An innovative public-private partnership

ForRCH focused healthcare to the urban

poorDr Hemant Kumar

MBBS; MBAConsultant – Health systems developmentSector Investment Program, Haryana

Swasth KutumbSwasth Kutumb

Problem statement

To provide affordable and accessible quality primary health care with a particular focus on RCH services - to the urban poor population in the state.

Absence of appropriate & affordable health providing infrastructure/ services for urban poor

Situation Analysis Health indices among the urban poor

are consistently worse as compared to the rural population in the state.

Situation Analysis - II

Utilization of public health facilities very poor – just 6% of all deliveries take place in public health institutions

Infrastructure set up cost very high – yet no guarantee of optimal utilization

State has a robust private health sector with significant spare capacity – more than 75% people use pvt sector.

Swasth Kutumb

Public Private Partnership model to provide quality healthcare to the urban poor.

Utilize the existing infrastructure and trained manpower in the private health sector.The government provides back up support, monitoring and regulatory mechanism.

Process of evolution of the project

MoHFW funds available for urban RCH projects.

Basic framework design in the dept of health

Wide ranging consultation with PHPs/IMA

Rapid urban survey to assess present health

seeking practices

Iterative meetings with GoI

External assessment by AFF

Beneficiaries

Urban poor in four district headquarters.

Includes the BPL population and families with a monthly income of less than four thousand per month.

An estimated 30% of the DHQ population would be covered.

Basic mechanism Identified Private Health Providers – PHPs

would be assigned a beneficiary population approximately 1500 families (7500 population).

These PHPs would be responsible for the provision of the entire range of primary healthcare services including outreach services in the community through health workers.

The focus would be on RCH related services

Payment StructureA total sum of Rupees one hundred per person per year would be payable to the PHP.Service offered Paymen

t by Govt

Payment by

beneficiary

Remark

OPD consultation Rs. 70 Rs. 5 First 5 visits are freeSpecialist consultation

Rs. 10 If available in-house

Basic medicines Rs. 20 Medicines other than those on the list to be purchased. PHP would make them available at fair price

Normal Delivery Rs 200 Includes all costs for medicines/consumables till the time the pt is discharged

Cesarean delivery

Rs 400

Referral Tpt. Rs 5 per km or a min of Rs 50

PHP setup Qualified medical personnel including a

General Practitioner, Gynecologist and Pediatrician with others specialists in-house/on call

In-house facilities in terms of OT, LR, facilities for NB resuscitation and Path Lab

Meeting basic standards of hygiene and service quality

Proximity to urban slum clusters

Sufficient spare capacity in both OPD and IPD

Government support & responsibilities

Providing free medicines/medical supplies under existing programs

Supply chain management support Referral services at District Hospital Promotion and awareness generation Monitoring, co-ordination and supervision Timely payment to PHP’s for their service

Key Success Factors

Monitoring

No misuse

Maintenance of service standards

Impact assessment

Stakeholder’s selection

Beneficiaries PHPs

NGO’s/ Co-ordinating agencies

Financials

Affordability Financial viability Value for money

Sustainability

IEC activities

Improving health seeking behaviour

Service Quality - Govt.

Support services Payment settlement Grievance handling

Service Quality - PHPs

Standards of services; availability & quality

KEY SUCCESS

FACTORS

Beneficiary selection

All the BPL population in the DHQ Survey of identified slum areas and

inclusion of all the families within the slum area.

District administration, department of health and NGOs aid in identification of beneficiaries.

PHP selection Applications invited detailing

infrastructure, manpower and present utilization levels.

The number of PHPs selected depends on the urban poor population identified

Proximity to a slum area is an important criteria.

Site visit and interview of the owner Signing of contract

Service Quality of PHPsImportant Issues

Timely & fair treatment to beneficiaries Availability of medical facilities/medicine Focus on preventive & outreach services Specialist & diagnostic facilities at fair

price Option of beneficiary to switch PHP Option of terminating contract Feedback from beneficiaries

Service Quality - Govt Ensuring free medicines/medical

supplies under National Health Programs

Availability of generic drugs at fair price

Timely payment to PHPs Back up referral services in place Minimized paper work Obtaining and acting on

beneficiaries feedback/grievance

Monitoring & Evaluation

Focus Areas Reduce/prevent the potential for

misuse of funds/supplies Service standards are maintained Beneficiaries are not exploited Tracking improvement through

performance indicators

M & E Proposed system

Family health booklets for beneficiaries Computerized tracking of all/most of the

transactions between the beneficiaries Sample verification of services provided Fund flow system with independent auditing Impact assessment survey Grievance redressal mechanism Record keeping by PHPs/Govt.

Family Health Booklet

ANC NoName – w/o

D.o.R

RegTM

LMP

TT 1 TT2

IFA

ANC VISITS

PNC No.1 2 3 4 5

Starting Date

D.o. last Delivery

Advised byDoc/ANM/

Self

Month for which OCP taken

Reason for discont Complaints//complications

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

ANC Details

OCP

Family Health BookletWeight ______B.P _________Diag.______________

Date_____________Presenting Complaints

O/EPrescribed Treatment –

Provided in-house

To be purchased

Doctor’s signature

District code :Service Provider code:

Sheet No :

Doctor/Staff Code:

Date of Visit :

•Computerization cost per transaction – 6 Paise

•Total characters=24

•Cost per service provider per year Rs. 500 approx

Sr.No.

Patient code(7)

Disease code(3)

Service code(3)

Likely cost of additional treatment to patient (4+4)

Specialty Referred(3)Medicine

Investigation

Swasth Kutumb service rendered sheet

Swasth Kutumb ANM service rendered sheet

S/N

Patient code

(7)

Service code (5)

Disease code(3)+3+3

Remark (3)

Appropriateness for beneficiaries

Easily accessible better health services at affordable costs

Arrangements for specialist and diagnostic services at fair price

PHPs to tie-up/provide in-house specialist, diagnostic service providers

Government financial support during initial stages

Appropriateness for PHPs

Low incremental costs Scope for additional income generation Attractive revenue cost analysis PHPs favorably inclined towards the

scheme Improved utilization of existing

infrastructure Fairly assured clientele base

Improved financial resource utilisation

Gradually reducing financial liability of the government

No capital cost towards infrastructure

No gestation period

Registration and actual services provided based payment

Reduced cost of providing services

Appropriateness for the government

Project Comparison: Public vs Private AFF estimates

* Assuming same number of patients treated in both the options

In the private option payment to PHPs for service delivery account for 80% of the total operating expenses

In the public option fixed staff costs account for 63%, drugs & Consumables for 28% of the total operating expenditure

Project Cost Comparison (205 PHPs vis-à-vis 40 CHCs)

Major Cost Head Private Option

(in lakhs)

Public Option

(in lakhs)

Capital expenditure (yr. 1)

- Infrastructure 19 5619 - Preparatory expenses 54 17

Revenue/operating expenditure (yr. 1-5) - Average per year * 1575 2018 - Cumulative for five year 7876 10091

Beneficiary selection Regulation of the private

sector / quality of care Systems for supply chain

management An independent coordinating

agency

Challenges

Only those who risk going too

far can possibly find out how far they can

go!!