Transcript Building Public/Private Partnership

Building Public/Private Partnership
for Health System Strengthening
Hospital Contracting
Professor EK Yeoh
School of Public Health and Primary Care
The Chinese University of Hong Kong
Bali Hyatt Hotel, Sanur, Bali
21-25 June 2010
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Understanding the nature of hospital
contracting and context under which
hospital contracting may be considered;
Knowledge of different models and options
of hospital contracting;
Understanding why and how hospital
contracting works; and
Developing a framework for hospital
contracting
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Discussing nature and rationale of hospital
contracting
Different models and options of hospital
contracting from the experience of a
number of countries
Discussing the issues, logistics and
application of hospital contracting in
different countries
Discussing the challenges and issues of
hospital contracting and PPP programmes in
the context of the health care system of
Hong Kong
Discussing a framework for hospital
contracting
3
What is Contracting?
Contracting is a mechanism for a financing
entity (such as a government ministry) to
acquire a specified set of services, with
specified objectives, of a defined quantity,
quality, and equity, in a particular location, at
an agreed-on price, for a specified period,
from a particular nonstate provider (such as an
NGO, private sector firm, or private
practitioner).
Source: Benjamin Loevinsohn, Performance-Based Contracting for Health Services in Developing
Countries: A toolkit. World Bank, 2008
4
What is Performance-Based Contracting?
A form of contracting that explicitly includes a
clear definition of a series of objectives and
indicators by which to measure contractor
performance, collection of data on the
performance indicators, and consequences for
the contractor based on performance such as
provision of rewards (such as performance
bonuses or public recognition) or imposition of
sanctions (such as termination of the contract
or public criticism).
Source: Benjamin Loevinsohn, Performance-Based Contracting for Health Services in Developing
Countries: A toolkit. World Bank, 2008
5
Difference between Grant, Contracting
and Performance-based Contracting
Grant
Defining
services
Performance
monitoring
Sanction
Contracting
Performance-based
Contracting
“Loosely”
defined
Clearly
defined
Insufficient
Sufficient
Weak
Strong
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“the impetus for all the contracting
initiatives [studied] was the inadequate
quality and coverage of government
services, especially for poor people.”
Benjamin Loevinsohn, April Harding. Buying results? Contracting for health service delivery in developing countries.
Lancet 2005; 366: p. 680.
7
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Performance-based
- clear objectives and indicators,
- systematic data collection of the progress of the selected indicators
- rewards or sanctions based on performance.
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Services
- primary healthcare; hospital surgeries; establishing a health insurance system;
setting up and operating a voucher project; providing ancillary services such as
equipment maintenance, cleaning, waste management, food preparation, and
security, etc.
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Typology
- a management contract and a service delivery contract approaches
- context and services specific
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Pay-for-Performance
- focus on important objectives and uses financial rewards to reinforce good
performance. Specific explicit, measurable outcomes and allows for termination
of the contract for nonperformance.
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Service
design
Government
Provider
selection
Government
Services
management
Government
Infrastructure
setup
Government
Financing
Government
Example
Government sets up public
primary health care centers
Government-1
Government-1
Government-2
Government-2
Government-1
Government transfers funds
from federal to provincial
governments
3. Management Government
contracts
Government
Private sector
Government
Governmenta
4. Service deliveryGovernment
contracts
Government
Private sector
Private sector
5. Government Private sector
grants to NSPs
Government or
donor
Private sector
Private sector
6. Private sector Private sector
services
Consumer
Private sector
Private sector
Arrangement
1. Government
services
2. Intergovernmental
agreements
Government hires a private
sector manager to manage
existing government health
services
Governmenta Government hires NGO to
provide services where
none exist
Government
NGOs submit proposals to
(w/ or w/o NGO government for needs identior community fied by community or NGO
contribution)
Consumer or
?NGO establishes health
NGO/donor
services in slum areas
using its own funds
?For-profit providers
establish private clinic
Note: Government-1 and Government-2 refer to different levels of government. NGO = nongovernmental organization; NSP = nonstate provider.
a. Financing may be supplemented by formal or informal user charges.
Source: Benjamin Loevinsohn, Performance-Based Contracting for Health Services in Developing Countries: A toolkit. World
Bank, 2008
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Type of P4P
Who receives
the funds
1. Rewards for localLocal
governments
governments
2. Rewards
National
to national
governments
governments
3. Payment per
Individual
service (fee for
health workers
service)
4. Performance
NSP
bonuses
5. Performancebased payment
Source: Author.
