1. INTEGRATED INFRASTRUCTURE DELIVERY – FINDING A PPP MODEL

2. Integrated Approach Hospital Revitalisation Infrastructure Management The integrated approach to Infrastructure Delivery entails that all the facets of the infrastructure and aspects that will impact on the design and construction of a facility must be addressed up-front and throughout the infrastructure delivery process in order to achieve a fully functional facility that addresses the needs of the community it is meant to serve

3. Composite Functions Strategic planning Facility planning & Costing Design & construction Equipping HT & ICT Staffing & Organisational development Commissioning & Operationalisati on Facility Management & Maintenance

4. Health Planning. Macro – Strategic Level  Develop Standards and Norms  Develop Service Transformation Plans  Develop Referral Pathway Structures Facility Level  Business Cases/ Feasibility Studies  Health Briefs  Operational Narratives  Accommodation Schedules  Room Data Sheets  HT Schedule  Staffing Complement  Design Brief Strategic &

5. Facility Design.  Rezoning, subdivisions and consolidations  Environmental Approvals  Bulk services reports  Traffic Impact Studies  Master planning  Architectural design  Engineering design – civil, structural, mechanical electrical & electronic  Peer reviews & value engineering  Approvals from relevant authorities  Building contractor procurement

6. Project Management.  Site handover: construction process  Monitor and manage: - Construction Program - Quality Assurance and Cost Control - Health and Safety Management  Legal contract compliancy  Technical Support  Financial Control  Progress reports  Practical Completion and snagging  Building Commissioning Construction

7. Technology.  Health technology gap analysis  HT- schedule – start with Health Brief  Development of specifications  Lead time management  Space and fitting implications  Equipment procurement process  Program and oversee supply and installation  Technical training on equipment  Maintenance Manuals Health

8. eHealth  ICT Gap analysis  Integrated Platform and Interoperability  eHealth – telemedicine  Digital equipment  Lead time management  Equipment procurement process  Program and oversee supply and installation  Technical training on equipment  Maintenance Manuals ICT &

9.  Organizational Development  Change (Behavioural) Management  Business re-engineering  Quality of Care and Customer satisfaction  Quality Assurance  Business flow and administration systems  Functional Narratives  Monitoring & evaluation methodology Organisational Development

10. Logistics & Operationalisation  Logistical Program  Physical move  Testing of equipment and systems  Operational Training  Hand-over  Commissioning of facilities  Clinical Handover  Decanting of patients  Operationalisation

11. Facility  Maintenance Plans and Programmes  Maintenance needs for equipment and life cycle management  Clinical engineering  Develop facility management options for buildings  Planning routine and incidental maintenance  BMS – Building Management System  Management of facility maintenance progra m  Control Centre: Call Centre and Maintenance Inspectorate Maintenance

12. Facility  Facility Management regime  Building Management Systems  Energy management  Cleaning Services and Infection Control  Security  Porter Services  Garden Services  Security  Mortuary  Hotel Services  Laundry  Catering Management

13. C onsidering PPP’s. What motivates our interest in considering PPP as a model  Are we looking for a funding model  Provider of funded infrastructure  Provider of facility management services  Provider of maintenance  Provider of funded and maintained equipment  Provider of Clinical services Or a combination Are we really looking for a partner

14. PPP Models.  Most Comprehensive – Where the Private Party  Designs, builds, equip, finances, maintains, do facility management, staffing and clinically operates  Clinical services to public patients at a unitary fee per patient with a fixed fee component  With the right to treat private patients for its own account In this model is Government not essentially outsourcing its constitutional responsibility? Most of the time we find that Government wants to retain the clinical operations – and rightly so

15. PPP Models (Continued...  Question is whether the Comprehensive Model can work on the various levels of care  Primary Health Care (Clinic) and Community Health Centre  District, Referral and Tertiary Hospital  Answer is probably at the first two levels not at all  At the other three levels it could probably work – but in an adapted format  Where it could work is for specialist units where special centres of excellence can be created and where the population does not justify duplication of facilities  i.e. cardiac centre, oncology centre and high tech facilities such as imaging, CT-scans etc.

16. PPP Models (Examples....  If it is not the comprehensive model we must consider what the PPP service-package would encompass:  What is popular is packages for delivery of a specific service which is structured as a PPP rather than outsourcing  Typically where there can be centralization of services -  Laundry  Kitchen/catering  Pharmaceutical  Laboratory

17. PPP Models (Examples....  PPP at the Universitas Hospital in Bloemfontein – Netcare provided and runs a component of the hospital with public and private patients  Inkosi Albert Luthuli Central Hospital – Impilo Consortium supply, own, maintain and life cycle management of equipment and ICT & provide services cleaning, security, parking, laundry  Few PPP’s where Life Health runs a private ward in a district hospital in exchange for upgrade facilities provided to the public side of the hospital

18. PPP Models (Examples....  Limpopo Provincial Department of Health and Social Development had a hybrid PPP model for infrastructure delivery  Operated on the principles of a BOT – Design Build Operate and Transfer  The design, construction, commissioning and maintenance responsibility and risk were passed to the Private Party  Still funded by the Department  Period covered design, construction and commissioning with a 5-year facility maintenance obligation

19. PPP Models (Question....  Are we not looking for a model that can deliver with the capital outlay of the Private Party - infrastructure and equipment, maintenance and life cycle replacement, complemented by specific FM services, i.e. security, cleaning, gardening, at an affordable unitary fee within a regime of performance indicators and penalties that can create the environment for Government to deliver its core function of medical and clinical services to the public?  If that is so, are we not essentially looking at an Accommodation PPP Model?

20. PPP Models (Accommodation...  Accommodation PPP Models generally works because the service delivery indicators and matrix of risk transfer can be concretely defined – costs are known and risks can be properly priced.  South Africa examples of successful accommodation PPP’s – Head Office PPP’s for DTI, Foreign Affairs, Basic Education  Typically the Private Party is responsible for design, finance, build, maintain, life cycle management and replacement and management of utilities all within a clearly defined set of user requirements, performance indicators and a penalty regime

21. PPP Models (Accommodation...  Concession Agreement for twenty five (25) years inclusive of the design and construction to commissioning period  Serves as an incentive to get to commissioning as soon as possible as the payment of the unitary fee only commences on commissioning  BOT – Build Operate and Transfer – including design and finance  Unitary fee tied to an index like CPI  Certain rates (like for utilities) may be reviewable or adjustable  Replacements costs reviewable 5 year intervals

22. Commitment to PPP.  Government must make a clear commitment to PPP’s as an infrastructure delivery model  Government must have a clear definition of what it wants to achieve through a PPP Model and the model must be clearly defined  Turnaround time on PPP process must be reasonable from EOI – RFP – Preferred Bidders – BAFO – Financial Close  If this is not there and proven - Private Sector will loose confidence and loose interest and will over- price or not participate sufficiently to provide a broad base of competition

23. Advantages PPP.  Advantages are that a capital budget gets converted into a unitary fee structure and more facilities can be delivered with the same amount of money  Private Party best placed to manage and control infrastructure delivery, maintenance and life cycle management and facility management  Government can focus on their core constitutional function of service delivery

24. & Questions Answers