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Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
Dr Deoki Nandan
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Dr Deoki Nandan
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Dr Deoki Nandan

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  • 1. PUBLIC PRIVATE PARTNERSHIP IN HEALTH SECTOR: MODELS &amp; THE AGRA EXPERIENCE<br />Prof. Deoki Nandan<br />Director<br />National Institute of Health <br />&amp; Family Welfare, New Delhi<br />
  • 2. Public Private Partnership in Health<br />Definition:<br />Public-Private Partnership (PPP) is a collaborative effort, between private and public sector, with clearly identified partnership structures, shared objectives, and specified performance indicators for delivery of a set of health services (MOHFW,GOI) <br />
  • 3. Objectives of Public Private Partnership in Health<br />Improving access to essential services <br />Improving the quality of services available<br />Exchange of expertise<br />Mobilize additional resourcesfor activities<br />Improve efficiency<br />Better Managementof Health services<br />Increasing scope and scale of services <br />Increasing community ownership of programs.<br />Ensuring optimal utilization of govt. investment and infrastructure<br />
  • 4. Economies of Scale<br />Economies of Scale<br />Utilising Existing Capacity<br />Utilising Existing Capacity<br />Create Synergy<br />Create Synergy<br />Better Services<br />Better Services<br />Better Health<br />Targeting the Poor<br />Targeting the Poor<br />Flexibility in Action<br />Flexibility in Action<br />Resource Mobilisation<br />Resource Mobilisation<br />Technical Upgradation<br />Technical Upgradation<br />The Benefits of PPP are<br />
  • 5. Models of Public Private Partnerships in Health<br />Social Franchising <br />Branded Clinics <br />Contracting <br />Social Marketing<br />Build, Operate and Transfer <br />Joint Venture <br />Voucher System <br />Donations from individuals<br />Partnerships with Social Clubs and Groups (e.g. Rotary Club)<br />Involvement of Corporate sector<br />Partnership with Professional Associations<br />Capacity Building of Private Providers<br />Autonomous Institutions<br />Mobile Health Vans<br />Health Insurance<br />
  • 6. Social Franchising<br />“ A franchise is a contractual relationship between the franchiser and franchisee in which the franchiser offers or is obliged to maintain a continuing interest in the business of the franchisee in such areas as know-how and training; wherein the franchisee operates under a common trade-name, format and/ or procedure owned and controlled by the franchiser and in which the franchisee has or will make a substantial capital investment in his business from his own resources”<br />-International Franchise Association<br />
  • 7. The Merrygold Network (USAID, SIFPSA &amp; HLFPPT), Uttar Pradesh<br />Provides high quality MCH services at affordable prices. <br />Network comprises of seventy - 20-bed Merrygold Hospitals, 350 - Merrysilver clinics and 10,500 - Merrytarang Ayush partners. <br />The franchisees of this network are being provided training, marketing and quality assurance support<br />
  • 8. <ul><li>Controlling Quality of Services
  • 9. Positioning on Price/ Quality – Trade off between Social goals and Provider Satisfaction
  • 10. Understanding motivation of Clients for Accessing Services</li></ul>Challenges<br />
  • 11. Social Franchising - Criteria for Initiation<br />Revitalising present Government structure is slow<br />Resources required to expand public health infrastructure is enormous. <br />High demand but poor supply from government health institutions<br />Availability of vast network of private hospitals in places needed<br />When objective is to improve access to services on immediate basis.<br />Improve quality standards of private sector and provide high quality care at affordable prices<br />
  • 12. Branded Clinics<br />Chain of Clinics – Same Organisation<br />Cater to better-off clients – Market Segmentation<br />More Income More Sustainable<br />Eg. Butterfly clinics, titli centres in Bihar,MP<br />
  • 13. Example <br />With the support of States, an NGO Janani set up a network of more than 21,000 Titli (butterfly) centres and more than 500 Surya (sun) clinics in Bihar, Jharkhand and Madhya Pradesh. Surya clinics are referral clinics run by formally qualified, state-registered doctors in the towns.Titli centres are situated in villages and run by RHPs who have been trained to provide family planning counselling and sell non-clinical contraceptives.<br />
  • 14. Branded Clinics – Criteria for initiation<br />Need to expand services rapidly<br />Need to provide high visibility to services available<br />Offer a package of services selected for the purpose<br />Provide high quality services at comparatively affordable prices<br />
  • 15. Contracting – Contracting-in and Contracting-out<br />Legally enforceable Contract<br /><ul><li>Defined Set of healthcare services
  • 16. Quantity of services
  • 17. Quality of services
