presentation is all about ppp in one hand and ppp in health on the other. ppp is not only remain as collaboration for the use of government mobey by the private party but now has legal and administrative aspects as well. however, to make ppp as vibrant and result oriented, mutual trust has to biult between both the parties that would be supplemented by some successful cases of ppp specially in health sector.

1. Public Private Partnership in Health
Service Delivery
Digvijay Trivedi
MBA (HR), MA(Eco.) PGDCPM, PGDRD

2. Public Private Partnership

3. Setting the tone…..
A quick introduction to Public-Private Partnership.mp4

4. WHY PARTNER WITH THE PRIVATE SECTOR?

5. Omnipresence of Private Sector
• 93% of all hospitals
• 64% of all beds
• 80% doctors
• 80% of OP and
• 57% of IP ….are in the Pvt. Sector
(World Bank 2001)
• Estimated at Rs. 1,56,000 Cr. in 2012 +Rs. 39,000Cr. for health insurance
(NCMH 2005)

6. Share of Pvt. Sector-
Non- Hospitalized care (60th NSS-2004)
0
10
20
30
40
50
60
70
80
90
100
79
95
79
32
66
77
49
84
56
82
90
8180
89
82
14
84
77
46
82
47
65
87
80
Rural Urban

7. Share of Pvt. Sector-
Hospitalized care (60th NSS-2004)
73
86
69
22
60
42
21
71
48
57
73
21
58
64
79
74
11
71
52
27
74
36
66
69
35
62
Rural Urban

8. Implications
>80% of health expenditure is out-of-pocket
(World Bank 2011)
Debilitating Effects on the poor: Liquidation of
assets, indebtedness. 40% of hospitalized & 2%
in the country every year end up BPL
(World Bank, 2001)
Compounded by poor regulation of private sector
14%
86%
Out of pocket expenditure in
health
Government Expenditure Out of pocket expenditure
Source: www.data.worldbank.org

9. Private sector is needed because...
India needs an additional
7,50,000 beds
5,20,000 doctors
Overall investment Rs 1,50,000 Cr.
80% likely to come from the private sector (NMCH,2005)

10. PPP Approach
PPP
approach
•Attract private investmentsGoal
•Lack of Budgetary Resources
•Need to improve efficiency in service delivery
Need
Private Sector contribution for: Public Sector contribution limited to:
Financial investments
Best Management practices
Efficiency in service delivery
Efficient use of capital resources
Providing institutional commitment
Project Development
Selection of Developer
Viability gap funding (VGF), if any

11. PPP MODELS & TYPES
Not all interactions between the Government and
Private sector are PPPs

12. Putting the projects on “shelf”
Project
Preparation
Partnership
Management
Project
Identification
Viability Structuring Do-ability
Procurement
Strategy
Bid Process
Management
Operations
Management
Identification/
Assessment

13. Financing vs Delivery: Public vs Private modes
Public Provision Private Provision
Public
Financing
Public Hospitals
Voucher
Contracting
Insurance
Private
Financing
User Fee
Hospital Autonomy
Private Hospitals

14. Common PPP Models
• Contracting (‘in’ and ‘out’)
• Joint Ventures
• Build/ Rehabilitate, Operate, Transfer
• Health Financing (Vouchers, CBHI, Illness fund)
• Mobile Health Units
• Franchising
• Social Marketing
• Technology demos (e.g. Telemedicine)
• Public-Private Mix

15. Core Principles of Partnership
True partnerships entails
• Relative Equality between partners
• Mutual Commitment to Public Health objectives
• Benefits for the Stakeholders
• Autonomy for each partner
• Shared decision-making and accountability
• Equitable Returns / Outcomes