NSP
What the funds can Who provides
be used for
the funds
Relationship to
Contracting
Programs of local
governments
Programs of national
governments
National
government
Development
partners
Performance agreements
rarely true contracts
Not related
Personal uses
Government,
individuals, or
NSPs
Purchaser
May be easier to introduce
in the context of contracting
with NSPs
Sometimes used in health
care contracting
Purchaser
Can be incorporated fairly
easily into contracts
Other programs or at
the discretion of the
NSP
At discretion of the
NSP
Note: DPT3 = third dose of diphtheria/pertussis/tetanus vaccine; GAVI Alliance = formerly the Global Alliance for Vaccines and Immunization; NGO = nongovernmental
organization; NSP = nonstate provider.
Source: Benjamin Loevinsohn, Performance-Based Contracting for Health Services in Developing
Countries: A toolkit. World Bank, 2008
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Franchising Public authority contracts a private company to manage existing
hospital
DBFO (design, build, finance, operate) : Private consortium designs facilities
based on public authority’s specified requirements, builds the facility, finances
the capital cost and operates their facilities
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BOO (build, own, operate) Public authority purchases services for fixed period
(say 30 years) after which ownership remains with private provider
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BOOT (build, own, operate, transfer): Public authority purchases services for
fixed period after which ownership reverts to public authority
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BOLB (buy, own, lease back) Private contractor builds hospital; facility is leased
back and managed by public authority
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Alzira model Private contractor builds and operates hospital, with contract to
provide care for a defined population
Martin McKee, Nigel Edwards, & Rifat Atun, Public–private partnerships for hospitals. Bulletin of the World Health
Organization, November 2006; 84 (11)
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Option
PrivatePrivate
sector responsibility
sector
Operates private wing for private
patients. May provide only
Colocation of private wing
within or beside public hospital accommodation services or clinical
services as well.
Public sector responsibility
Manages public hospital for public
patients and contracts with private wing
for sharing joint costs, staff, and
equipment.
Outsourcing nonclinical
support services
Provides nonclinical services
(cleaning, catering, laundry,
Provides all clinical services (and staff)
security, building maintenance) and and hospital management.
employs staff for these services.
Outsourcing clinical support
services
Provides clinical support services
such as radiology and laboratory
services.
Provides specialized clinical
Outsourcing specialized clinical services (such as lithotripsy) or
routine procedures (cataract
services
removal).
Manages hospital and provides clinical
services.
Manages hospital and provides most
clinical services.
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Option
Private management of public
hospital
Private sector responsibility
Manages public hospital under contract
with government or public insurance fund
and provides clinical and nonclinical
services. May employ all staff. May also
be responsible for new capital investment,
depending on terms of contract.
Public sector responsibility
Contracts with private firm for
provision of public hospital services,
pays private operator for services
provided, and monitors and regulates
services and contract compliance.
Private financing, construction, and Finances, constructs, and owns new public Manages hospital and makes phased
hospital and leases it back to government. lease payments to private developer.
leaseback of new public hospital
Finances, constructs, and operates new
Reimburses operator annually for
Private financing, construction, and
public hospital and provides nonclinical or capital costs and recurrent costs for
operation of new public hospital
clinical services, or both.
services provided.
Sale of public hospital as going
concern
Pays operator for clinical services and
Purchases facility and continues to operate
monitors and regulates services and
it as public hospital under contract.
contract compliance.
Sale of public hospital for
alternative use
Purchases facility and converts it for
alternative use, depending on sales
agreement.
Monitors conversion to ensure
adherence to contractual obligations.
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Universal access.
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Funding.
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Consolidation.
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Competition.
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Regulation.
To ensure that all public patients, particularly the
poor and uninsured, have access to adequate hospital care, most
contracts for private management of public hospitals require the
provider to continue service to all public patients.
Governments generally fund public hospitals through
budgetary payments or public health insurance programs, shifting the
basis for payments from historical or input costs to the clinical mix of
patients to be treated.
Many countries, particularly in Eastern Europe, have
too many public hospitals and will need to downsize, consolidate, and
close some facilities. Public-private partnerships can spur consolidation
of services.
Competition between hospitals stimulates
improvements in the quality and efficiency of service.
Public-private partnerships may impose additional
public policy obligations that require monitoring, sanctions for
noncompliance, and dispute resolution procedures.