  • 18. Duration of Service Provisioning</li></ul>Private<br />Public<br />Remuneration<br />
  • 19. Contracting Out &amp; In<br />Examples<br />Contracting out<br />State Govts. Has contracted out few PHCs in Karnataka, Arunachal Pradesh to by Karuna Trust, VHAI <br />Subcentres in Uttarakhand to NGOs<br />Contracting in<br /> Human resources by almost all states under NRHM <br /> -Radiology, drug stores etc.eg. SMS Hospital, Jaipur <br /> -Diet, cleaning, laundry etc. in almost all states <br />
  • 20. Criteria for initiating Contracting-out<br />Difficult to manage government health units in remote and inaccessible areas <br />Utilization of services and performance levels are consistently low due to non-availability of staff <br />Aim is to put government health facilities to optimum use <br />Increase responsiveness of government health facilities to local needs through community involvement<br />
  • 21. Criteria for initiating Contracting-in<br />Improve efficiency levels of services provided<br />Make management of services more effective<br />Conserve scarce resources by cutting costs <br />Try out innovative approaches to improve efficiency and effectiveness<br />
  • 22. Voucher System/ Demand Side Financing<br />A voucher is a document <br />that can be exchanged <br />for defined goods or<br /> services as a token of payment (tied-cash).<br />Eg: AGRA, Hardwar<br />
  • 23. Voucher System – Criteria for Initiation<br />Improve access to services and provide choice<br />Where costs act as a major barrier to services<br />Existing public healthcare service delivery points do not have provision for all types of services<br />Inadequate knowledge about the value of services (e.g. importance of antenatal care)<br />Need to generate demand for healthcare services<br />Possible to do regular monitoring for ensuring quality standards<br />Training of providers and network with the people to ensure proper use of vouchers is possible<br />
  • 24. Donations From Individuals<br />Donations from <br />rich philanthropists<br />institutions<br /> Need for simple and transparent mechanisms to encourage donations<br />
  • 25. Partnerships with Social Clubs and Groups<br />Social Clubs like<br />Rotary<br />Lions’<br />They have been proven to be useful in:<br />Popularising reformed healthcare service delivery outlets<br />In communication campaigns <br />Management of camps on a large scale<br />Providing additional resources and technical expertise <br />Advocacy efforts<br />
  • 26. Involving the Corporate Sector<br />Organised Corporate Sector through<br />CII<br />FICCI<br />E.g. Indo-Gulf Fertilisers’ Health Initiative and recent Health Conclave by CII<br />Adoption of Villages for providing primary health care services – TVS -in Karnataka <br />
  • 27. Partnerships with Professional Associations<br />Expert Pool<br /><ul><li> IAPSM, IPHA
  • 28. FOGSI – Vande Matram scheme
  • 29. IMA – Aao Gaon Chalein
  • 30. TNAI
  • 31. Pharmacists Associations</li></ul>Protocols/ Quality Assurance/ Accreditation<br />
  • 32. Mobile Health Vans<br />Already implemented in inaccessible areas<br />Comprehensive Health Services<br />Fixed Journey Plans <br />Public Sector contribution Medical Officers and Medicines<br />Private Sector for Purchase and Management of Vans<br />These vans are useful in:<br />Provide access to services people living in inaccessible terrain<br />Make services available at central location to reduce travel time and costs of clients<br />Under NRHM many states have introduced this scheme <br />
  • 33. Health Insurance <br />CGHS – Tie up with private hospitals <br />RSBY – Empanelled private hospitals <br />ESIS - Panel of private hospitals &amp; empanelment of private doctors<br />
  • 34. Initiating Public Private Partnerships in Health<br />Prioritizing needs<br />Evaluating and analyzing the ground realities<br />Selecting the appropriate model<br />Piloting the model<br />Evaluating the pilot<br />Scaling up<br />
  • 35. Initiating PPP in Health - Vital Components: STRAIGHT<br />Identifying the SCOPE of partnership<br />Identifying the appropriate TARGET POPULATION<br />Selecting the RIGHT PARTNERSand theRIGHT MODELof PPP<br />Ensuring ACCOUNTABILITY of private providers<br />Ensure active INVOLVEMENTof the government<br />GENERATE SUPPORT of all the key stakeholders through IEC, advocacy and rapport building<br />HIGHLIGHT ACHIEVEMENTS of the partnerships<br />Build TRUST of all the partners and clients<br />
  • 36. Initiating Vouchers scheme for MCH care for BPL in Agra<br />
  • 37. The task was to bring <br />government health sector, <br />private health care providers,<br />NGOs <br />work together on one platform<br />and <br />Policy makers <br />To accept PPP in health as an implementable issue<br />
  • 38. Key policy makers were:<br />State Government<br />Health Department Bureaucracy-Principal Secy M&amp;H<br />Senior technocrats at state HQ<br />
  • 39. Existing Rules were……..<br />It cannot be done!<br />
