Public-Private Partnerships: An experience from Kenya Presented by Dr. Sam Thenya, Group CEO, the Nairobi Women’s Hospital at the Cambodian National Forum on Public-Private Partnership in Health on November 7, 2012

Objective/purpose : To give insights on how the Nairobi Women’s Hospital/GVRC has been able to harness the power of PPPs, and in addition to highlight the PPP process To inspire Cambodians to embrace PPPs for healthcare to reap the benefits from PPPs 2 Scope: This presentation gives an overview of PPPs at the Nairobi Women’s Hospital/GVRC Expected results/outcome: Improved understanding of the potential that healthcare PPPs have in any developing country

3 NWH Hurlingham, the mother branch NWH Adams NWH Ongata Rongai Other branches: Kitengela – 2012 Eastleigh – 2012 Nakuru

The Nairobi Women’s Hospital/GVRC 4 Founded in 2001, the NWH/GVRC has for the past eleven years provided quality and affordable healthcare to Kenyans as well as medical and psychosocial support to survivors of gender-based violence Since our inception in 2001, we have seen over 600,000 patients while our Gender Violence Recovery Centres housed in all our branches have attended to over 22,000 survivors Our mission, “We are trusted with the healthcare of our women in Africa” is embodied in a unique model which incorporates the Gender Violence Recovery Centre (GVRC) in whichever region we expand to NWH has a Medical Training School with a School of Nursing and Healthcare, and a Waste Management arm with a commercial incinerator

General advantages of healthcare PPPs: Improved health care facilities with better services, better equipment, increased bed occupancy and access Reduction of child mortality rates through concerted efforts and eventual achievement of MDGs Increased participation of the private sector in healthcare More willingness by the public to contribute to the national health fund Increase in number of health facilities, especially in rural areas Improved monitoring and evaluation of state- and privately- funded projects through better project preparation, better risk allocation, increased transparency, wider quality control, and greater efficiency PPP encourages the private sector to be more involved in Corporate Social Responsibility activities, for example free medical camps etc 5

Step 1. Assess private health sector and policy environment Step 2. Dialogue to create shared vision and identify potential areas of collaboration Step 3. Agree on PPPs to carry out together Step 4. Take actions to implement PPPs together Steps to PPP engagement 6

1. Policy dialogue to engage the private sector 3. Partnerships to improve availability & accessibility of healthcare 2. Policy reform to create supportive environment for PPPs PPP framework 7

8 Staff at a strategy world café session

PPPs examples at the NWH/GVRC: Project title and timeframe: Change management and strategy alignment advisory support (2011 – 2012) Implementer: The Nairobi Women’s Hospital/GVRC Key stakeholders: Customers, staff, doctors, suppliers, government regulators and the general public Financial support from: The GIZ health sector Geographic areas and target group: Kenya – key stakeholders Objective: Strategic, managerial and organisational re-orientation of NWH/GVRC to improve its sustainability It was designed by Frank Kretchmar, Stepwise Management, Germany using findings from study of hospital and centre Through the PPP NWH/GVRC was able to formulate and implement a new robust strategy in form of a structure tree; and a business model (the caring and protecting cycle); train managers on critical professional skills such as leadership styles, problem solving and total quality advantage as well as coaching and mentorship There were no difficulties faced in the PPP approach; but as is expected the change process always has people and process challenges 9

10 Participants at a GBV training in Isiolo, Kenya

PPPs examples at the NWH/GVRC: Project title and timeframe: Emergency Response GBV/SRH and MCH Project (November 2011-March 2012) Implementer: GVRC/NWH Key stakeholders: Ministry of Health, District Security Group Members, Teachers, Community leaders and community Members Financial support from: The GIZ health sector Geographic areas and target group: Select Counties of Turkana, Kitui, Garissa, Isiolo, Wajir, Mandera, West Pokot, Makueni, Machakos, Samburu and Marsabit Objective: To develop the capacity of service providers and the community in the areas of Gender-Based Violence (GBV), Sexual and Reproductive Health (SRH) and Maternal and Child Health (MCH) in regard to emergency response It was designed by NWH/GVRC in-conjunction with GIZ The team was able to build capacity of service providers on GBV/SRH and MCH, perform job mentoring on GBV/SRH and MCH and attend to health needs of communities through medical camps 11