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Cost: There are significant costs for the firms bidding for a public–
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Quality: Trade off between cost, time and quality. Priority has been to
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Flexibility: Public–private contracts are often specified in details with
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Complexity: Projects involve many different types of stakeholders,
private partnership and for the health-care provider.
meet the specifications agreed in the initial contract, with a reluctant
acceptance that the project may go over time or budget.
large penalties for introducing changes, leading to a lack of flexibility.
Some hospitals has been out of date by the time they are opened in a
changing environment.
such as universities and research funders. The difficulties in reaching
agreement with all of the stakeholders, combined with the high costs of
the projects, may eventually lead to collapses in the project.
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• Limited health services but with “mission” clinics or other faithbased organizations
• Poorly performing districts, provinces, or states with existing
government health services
• Uncoordinated NGO-delivered services with multiple donors (for
example, post- conflict situation)
• Few services of any kind, or new kinds of services required (for
example, HIV prevention, nutrition services, early childhood
development services)
• Existing government services where improved management is
needed or innovations are required
• Urban health services with many different providers but limited
coverage of preventive services for the poor
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Contracting out dietary services (Bombay)
Contracts to hospital security and cleaning, and
ambulance services (Port Moresby, Papa New
Guinea)
Contract for major items, such as CT scanners
(Bangkok)
Contract for rural district hospitals (Africa)
Contact with a mining companies for the use of
their hospitals to provide hospital services in
district (Zimbabwe).
Source: Anne Mills To contract or not to contract? Issues for low and middle income countries. Health Policy and
Planning; 1998; 13(1): 32-40.
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Reduction of the workload on management; expected to be
cheaper; reduces wastage and pilferage; avoid service
interruption (type: catering; place: Bombay)
Obtain cheaper; better quality service (type: cleaning; place:
Bangkok)
Obtain latest equipment; avoid difficulty and delays in getting
government approval and funds; overcoming difficulties of
maintenance (type: medical equipment; place: Thailand)
Make use of private sector capital (type: building district
hospital; place: South Africa)
Lack of government capacity (type: contract with private
hospitals with spare capacity; place: Zimbabwe)
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Sufficient private sector capacity for efficiency gain
Government offers an attractive business market
Failure for the government to provide efficiently
Inflexible and inefficient public provision
Social, political and economic environment such as
functioning legal, banking, and government
procedure, resistant to corruption and patronage
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Unclear responsibilities for contract design
and for monitoring contract performance.
Unclear specification of services to be
contracted out
Unclear incentive schemes to motivate
performance
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Strengthening healthcare financing
Cost containment and efficiency gain
Improve healthcare quality (such as reduce
waiting time) and patient safety
Development of regional medical hub
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Step
Step
Step
Step
1:
2:
3:
4:
Conduct Dialogue with Stakeholders
Define the Services
Design the Monitoring and Evaluation
Decide how to select contractors and
establish the price
Step 5: Arrange for contract management and
develop a contract plan
Step 6: Draft the contract and bidding documents
Step 7: Carry out the bidding Process and Manage
the contract
Source: Benjamin Loevinsohn, Performance-Based Contracting for Health Services in Developing
Countries: A toolkit. World Bank, 2008
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Specify outputs
Payment method
Price/rate determined
Delivery monitored
Compliance
Conflict resolution
Incentives to induce participate
Risk sharing arrangements
Managing uncertainty
Cost recovery and profit
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a) the decision to contract;
b) the process to contract;
c) the relationship between government, public
sector employees, non-government providers,
and citizens
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Why Contracting work?
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Focus on Results. The very act of drafting a contract can help
the purchaser define exactly what services are needed and help
make objectives explicit.
Flexibility. NSPs have the important advantage of being less
constrained by “red tape” (excessive regulation), bureaucratic
inertia, and unhelpful political interference. In many
circumstances, this is the largest advantage of NSPs over
government delivery of the same services.
Reduction of Important Aspects of Corruption. Contracting
appears to reduce some aspects of corruption that plague public
health care systems, such as absenteeism, theft of drugs, selling
of positions, leakage of funds on their way to peripheral health
facilities, and informal payments to providers.
Constructive Competition. Contracting uses constructive
competition to increase effectiveness and efficiency. Nonstate
providers are impelled through competition to develop the most
effective and efficient ways of delivering services, both during
the bidding process and during implementation.
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Why Contracting work?
