.,sl fi!LH fiajdjka i|yd jshou 1990-99

20. 20 Source: National health Accounts-2002 National Health Expenditures by Source as Share of GDP fi!LH jshou o< foaYSh ksYamdokfha m%;sY;hla f,i

21. 21 Component of private Health Sector fm!oa.,sl fi!LH fiajdfjs wx.hka Private hospitals and nursing homes fm!oa.,sl frday,a iy ud;D ksjdi GPs full time (western & Indigenous medicine) fm!oa.,sl ffjµ jD;a;sljka ^ngysr foaYSh& Private practice of government health workers(MS, Dental Sur. Paramedics) rcfha fi!LH ldrH uKav, j, mqoa.,sl fiajd Private pharmacies -5000 fm!oa.,sl T!IO Yd,d Private laboratories -450 ridhkd.dr Private ambulance services.s,ka r: fiajd Contracting out of government services rdcH wxYh fj;,nd fok.sjsiqus.; fiajd Insurance companies. rCIK wdh;k Medical Manufactures /agents ffjµ ksYamdok ksfhdacs;hka f,I Traditional healers iusm%odhsl iqj lrkakka Quacks etc… iqÿiqlus fkdue;s ffjµ ‘ffjµjreka’ ^wOHCI-fm!oa.,sl ffjµ fiajd 2005&

22. 22 Source: CPCEH 2004 Contribution of Private Health Sector in Sri Lanka fm!oa.,sl wxYfha odhl;ajh

23. 23 fm!oa.,sl frday,a - jhT m<d;

24. 24 Source: CPCEH 2004 fm!oa.,sl wxYfha frday,a j, wdodhu

25. 25 This shows that estimated private health expenditure to grow from 30 to 34 Billion Rupees in 2002 to between 98 & 291 billion Rupees in 2015. Source: CPCEH 2004 fm!oa.,sl wxYfha jshou 2002 § ns,shk 30-34 jk w;r 2015§ ns,shk 98-291 jkq we;

26. 26 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004 fm!oa.,sl frday,a j, we|ka ixLHdj 1990 - 2001

27. 27 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004 Percentage distribution of private hospital beds by province, 2001 m,d;a wkqj mqoa.,sl frday,a we|ka m%;sY;h -2001

28. 28 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004 Private sector admissions as a share of total admissions in the country mqoa.,sl frday,a fkajdisl frda.Ska uq,q osjhsfka fkajdisl frda.Skaf.a m%;sY;hla f,i

29. 29 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004 fm!oa.,sl wxYfha fiajd iemhSu 1992 - 2001 fkajdisl ndysr

30. 30 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004 iuia: fkajdisl frda.S ixLHdj – fm!oa.,sl wxYh 1990 - 2001 fkajdisl frda.Ska we;=,;a lsrSu

31. 31 Source:Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004 iuia: ndysr frda.S fiajdjka – fm!oa.,sl wxYh 1990 - 2001 mqoa.,sl wxYfha we;s ndysr frda.Ska

32. 32 Current situation in partnership iyfhda.S;djfha jrA;udk ;;ajh 1.No proper legal frame work ukd kS;suh mokula ke; 2.No coordination between two sectors wxY foflys iyiïnkaO;djhla fkdue; 1.Private sector institutions are not registered in health department mqoa.,sl fi!LH wdh;k rcfha,shdmosxÑ lr fkdue; 2.No feedback mechanisms jsOsu;a ixksfjSok l%ufõohla fkdue; 3.No monitoring mechanisms wëÌK ms<sfj;la fkdue; 3.No participation in health planning & implementation fi!LH ie,iqï lsrSfï iy l%shd;aul lsrSfï iyNd.S;ajhla fkdue; 4.No quality assurance mechanism for private sector mqoa.,sl wxYfha ;;ajmd,k l%uhla fkdue; 5.No sharing of resources for the benefit to community fmd\q iïm;a mrsyrK l%ufõohla fkdue; 6. Wastage and Duplication of works lghq;= oaú.=Kùfuka iïm;a wmf;a hdu

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34. 34 Possible causes for weak partnership \qrAj, iyfhda.S;djhg fya;= 01. Lack of tradition in collaboration between two sectors. tjeks iïm%odhla fkdmej;Su 02. Objectives are differ tlu wruqKla fkd;sîu 03. The weak information system. ÿrAj, ikaksfõokh 04. Lack of capacity in public sector to manage and regulate relationship with private sector. mqoa.,sl wxYh iu. iïnkaO;d meje;aùfï oÌ;d rdcH wxYh fj; fkd;sîu 05. Political pressure. foaYmd,k n,mEï 06. Pressure from trade unions other stakeholders in health. jD;a;Sh iñ;s we;=,q wfkl=;a mdY_jlrejkaf.a n,mEï 07. Mistrust. wúYajdih 08. Weakly organized private sector in the country. mqoa.,sl wxYh ;=, ukd ixúOdkh ùula fkd;sîu

35. 35 cont….Possible causes for weak partnership 09. Strong public confidence on government health system 09. Strong public confidence on government health system (socio-cultural influences). (socio-cultural influences). rdcH wxYh flfrys we;s oeäúYajdih rdcH wxYh flfrys we;s oeäúYajdih 10. Weaknesses of private sector in maintaining quality assurance mechanism and fulfilling social responsibilities as expected by mechanism and fulfilling social responsibilities as expected by the people the people ck;d wfmaÌdjkag wkqj fiajh ie,iSug mqoa.,sl wxYh wiu;a ck;d wfmaÌdjkag wkqj fiajh ie,iSug mqoa.,sl wxYh wiu;a ùu ùu 11. Dependency of private sector on public sector for human resources mqoa.,sl wxYh rdcH wxYfha udkj iïm;a u; resources mqoa.,sl wxYh rdcH wxYfha udkj iïm;a u; hemSu hemSu 12. No legal framework for partnership kS;s iïmdok fkd;sîu kS;s iïmdok fkd;sîu 13. Less public interest. ck;d Wkkaÿj wvq nj ck;d Wkkaÿj wvq nj 14. Unsuccessful out comes from partnerships in other sector fjk;a wxYj, rdcH-mqoa.,sl iúnkaO;djhka widrA:l ùu fjk;a wxYj, rdcH-mqoa.,sl iúnkaO;djhka widrA:l ùu