  • 40. Principal viewpoints against scheme were…<br />Government-<br />Why should we give government money to private providers?<br />Private providers are profiteers, so why link with them? <br />It has not been done before so how can we do it now?<br />Health department Technocrats-<br />We give services for free! why should they get money for it <br />We will lose our constituency and control on public health<br />Private health care providers-<br />Government is corrupt, we will not work with them<br />
  • 41. Key supporters were<br />NONE<br />Except the funding agency<br />
  • 42. How we progressed<br />
  • 43. Signals<br />We compiled a data bank on<br /><ul><li>Existing health indicators in the district
  • 44. Comparative cost of treatment to patients in Govt. vs Private sector
  • 45. Percentages of un-served BPL patients in the state
  • 46. Comparative reach of private sector
  • 47. Increasing inclination of population towards private health care</li></li></ul><li>Consultation and Formulation<br /> Step-1<br /><ul><li>Called on the key government representatives to share data
  • 48. Discussed successful models to remove doubts
  • 49. Discussed the pro poor spectrum of this scheme
  • 50. Shared experiences from the other states/developing countries
  • 51. Tried to convince that this is cost effective</li></li></ul><li> Step-2<br /><ul><li>Called a consultative meeting of all stakeholders at Agra</li></ul>This included- Bureaucrats, Senior government officials,Nursing home Associations, IMA, Nursing council, Civil Society reps, Senior reform advocates and subject specialists<br /><ul><li>Had discussions, did documentation, developed models and presented findings to government with a draft plan recommendation</li></li></ul><li>Aggression<br /><ul><li>Followed up with fostering pressure groups inside </li></ul>state bureaucracy. Also aggressively advocated with senior <br />technocrats in health directorate<br /><ul><li>Sent the proposal to Government for ratification
  • 52. Confronted objections through evidence in hand</li></li></ul><li>Mechanism Proposed was…<br />SN MEDICAL COLLEGE AGRA <br />WITH REPRESENTATION OF <br />GOVT,NGOs,NURSING HOMES AND<br />DISTRICT ADMINISTRATION AS VOUCHER MANAGER<br />NGOs AS DISTRIBUTORS AND MOBILIZING PARTY<br />SELECT 5-10 BED NURSING HOMES AS SERVICE PROVIDERS<br />
  • 53. Government said no to SNMC as voucher managers<br />And proposed CMO in place to retain control<br />We said OK<br />Government asked: at what cost NHs <br />Will give services<br />We said cheap and not more than RGI figures<br />Government asked about NH accreditation criteria<br />We said that we will develop<br />Government asked the spread of Pvt facilities in Agra<br />We said we will survey<br />
  • 54. WE REDEVELOPED THE MANAGEMENT STRUCTURE <br />WITH CMO AS LEAD <br />WE SURVEYED AND MAPPED NHs in AGRA IN 3 MONTH<br />WE NEGOTIATED COSTS WITH NHs <br />IN JOINT CONSULTATIONS AND REACHED <br />THE BEST RATES IN INDIA IN 1 MONTH<br />WE DEVELOPED ACCREDITATION <br />CRITERIA FOR 5-10 BED NHs IN 2 MONTHS<br />WE DEVELOPED FIELD DEFINITIONS OF ALL MCH CLINICAL <br />SERVICES TO ENSURE UNIFORM STANDARDS AND QUALITY<br />IN 2 MONTHS<br />
  • 55. Implementation<br />State bureaucracy was now happy because they were leading the expansion<br />Nursing homes were happy on the proposed fund dispersal mechanism (advances ) and assured increase in patient numbers<br />Health technocrats were happy that they retained power<br />Politicians were happy as the scheme reaching their poor electorate<br />NGOs were happy on services they could do in the areas they work<br />
  • 56. THE PROPOSAL WAS SENT TO CHIEF SECRETARY <br />FOR RATIFICATION BY CABINET<br />
  • 57. AND WAS IMPLEMENTED!!!!!!!!<br />
  • 58. Evaluation &amp; Feedback<br />:<br /><ul><li>3 months later a review was done and additional grants </li></ul>were provided on field requirements, including refresher <br />trainings on clinical field definitions<br /><ul><li>Medical audits for quality assurance, financial audits </li></ul> for transparency conducted after 6 months <br /><ul><li>Additional NHs contacted and accredited
  • 59. Scheme expanded to two more Districts (One by UPHSDP)
  • 60. PPP is now an official government policy for all sectors in UP</li></li></ul><li>PPP is Likely Democracy- For the People- By the People-Of the People<br />
  • 61. PPP For People<br />
  • 62. Framework for Developing <br />Problem<br />Profile of Partners<br />Process of Building a partnership<br />Profit – Mutual Benefit<br />Phase – start small &amp; build<br />Proliferate –Grow, Expand, &amp; Sustain<br />Priorities &amp; Preferred group<br />
  • 63. Framework for Developing PPP<br />Policing – Mechanism of Monitoring &amp; Transparency<br />Politics – Governance, Administration, People’s audit<br />Protection/proof: A security system <br />Price: A cost share in terms of money/kind<br />
  • 64. Framework for Developing<br />Professional Network<br />Platform <br />Prize: Acknowledgement/recognition<br />
  • 65. PPP is a required PUNCH<br />
  • 66. Thank You<br />

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