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Improved Absorptive Capacity. Nonstate providers are usually
better at overcoming “absorptive capacity” constraints that often
plague government health care systems and prevent them from
effectively using the resources made available.
Better Distribution of Health Workers. As a result of greater
flexibility and innovative approaches, NSPs can often improve the
distribution of health workers and help ensure that skilled health
workers are available and working in underserved areas.
Managerial Autonomy. Contracts, if drafted properly, provide
managerial autonomy and decentralize decision making to
managers closest to the ground.
Government Focus on Stewardship Role. Contracting provides a
greater opportunity for government to focus on roles that it is
uniquely placed to carry out, such as planning, evaluation,
standard setting, financing, and regulation.
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Singapore – Exploring the role of PPP in
healthcare delivery and financing
Malaysia – PPP in healthcare financing via
private health insurance
Hong Kong – mainly for healthcare delivery
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Case Study
PPP in Hong Kong’s
Healthcare System
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“no one should be denied adequate
medical treatment through lack of
means”
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Hong Kong’s Healthcare System
“Dual” health care system
Public sector
Private sector
Food & Health Bureau
Department of
Health
•
Execute health
care policies &
statutory
functions
Hospital Authority
•
Statutory body
responsible for
management of public
hospitals
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Primary care
◦ Health promotion & disease prevention services
mostly provided by the public sector
◦ Primary care curative services
 Service provided by Out-Patient departments of HA
hospitals (26%)
 Service provided by private Western medicine doctors
(57%)
 Service provided by private Chinese medicine
practitioners (13%)
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Secondary & tertiary services
◦ Public sector is the dominant provider (79%)
Source: Thematic Household Survey 2008
31
Public Sector
Private Sector
•
Hospital Authority (HA)
operates 74 general
outpatient clinics and 48
specialist outpatient
clinics throughout the
territory
•
Around 3,500 private
clinics providing primary
& specialist medical care
•
HA manages 27,555
•
hospital beds in 38 public
hospitals
12 private hospitals,
operating a total of 3,438
beds
Source: Hospital Authority Statistical Report 2007-08
32
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Total health care expenditure (2005/06
figures)
◦ 5.1% of Gross Domestic Product (GDP)
 Public sector (52%)
 Private sector (48%)
Source: Hong Kong’s Domestic Health Accounts, 1989/90-2005/06
33
Tax-based Financing
As percentage of total expenditure on health 2001
(All figures refer to calendar year)
(%)
2004
(%)
General Government
56.9
55.7
Social Security Funds
0
0
Private household out-of-pocket
expenditure
29.5
31.1
Private insurance
12.1
12.3
All other source
1.4
1.0
Sources: Hong Kong’s Domestic Health Accounts, 1989/90-2004/05
34
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Public sector: heavily subsidized (2006/07
figures)
Public Hospitals &
Clinics
User
Fees ($)
Cost
($)
Government
Subsidy (%)
In-patient
(ward level – per day)
100
3,290
97.0
A&E (per visit)
100
700
85.7
SOPC (per visit)
- first visit
- subsequent visits
100
60
740
86.5
91.9
GOPC (per visit)
45
260
82.7
In-patient cost represents general in-patient services, excluding infirmary, mentally handicapped and
psychiatric services (Sources: Healthcare Reform Consultation Document, FHB 2008)
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Private sector: fee-for-service, free market
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- Pre-Hospital Authority era
- Establishment of Hospital Authority
- Post-Hospital Authority era
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A mix of public hospital services provided by
government departments and 15 Nongovernment Organisations on a subvented basis
Overseen by the Medical and Health Department
Lack of explicit services agreement and
contracting
Problems: over-centralization, lack of financial
incentives, inflexibility, low staff moral, lack of
courtesy to patients, long waiting time, overcrowding, poor coordination between
government and subvented hospitals
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The HA was found in 1990.
Establish governance and management
systems across all constituent hospitals.
Manage HK’s public healthcare services
including hospitals, specialist out-patient
clinics and general out-patient clinics
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A single corporation that manages the
public hospitals in HK
Explicit services agreement
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Public Private Partnerships (PPPs) are
arrangements where the public and private
sectors both bring their complementary skills
to a project, with varying levels of
involvement and responsibility, for the
purpose of providing public services or
projects.
