Public-Private Partnerships A presentation on behalf the National Council for Health Policy and Planning Data from MoH, PCBS, UN-OCHA

WHO aims for PPP Encourage industry to abide by the health-for-all principles Facilitate universal access to essential drugs and health services; Accelerate R&D in the fields of vaccines, diagnostics, and drugs for neglected diseases; Prevent premature mortality, morbidity, and disability by giving special attention to policies and behavioral change; Encourage industry to develop products in ways that are less harmful to workers and the environment Acquire knowledge and expertise from the commercial sector

Palestinian Health Delivery System Large governmental delivery system at all levels Large delivery systems in the non-governmental and UNRWA sectors There is no consensus yet as to how the over all health system will be structured, how it will function, and funded

Summary of Service Provision (PCBS,2008) 2 Military Hospitals MoH 24 General hospitals 2 Military 414 Medical center 0 Maternity homes 0 Rehabilitation 46% of visits Non-MoH (UNRWA, NGO, for-profit) 25 NGO hospitals 25 private 11 Maternity homes 10 Rehabilitation 198 Medical center 53 UNRWA centers 54% of visits

Role of the Ministry of Health Largest insurer Largest single sector provider Largest contractor Most health providers depend of MoH and to a lesser degree UNRWA contracts for survival What is the future role of the MoH as a 1) provider 2)contractor 3) insurer 4)regulator?

Partnerships Issues in 2000 (October 2000 MoH & World Bank) General policies of, and commitment from, the Palestinian Authority with respect to health systems planning and organization Laws and regulations directly and indirectly related to the health system Quality assurance/improvement mechanisms Economics and financing Contracting mechanisms

Recommendations in 2000 The formation of a Public Private Sector Coordinating Committee Mandate, roles and responsibilities of, the committee Committee Action Plan that includes but is not limited to definition of contractual mechanisms and procedures for monitoring and evaluating contracted services There should be an executive body for NGOs which would represent NGOs in the West Bank and Gaza

Reform in the 9th Government Cabinet approved an MoH reform committee General targets were assigned One national workshop was conduct Emphasized the role of the planning unit and council in the MOH

New MoH National Approach 12th Government National Council for Health Policy and Planning Partnership through wide representation Strategic planning issues Health Reform Donor relations MoH policy and planning unit Operational and funded Erase culture of “referral abroad” Strengthen national insurance

Experiences in PPP in Palestine Primary care Clinic partnerships Red Crescent PMRS HWC Secondary/Tertiary East Jerusalem Hospitals Other non-for-profits For-profits Regional sensitivities

Experiences in PPP in Palestine Policy Council Thematic groups National committees University research Training Protocols Documentation Research

Contracting Environment Secondary and Tertiary Care Contracting is undertaken in an environment of Occupation Non-equity in access Physical mobility Socio-economy Technology restrictions The State is non-sovereign under its own jurisdiction Major advantage in that medical referrals re-connect the country

Clinical Services Contracting Current status and benefits to the MoH: Shift costs of capital investments, training and development MoH contracts and sustainability Legal framework – weak Financial feasibility of contracts – unrealistic Quality monitoring – casual Donors and philanthropy to the rescue (not-for-profit) Development Operations Training Quality Emergency Investors to the rescue (for-profit) Thus, the basis for contracting is non-representative

Contracts (MoH) Case of Hospital Contracting 75 million USD Number of contracts with non-governmental hospital in the West Bank = 31 Number of contracts with non-governmental hospitals in Gaza = 11 Number of contracts with hospitals in Jordan = 7 Number of contracts with hospitals in Egypt = 3 No contracts with Israeli hospitals Total number of contracts administered by the MoH = 52 Total amounts for contracting for 2008 = 75 million USD

Statistics-2008 (MoH) Examples of the higher case load referred outside MoH hospitals Oncology = 7125 Ophthalmology = 7637 Neurosurgery = 1529 Cardiac surgery = 1109 Nephrology = 1328 Cardiac Catheterization = 1794 Orthopedic surgery = 1960 Hematology = 1199 Radiology = 3144 Rehabilitation = 1666 Urology = 2207 Nuc. Med. = 1122

W.B. Statistics-2006 Percent cost of treatment outside MoH for 2006 (by country)

Analysis and Lessons MoH policy is clear in using local institutions Most referrals inside Palestine Gaza still has higher numbers Most emphasis on curative services…not screening and prevention No national economic reform plan to sustain health expenditure Still heavily dependent on donors

Clinical Services Contracting Current status and benefits to the Non-governmental & profit sector Partnering in 1°,2°,3° care Provides a security blanket for operations Complementary and non- competitive Erratic but assured funding from MoH Quality monitoring and outcomes minimal Partnerships provides funding opportunities Political empowerment (East Jerusalem)

Most Recent Initiative World Bank and MoH 2007 Established new contracting model Included all the stakeholders Initial establishment of the process and design Periodic review of the tenders ToR’s Allowed for political sensitivities Documentation is promising to address challenges Tender parts issued now Market confidence is still low due to prior experience Only effective and efficient implementation of this contract will push this reformed process to success

Partnership Challenges Services Levels Inclusions Quality Weak legal environment Pricing Operations Development Finance MoH as a purchaser has economy of scale Deficiency of Quality Monitors Maturing National Insurance System

The Internal Politics of Partnerships Causes for political support: Respond to need & public demand Reduce cost Create a Win-Win situation Causes for political resistance: Interpretations like: a Win for the non-governmental = Lose for the government A partner in success = a partner in control and jurisdiction

Contracting Reform Contract preparation Base on strategic national objectives derived from community demands, MoH unmet needs, health providers’ plans Detail comprehensive services: levels, inclusions, and quality standards Reference a clear legal / medico-legal framework Establish a feasible pricing system that allows for operational success at least Document clear measures of risks mitigation that includes awareness of risks Establish clear quality standards, documentation, and monitoring system that allows for adjustments

Contracting Reform Contract preparation (cont.) Create centers of excellence (main strategy) Draft plans that take in political considerations. It must be transparent Monitoring plan with provisions for adjustments and rewards Improve MoH capacity in overall contracting mechanism (contract unit or function)

Contracting Reform Contract implementation (MoH) Balance competition with complementation to drive quality up and prices down-not passive Communication constant and consistent with the community and stakeholders on expectations and standards Transparency in an economy where the contract can make or break an institution

Contracting Reform Contract Monitoring Programmatic performance Financial performance Quality performance Legal / medico-legal performance Outcomes research –medical, financial Consumer education and access to contract outcomes (use external bodies)

Conclusions PPP can make MoH more responsive to people’s needs Improve access to quality at low costs Enrich MoH experiences It can shift capital and development cost MoH can play a larger role in policy, regulation, quality and research Good contracting is a Win Win

Special Thanks to: Dr.wadah baaba DG,MoH…for referral statistics Council members…for input and editing