12 Sometimes, implementation of activities is delayed, especially at the beginning of the partnership, due to lengthy negotiations and discussions. However, upon signing the contracts, most of the time the projects’ implementation has been smooth, with few operational interruptions, mostly caused by local situations on the ground. For example this year, some GVRC activities were delayed due to national teachers’ and doctors’ strikes held countrywide, and as such, since both the teachers and doctors are key partners, most activities had to be postponed. More interaction with partner staff is encouraged for better understanding of issues on the ground, so as to enhance programming. Main challenges

13 Students at the2011 Graduation Ceremony

PPPs examples at the NWH/GVRC: Healthcare education is relatively expensive with a Diploma in Community Nursing costing between Kshs. 135,000 (USD 1,580) to Kshs. 250,000 (USD 2,925). This means a majority of students from poor backgrounds are unable to access this education. The NWH Medical training College is working with a scholarship program for health workers in Kenya designed by the Higher Education Loans Board (HELB) in collaboration with the Ministry of Medical Services and the Ministry of Public Health and Sanitation, and supported by USAID-funded FUNZOKenya to link would-be students with the fund. The project targets bright and needy students who are committed to becoming health workers and in-service health workers who would like to further their studies. This year one of our students was awarded a Kshs. 135,000 scholarship. It being our first year engaging with FunzoKenya, we hope to have more students from our Nursing School and Community health courses receive scholarships. 14

15 Incinerator

PPPs examples at the NWH/GVRC: Project title and timeframe: Establishing of hospital waste management according to NEMA (2009/2011) Implementer: The Nairobi Women’s Hospital Key stakeholders: The government, hospitals and clinic (public and private), waste collectors, general public Technical support from: The GIZ health sector Geographic areas and target group: Nairobi and its environs - key stakeholders Objective: Implementation of best practice in biomedical waste management and proper institutionalisation of waste management in Kenya It was designed by the GIZ and NWH team using local government body, NEMA and available international guidelines on healthcare waste management Through a social marketing campaign the project is able to inform, educate and empower the community on proper healthcare waste management 16

17 Surefire Manual load medical/general waste incinerator-TS200/4 Waste Density: kg/M Waste CV: 3,000KCAL/kg Moisture Content: 10-25% Estimated Ash Residue: 5-10% Nominal Capacity: 200Kg/hour batch load Secondary Chamber: 0.5 second at 850◦C Environmental: World Bank & World Health Organization Emission Standards, UK Clean Air Act 1999, BS Incinerator specifications:

18 Initial outlay Amount in Kshs. Enviromental Impact Assesment EIA) 175, Submission of report to NEMA 10, purchase of incinerator 14,544, Installation site 1,391, Incinerator Operating license-Application form 3, Incinerator Operating license (Annual Fee) 75, Truck 2,500, Weighing Scale(500kg) 50, Safety Attire (2) 80, Metallic ash bins(200L)(3) 6, Storage cage(2) 80, Signage 5, Additional Equipment-Fire extinguisher & First aid kit 10, Total 18,929, Recurrent Costs Garbage collection 80, Fuel(NWH waste only) 2,064, Maintenance/service) 12, Total 2,156, Grand total 21,085, Cost:

19 The tower Challenges: Before GIZ support the NWH had no technical knowledge/experience on health waste management The GIZ technical consultant found technical differences in what had been ordered and what had been delivered The project had a huge initial outlay (>Kshs. 20 million) Being located in a residential area the incinerator had to be of unique specifications (for example, the chimney had to be 3 metres taller than the tallest building)

Conclusion: 20 We at the NWH/GVRC believe that PPPs do work and we are grateful to GIZ for the help it has given throughout these projects. We plan to implement the waste management project in all our branches and future branches outside Nairobi - in Nakuru, Kisumu, Mombasa. To conclude, I would like to urge the private sector and the government to come together and find suitable PPP models for health care, as this is a win-win partnership for all parties involved.

21 The incinerator launch, 2011