Source: Efficiency unit, HKSAR Government
40
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Large scale expensive long-term projects usually involving
the construction of a new facility designed to deliver
particular services;
The Government defines the quality and quantity of services,
and the timeframe in which they are to be delivered;
The private sector is responsible for delivering the defined
service while the government is mainly involved in regulation
and procurement;
A long term relationship is established, typically between 10
years and 30 years, depending on the nature of the facilities,
assets or services to be delivered
Source: Efficiency unit, HKSAR Government
41
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Responsibilities and risks are allocated to the party best able
to manage them;
The private sector and/or the Government finances the
project (wholly or in part). The private sector and/or the
Government would recoup its investment from charges on
end-users or payments made by the Government during the
life of the contract;
The private sector is encouraged to make use of its
innovation and flexibility to deliver good quality, costeffective services throughout the project lifecycle; and
The different functions of design, construction, operation and
maintenance are integrated / use a whole-of-life approach.
Source: Efficiency unit, HKSAR Government
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Financial pressures on the government
provision of public healthcare
Aging population
Medical technology
Social expectation
Continued reliance entirely on public supply
and funding - sustainable?
Any alternatives: financing system; expanding the role
of PPP, enhancing public-private interface
43
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Cataract Surgeries Programme
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Haemodialysis Public Private Partnership Programme
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General Outpatient Clinic Public Private Partnership
Programme
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Shared Care Programme
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Development of private hospitals - North Lantau
Hospital Phase 2 Public-Private Partnership Project
Hong Kong Hospital Authority: http://www3.ha.org.hk/ppp/pppprogrammes.aspx
44
Cataract Surgeries Programme
(starting from February 2008)
To shorten waiting time for cataract surgery
in public hospitals
45
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Target Group
Patients who have been on the HA routine cataract surgery
waiting list as at 1 Feb 2008
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Financial incentives
A One-off funding (HK$ 40million) by the Government for
implementation– Providing subsidy to patients to receive
cataract surgery in private sector
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Fees and Charges
◦A maximum subsidy of HK$5,000 to patients for cataract
surgery provided by private ophthalmologists.
◦Co-pay not more than HK$8,000
◦Consists of 1 pre-op assessment, the intraocular lens in the
surgery and 2 post-op checks
46
Outcome
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Shorter waiting time: reduce from 35.5 months to 31
months (Dec 2009)
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91% of patients are satisfied with the Programme
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98% of patients say:
- Easy to select a suitable ophthalmologist from the
pool of participating private ophthalmologists,
- The Programme has helped them to receive surgery
earlier.
Smooth cooperation between the public and private
sectors in arranging surgeries and providing follow up
support service
47
Haemodialysis Public Private
Partnership Programme
(3-year pilot starting from March 2010)
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To enhance HD service for ESRF patients
To enhance patients’ self care capacity and
improve QoL
To enhance collaboration between HA &
community medical organizations
48
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Target Group
Patients on haemodialysis (HD) in HA hospitals with stable conditions
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Arrangement
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Fees & Charges
HA will collaborate with community medical organisations to provide
options for patients to receive HD in the community
1. Nephrologists assess patients conditions and invite suitable patients
2. Patients complete and sign consent
3. Patients enroll in the “Public-Private Interface-Electronic Patient
Record Sharing Pilot Project”
4. Patients receive HD in the community; HA will provide follow-up,
medications and examinations.
Patients pay the community HD centres the same fee as charged by HA
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Outcome
To be evaluated
49
General Outpatient Clinic (GOPC) PublicPrivate Partnership Programme
- Tin Shui Wai Primary Care Partnership
Project
(a pilot starting from June 2008)
To expand GOPC services in districts with increasing
demand for GOPC services by piloting a PPP model for
the delivery of primary care service and promote the
family-doctor concept in the community
50
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Target Group
Patients suffering from specific chronic diseases such as DM,
HT, COAD, etc. with stable medical conditions and in-need of
long-term follow-up treatment at GOPCs
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Arrangement
◦HA to purchase primary care services from private medical
practitioners
◦Patients to receive a maximum of 10 subsidized visits to a
private doctor for treatment of specific chronic illness and
episodic illnesses per each 12 month period of participation
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Fees & Charges
◦Patient pay for private GP services at the same fee that they
currently pay for GOPC services. Outside the 10 subsidized
visits, the patient can choose to be treated by private doctor at
his/her own cost or attend GOPC for follow up.
51
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Outcome
◦ Over 1,000 patients have been enrolled
◦ High satisfaction rate from both participating
patients and PMPs.
An extension phase of the GOPC PPP pilot is under
consideration.