36. 36 Outcome of weak partnership. ÿrAj, iyfhda.S;djfha m%;sM, 01. Uncoordinated activities. wixúOdkd;aul l%shdldrlï wixúOdkd;aul l%shdldrlï The health authorities have no information on private sector investments or activities and private sector, therefore not involved in national health policy formulation and their contribution towards implementation of national health strategies are not significant. The health authorities have no information on private sector investments or activities and private sector, therefore not involved in national health policy formulation and their contribution towards implementation of national health strategies are not significant. 02. Waste of resources from both sectors due to duplication or overlapping of investments. iïm;a wmf;a hdu 03. Lack of sound quality- assurance mechanism in private sector. mqoa.,sl wxYfha ukd ;;aj md,khla fkd;sîu mqoa.,sl wxYfha ukd ;;aj md,khla fkd;sîu 04.Increasing cost to the government in health care provision. rdcH wxYh wkjYH úhoula oerSu 05. Reluctance from donor agencies m%;smdok imhk wdh;k ukafoda;aidyS ùu

37. 37 Policy options in public-private partnership m%;sm;a;suh úl,am 1. A national policy should be developed to allow private and other non- government sectors to actively participate and contribute in optimum manner to achieve national health objectives in maximum cost effective manner. rcfha ueosy;aùfuka m%;sm;a;s ilia lsrSu’ 2. Policymakers should achieve this task with the participation and consultation with all internal and external stakeholders of health. ish,q odhl;ajhka iu. tl.;djhlg meñKSu 3. Formulation of guidelines and protocols for partnership, including modalities for monitoring. fldgialrejka ùu ms<sn|j ish,q kS;s iy Wmfoia iïmdokh lsrSu 4. Orientation of private and other non-government sectors on national health policies and strategies. wfkl=;a rdcH fkdjk iy mqoa.,sl wxY rcfha fi!LH m%;sm;a;s iy Wmdh udrA. ms<sn| oekqj;a lsrSu Development of consensus among all stakeholders on partnerships. mdY_jlrejka w;r wfkHdkH wjfndaOhla we;s lsrSu Cont..

38. 38 6. The areas of possible partnerships should be identified, both in central and peripheral level. fldgialrejka ùu wjYH wxY yÿkd.ekSu 7. Address to the barriers for partnership. ndOl yÿkd.ekSu 8. Capacity building and sharing of information in both sectors initially and provision of necessary assistance to the private sector for its development and participation. mqoa.,sl wxYfha iïm;a ixjO_kh i|yd iydh oSu 9. Formulation of coordinating committees in national and peripheral level. cd;sl iy m%dfoaYSh kshdul lñgq msysgqùu 10.Formulation of legal frame works for partnerships. kS;s iïmdokh lsrSu kS;s iïmdokh lsrSu 11. Operational research to evaluate the existing and identified areas of partnership. ióÌK u.ska l%shdldrlï we.ehSu ióÌK u.ska l%shdldrlï we.ehSu

39. 39 Areas where public- private sector partnerships could be established rdcH-mqoa.,sl iyfhda.S;djh we;s l<yels fldgia * Joint policy formulation bodies and coordinated implementation of national health strategies. of national health strategies. cd;sl fi!LH m%;sm;a;Ska l%shd;aul lsrSu cd;sl fi!LH m%;sm;a;Ska l%shd;aul lsrSu * Supportive services, Cleaning\Transport\ Training\ Security Wmldrl fiajdjka ^msrsisÿ lsrSu/ m%jdykh/ mqyqKqj/ wdrÌl fiajd& Wmldrl fiajdjka ^msrsisÿ lsrSu/ m%jdykh/ mqyqKqj/ wdrÌl fiajd& * Sharing of information f;dr;=re fnodyod.ekSu * Coordinated curative activities. taldnoaO m%;sldr fiajd * High tech laboratory & curative services wë;dlaIksl ridhkd.dr iy m%;sldr fiajd * Long-term care oS._ ld,Sk m%;sldr * Community based care m%cd fi!LH fiajd * Rehabilitation mqkre;a:dmkh * Coordinated investments. taldnoaO wdfhdackh * Training of human resource for private sector. mqoa.,sl wxYh i|yd udkj iïm;a ixjO_kh mqoa.,sl wxYh i|yd udkj iïm;a ixjO_kh * Quality assurance mechanism ;;ajmd,k l%ufõo

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41. 41 Possible stakeholder reaction wfmaÌs; m%;spdr 1. Possible antagonism by trade unions jD;Sh iñ;s úfrdaO;d 2. Political sensitivity foaYmd,k m%;spdr 3. Cooperation or resistance by health care managers fi!LH l<ukdlrKfha m%;sfrdaOhka 4. Low Interest from private sector mqoa.,sl wxYfha WodiSk nj 5. Possible resistance of private sector mqoa.,sl wxYfha m%;sfrdaOh 6. Support from donor agencies m%;smdok imhkakkaf.a iyfhda.h 7. Resistance from the public uyck úfrdaO;d uyck úfrdaO;d

42. 42 THANK YOU