ENGAGING PRIVATE SECTOR IN PRIMARY CARE FOR UHC A.VENKATRAMAN Faculty of Management Studies (FMS) University of Delhi UHC DAY, 12TH DEC., 2017

WHY P.S.E. IS CRITICAL IN INDIAN CONTEXT? DEMAND FOR HEALTH INFRA. MORE HUMAN RESOURCES MORE HOSPITAL / BEDS OPTIMAL USE OF PUBLIC FACILITIES LARGE VACANCIES LACK SPECIALTY SERVICES PROTECTING THE POOR FROM OOP PAY FOR SERVICE STRATEGIC PURCHASE 1.8 million additional beds by 2025 (Bains Report) to reach 2 beds per 1000 (In China it is 3.8 beds per 1000) 250,000 doctors for 1:1000; 1.2 Million if 2.5 doctors per 1000 Investment of US$ 60 Bill or 1.62 lakh crores >30% of PHCs unstaffed >80% specialist positions vacant >85% of population not insured A.Venkat Raman, FMS-Delhi Univ

Share of Private Sector in Inpatient Care in India (3 decades) But dependence on public health facilities has risen by 6% for OPD and 7% for IPD between 2004 to 2015- mostly among rural women mostly for institutional deliveries (Janani Surakhsha Yojana) A.Venkat Raman, FMS-DU

A.Venkat Raman, FMS-Delhi Univ Kapoor, Raman , et al (2012) How Did the TB Patients Reach DOTS Services in Delhi? A Study of Patient Treatment Seeking Behavior. PLoS ONE 7(8) August A.Venkat Raman, FMS-Delhi Univ

PPP/PSE MODELS IN HEALTH SECTOR (Venkatraman, 2012) INFRASTRUCTURE PPPs Variants of Design, Build, Finance, Own, Operate, Lease, Transfer Models (DBF, BOO, BOOT, BOLT) Joint Ventures Financing (PFI, VGF) Land/ Tax Concessions SERVICE DELIVERY PPPs (Clinical/ Non Clinical Services) Contracting ('in' & 'out') Management Contract Co-location Franchising FINANCING / PURCHASING PPPs DSF (Vouchers/ Health Cards/ Coupons Conditional Cash) SSF (Incentive) Community Based Health Insurance Social Insurance/ Illness Assistance fund STRATEGIC PURCHASING OTHER P.S.E. OPTIONS Public Private Mix Technology Demo. (e,g. Telemedicine) Social Marketing Drug Research Capacity Building/ Human Resource Self Regulation (Networks/ Alliances) MODELS A.Venkat Raman, FMS-DU

MODELS OF ENAGAGING PRIVATE SECTOR IN PRIMARY CARE SCOPE OF SERVICES Management Contract Contracting Out/ In Franchising Social Marketing Demand Side Financing Supply Side Financing Community Based Health Insurance / Social Insurance Grant-in-Aid Tele-health/Informatics PHC / CHC Facility Management MNCH/ RCH Services (Delivery, IMNCI, Birth Control) Disease Control (TB, HIV) Mobile Medical Units-Boats Diagnosis/ Screening Community Mobilization IEC/ Advocacy/ Capacity Building Emergency Response Dental/ Eye Care

Private Sector in TB Control under UATBC, BMGF © Bill & Melinda Gates Foundation | © Bill & Melinda Gates Foundation

PHC Management Contract- Karuna Trust © Bill & Melinda Gates Foundation |

AP Free Diagnostics Scheme Source: WHO (2017) Evaluation of the Free Diagnostics Scheme in the State of Andhra Pradesh: Draft Report

Source: World Bank: Integrated Primary Care Model in Uttarakhand (Proposed)

Engage the Private Sector?….. Bah!… Yuck!! How dare!!! SELL-OFF!!!! WHAT DOES WORKING WITH THE PRIVATE SECTOR MEAN????

ISSUES AND CHALLANGES Mapping Private sector and its Capacity Diversity of capacity, quality, and regulatory oversight Purchasing from Primary Care Providers? Interface Agency? Political and Administrative Commitment PSEs cannot be ‘Relational / Good faith Contracts’ Hostility towards PSE / PPP- Cognitive level distrust Lack of Continued Dialogue with Key Stakeholders Clarity of Objective for PSE / PPP Define what is expected of the Private Sector under PSE? (Define level- Performance, Outcomes, Impact) Have realistic expectations

Policy, Regulatory and Institutional Ecosystem Policy based approach to Private Sector /PSE/PPP – Build Regulatory and Legal Framework Technical and Managerial Capacity Dedicated Organizational Units and Systems Capacity (Expertise) to design, implement and evaluate Contracts Dedicated Financing and Purchasing Modality PPPs fail due to Payment Delays Same tariffs for public and private sector under purchasing? Costing, Tariffs and Purchasing Modality

States State PPP Policy Andhra Pradesh Assam Bihar Chhattisgarh Goa PPP Legislation PPP Guidelines PPP Cell Health Sector PPP Policy Health Sector PPP Cell Andhra Pradesh × D √ √ F Assam √ P Bihar √ A Chhattisgarh Goa Gujarat × S Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Meghalaya Odisha Punjab Rajasthan Tamil Nadu √ F/A Telangana Uttar Pradesh Uttarakhand West Bengal

No Single ‘fit all’ model for PSE Contract: Contextual Design Private Sector Is Private Sector is keen to partner? Contract Design and Management: Move away from Traditional Tendering / Procurement (Input criteria) to Performance based contracting Clearly define the Scope of Services; KPIs; Governance Structure and Oversight; Monitoring; Dispute settlement; Renewal; Create Awareness- More detailed more Complex

PRIVATE SECTOR ENGAGEMENT: IDEAL STRATEGY (Venkatraman, 2012) E PPP/ PSE (Infra, Delivery, Financing) Institutional System (Policy, Unit, Capacity-M&S, Payment) Licensing Regulation STAKEHOLDERS & ECO SYSTEM Quality & Accreditation

PPPs ACROSS THE WORLD (KPMG, 2017)

Thank you !!! avr@fms.edu