52
Shared Care Programme
(Pilot to be started in mid 2010 at Sha Tin and Tai Po districts)
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To test a service model for public-private shared
care for chronic disease patients in the primary
care settings
To provide patients with choices of private services
outside the public healthcare system
To establish long-term patient-doctor
relationships in order to achieve the objective of
continuous and holistic care
53
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Target Group
Clinically stable DM and/or HT patients who are currently
taken care of by the public healthcare system
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Financial Incentives
Subsidy in the form of electronic health care
vouchers to patients to use the primary care services
from private medical practitioners
54
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Arrangement
◦ Patients: (a maximum subsidy of HK$1,400 per year)
(i) A subsidy of HK$1,200 for at least 4 consultations/case
management per year at an interval of not more than 4
months apart and drugs for treating DM and/or HT;
(ii) An incentive of up to HK$200 per year for patients who
can meet the preset health outcome indicators and
complies with the care requirements prescribed by their
private medical practitioners
◦ Private Medical Practitioners: Quality incentive of HK$200
each year for each patient under his/her care in the
Programme. They must meet all process indicators in order
to receive the payment.
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Outcome
To be evaluated
55
Development of Private Hospital
- North Lantau Hospital Phase 2 Public- Private
Partnership Project
(to commence in early 2010)
To increase the overall capacity of the
healthcare system of Hong Kong and
facilitate the development of the medical
industry through the promotion of private
hospital development
56
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To address the imbalance between the
public and private sector
◦ 39 Public vs. 13 Private Hospitals
◦ Over reliant on public service
◦ Limited competition and collaboration and choice
for patients
◦ Threat to long-term sustainability of healthcare
system
Development of private hospitals at sites at Wong Chuk Hang,
Tseung Kwan O, Tai Po and Lantau
Source: Invitation for Expression of Interest – Development of private hospitals at sites HKSAR 2009
57
Development of Private Hospitals
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Government to
facilitate the
development of
private hospitals
through enhanced
support in
hardware and
software
Hardware
Reserving suitable sites for
private hospital development
(4 sites situated in Wong Chuk
Hang, Tsueng Kwan O, Tai Po
and Lantau)
Software
Continue to enhance training
and development of
healthcare professionals;
attract oversea talents to
enhance sharing of expertise
and raise service standards
58
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Phase one – To build a public hospital with
180 beds to meet the needs of the local
community on Lantau Island
Phase two – To explore the introduction of
PPP for private sector to provide other
medical services and facilities in the
available area in the hospital site
59
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The following models are ruled out:
◦ Financing: Private provider to finance the building
of the public hospital.
◦ Ownership: The Government and the private
provider to share the ownership of a hospital
building.
◦ Operation of services: Private provider to deliver all
public clinical services through a contracting-out
arrangement.
60
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Co-location of public and private components
within the same buildings (i.e. vertical colocation) or in separate buildings on adjacent
sites (i.e. horizontal co-location)
61
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The private provider will finance, design,
build, own and operate the private
component on the land acquired from the
Government.
To transfer the ownership and operation of
the private facilities to the Government after
a pre-determined fixed period of time.
Government may entrust the private
provider to design and build the public
component in tandem with the private
development. The Government will bear the
costs for the public component.
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


The land and the hospital building to be
built thereon will remain the property of the
Government.
Part of the building (e.g. a number of floors)
will be let to the private provider to operate
and provide private services.
The Government may entrust the private
provider to design and construct the
hospital building, where both the public and
private components will be accommodated.
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
Purchase of services
◦ Clinical and allied health services
◦ Clinical supporting services

Other contracting-out arrangements
◦ Management and administration (e.g. accounting,
information technology)
◦ Building arrangement (e.g. maintenance, cleansing, security)
◦ Other ancillary services (e.g. catering, laundry, portering)

Staff arrangements
◦ Cross-attachment of staff between the public and private

Land disposal arrangements
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Framework for Hospital Contracting

Context
◦ Health Systems
 Policies
 Organisation
 Financing and payment
◦ Capacity
 Government
− Technical
− Political
 Private Sector
◦ Human resources
◦ Social-economic-political environment
◦ Societal values
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


Issues
Priorities
Objectives of contracting
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




Consider alternatives to contracting
Beside options for contracting
Assess impact of contracting options
Seven-steps to contracting
Monitoring and evaluation
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Thank You!
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