16. PPP Models in Practice

17. Demand side Financing- Voucher Scheme
Voucher Scheme, ANC, PNC Institutional
Deliveries
Primarily for poor

18. Demand side Financing- “चिरंजीवी, यशस्ववनी”
Chiranjeevi Yojana,
Gujarat
Institutional deliveries through
private obstetricians and
gynecologists
Scheme is primarily for women from poor
families, with prior ANCs from a govt.
hospital
Yeshasvini Health
Insurance Scheme
Karnataka
Hospitalization and care for more
than 1600 surgeries
Only for the members of farmers’ co-
operatives and their dependents

19. Social Franchising
Social Franchising, ANC, PNC Institutional
Deliveries
Primarily for poor

20. Ambulance Service
Ambulance service ANC, PNC Institutional Deliveries,
sick child, Emergency services etc.
Primarily for poor

21. Mobile Medicare Units
Uttaranchal Mobile Health and
Research Clinic
Clinical & Radio diagnostics through
health camps, lab tests
Free to all BPL cardholders

22. Contracting Out
SMS Hospital
Jaipur Rajasthan
Radiological (CT/MRI Scan)
Diagnostics
Free for all BPL Patients; Subsidized
rate for others

23. Build, Operate, Transfer
Karuna Trust,
Karnataka
Management of PHCs and sub-
centers; 24-hrs clinical services
Free services- diagnosis,
consultation, treatment and drugs

24. Contracting in
Karnataka Integrated
Tele-medicine & Tele-
health, Chamrajnagar
Tele-diagnosis and
consultation in cardiac care
and specialist care
Free diagnosis, medicines and
treatment for the BPL patients

25. EMERGING MODELS
• Regional Diagnostic Centres- Hub/Spoke
• Medicity
• Co-location of Specialty services
• District Hospital + Medical College (Hub)
• Franchised /Accredited Health Units
• Private surgical teams

26. Key Lessons & Challenges in PPP:
Indian Experience

27. Political and Administrative Commitment
• Half hearted support for PPP
• Policy makers enthusiastic but lack of positive outlook
amongst implementors
• Misunderstood as ‘privatization’
• Lack of Trust on both sides

28. Institutional Capacity
• Requirement for technical/ managerial skills for designing,
negotiating, implementing and monitoring PPP contracts
• Lack of institutional capacity at all levels, including
oversight role
• Administrative framework and readiness to meet
requirements

29. Policy and Institutional Framework
• Lack of policy driven strategy
• Lack of information on Private sector thus poor regulatory
leverage
• No institutional structures to manage PPP contracts
• Non functional specialized PPP cell

30. Diversity and Complexity of Private Sector
• Private sector is diverse; Predominantly individualistic
(owner operated units) and in both recognized and
unrecognized systems of medicine;
• Diversity of tariffs, thus complicating information on cost
vs tariff and tariff negotiations

31. Risks
•Private partner- Non-timely release of funds; Fear of
enquiry
•Government- unsuccessful/ failed contract leading to
lack of services – patients suffer, resources wasted

32. Few Constraints
• Payment delays
• Personality styles and trust level
• Local political interference / political flip-flaps
• Lack of capacity or willingness to supervise / monitor / guide the
project
• Perceptual and attitudinal orientation to private sector

33. Limitations in Contract Features
• Defining & verifying beneficiaries (BPL patients)- especially high
cost services
• Defining Quality or Performance or Outcome indicators
• Supervision and Monitoring mechanism
• Timely revisions / updating of contract
• Ombudsman for dispute settlement
• Clarity on user fee

34. Enabling Environment
• Successful partnerships are contextual
• Enabling conditions include
• leadership from both partners
• prior consultations
• relational / trust based contracting
• pilot testing
• timely payment
• periodic review and amendments / revision of contract
• specific performance indicators

35. Conclusion
• Public-private partnership (PPP) is not privatization
• Government continues to play a key role
• Requires high degree of institutional capacity

36. Contd…
• It does help in benefiting the poor.
• It is one of the pragmatic options for health service delivery, but
not an alternative to public delivery or better governance.

37. THANK YOU