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Public-Private Partnerships for Health Service Delivery in Africa: Three Myths to Destroy & We Public-Private Partnerships for Health Service Delivery in Africa: Three Myths to Destroy & We Can’t Continue Business as Usual Tonia Marek Lead Public Health Specialist, The World Bank Cambridge, March 2006

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

Who finances health ? Who finances health ?

The three myths • Health is mainly financed by the public sector • The The three myths • 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 not very developed in Africa

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

Existence of a large private sector Ex. Tanzania (2000) Public District hospitals Specialized clinics Existence of a large private sector Ex. Tanzania (2000) Public District hospitals Specialized clinics Dispensaries X ray units Laboratories Other hosp. (not regional) Private 81% 74% 68% 30% 10% 7% 19% 26% 32% 70% 93%

Existence of a large private sector Continent MDs working in the private sector ----------------------------ASIA Existence of a large private sector Continent MDs 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%

Existence of a large private sector The private sector also delivers prevention services Ex. Existence of a large private sector The private sector also delivers prevention services Ex. Nouakchott, Mauritania: Public Infant consultations Prenatal visits Deliveries Private 75% 93% 25% 9%

People are voting with their feet. . To what extent is the private sector 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 Malawi, 2000 Mali, 1996 Niger, 1998 Cameroon, 1998 Benin, 2001 Guinea, 1999 74% 69% 59% 44% 41% 38% by the 20% richest 71% 58% 28% 52% 58% 55%

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

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

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

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

Operating hours per day in public and private facilities Cambodia Public N=27 -Average weekday Operating hours per day in public and private facilities Cambodia Public N=27 -Average weekday hours -Average weekend hours Private N=31 6. 6 0. 0 11. 3 11. 7

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

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

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

Parallel payments Guinea’s 2 main public hospitals (MOH, GTZ study, 2003) Official tariff -External Parallel payments Guinea’s 2 main public hospitals (MOH, GTZ study, 2003) Official tariff -External consultation -Hospitalized patient Average paid 1, 700 FG 6, 500 FG 22, 000 FG 225, 000 FG

The private sector faces the same problems as the public sector % failure of 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: Vendor/shop: Health center: Teaching hospital: Pharmacy: 70% 50% 46% 44% 43% An example of solution: Kenya’s CFW Shops franchise operates over 40 essential drug outlets

The private sector faces the same problems as the public sector Quality of care: 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

The private sector faces the same problems as the public sector Two examples of The private sector faces the same problems as the public sector Two examples of solution: training and franchise Kenya’s 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

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

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

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

Results in Hyderabad, India Parameter NGO MOH No. of TB cases detected per year Results in Hyderabad, India Parameter NGO MOH No. of TB cases detected per year 563 466 Treatment success rate (%) 94% 80% Total cost per successfully treated patient ($US) $118 $138 $88 $98 Total cost per patient treated

PPP pitfalls to avoid: inefficiency of public-private alliances Contracts with NGOs (ex. of the 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 didn’t describe the services which the NGO - must provide and none had specific objectives none includes an incentive or disincentive system; 84% of contracts don’t have a clear definition of the costs 70% don’t establish who will monitor the contract more than 30% don’t mention the contract’s duration

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

The Legal Framework for Contracting • A General Health Law : - establishes the The Legal Framework for Contracting • 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 : - establishes the necessity for the public sector to contract and buy services from the private sector

The Legal Framework for Contracting A Social Security Law : Sets a pre-paid modality 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.

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

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

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

Types of PPP • Contracting • Franchising • Concessions • Leasing Types of PPP • Contracting • Franchising • Concessions • Leasing

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

Types of PPP • Contracting • Franchising • Concessions • Leasing Types of PPP • Contracting • Franchising • Concessions • Leasing

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

We can’t continue business as usual THE WORLD BANK & THE PRIVATE SECTOR REVIEW We can’t continue business as usual THE WORLD BANK & THE PRIVATE SECTOR REVIEW OF 40 PROJECTS • 1994 -98: 23% of projects with high PPP 1999 -2003: 57% of projects with high PPP • 33% of projects had no mention of private sector • Successes: - NGOs/Communities in nutrition - Communities in reproductive health

We can’t continue business as usual Adapting the World Bank for PPP • Conduct We can’t continue business as usual Adapting the World Bank for PPP • Conduct systematic assessment of private • • • sector in countries Seek support from private sector expertise to help Bank’s staff Need for more Bank’s management commitment of the institution on PPP Establish direct channels with private sector Set up a PPP fund to complement operations Donor coordination to limit # of procedures

We can’t continue business as usual: Adapting the public sector for PPP • Strengthen We can’t continue business as usual: Adapting the public sector for PPP • Strengthen the Role of the State to carry out its essential functions: Ø Policy setting Ø Resource generation Ø Health system financing Ø Regulation Ø Quality control Ø Monitoring Ø Information dissemination Ø Strategic purchasing

We can’t continue business as usual: Adapting the public sector for PPP • Capacity We can’t continue business as usual: Adapting the public sector for PPP • Capacity enhancement of Government, decentralized bodies, for contracting through training, lessons learnt. . .

We can’t continue business as usual: adapting the private sector for PPP • Get We can’t continue business as usual: adapting the private sector for PPP • Get organized to ease dialogue • Gain a place at the policy table

We can’t continue business as usual: 5 points to keep in mind to promote We can’t 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

We can’t continue business as usual: 5 points to keep in mind to promote We can’t continue business as usual: 5 points to keep in mind to promote PPP 3. Expand Contracting: Given the results so far, 4. 5. contracting may make a real difference in achieving MDGs. Evaluate: Evidence is good but not great. Debate on contracting should be decided by evidence 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. )

Resources on PPP www. msh. org (publications) www. opus. co. tt/ihsd www. advanceafrica. org Resources on PPP www. msh. org (publications) www. opus. co. tt/ihsd www. advanceafrica. org (best practices) www. idd. bham. ac. uk/serviceproviders/stage 2. htm (case studies) www. ihsd. org (purchasing) www. worldbank. org/hsd (health systems) www. nigi. org (contracting) www. cmsproject. com (provider network)

Resources on PPP Training www. hsph. harvard. edu/ihsg. html www. worldbank. org/wbi/healthflagship www. ncppp. Resources on PPP Training www. hsph. harvard. edu/ihsg. html www. worldbank. org/wbi/healthflagship www. ncppp. org/training/ncppp. html