Transcript Supporting the Development of PPPs in Health – Marie-Odile Waty

Supporting the Development of PPPs in Health –
The Health in Africa Initiative
Marie-Odile Waty
PPP in Health – Johannesburg – 4 March 2011
Presentation outline
What is a PPP?
The health context makes PPPs attractive
PPPs’ opportunities and challenges are significant
There are certain pre-prerequisites to ensure PPPs are
performing well and sustainable
The Health in Africa Initiative: support for establishing the
policy, legal and regulatory environment for Health PPPs
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What is a PPP?
 The acronym creates semantic turmoil over what it means and does
not mean.
 PPPs are a collection of models. PPPs are defined by the Health
Africa Initiative as a broad partnership between the private
contractors and Government, in which the public sector contracts
(usually on a long-term basis) with the private sector for the
provision of a public service.
Private health
care provider
Ministry of Health
Contract
Assets
New health care facility Assets ($, land,
(facility, skills, etc.)
or services
facility, etc.)
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The health context makes PPPs attractive (1/2)
 Governments are under strong pressure to meet growing health care
needs and expectations
o MDG 4, 5 and 6 still out of reach in many SSA countries
o Non-communicable diseases are developing fast (a «silent
epidemic »)
o People’s health expectations are increasing
 Health care expenditures are growing significantly in SSA, under the
combined effect of sustained economic and demographic growths
 Public health financing is low and severely constrained
Governments alone cannot meet rising health care needs and
demands of populations
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The health context makes PPPs attractive (2/2)
 Public health systems are ill-equipped to meet these challenges
o Shortage of skilled health personnel
o Lack of adequate health infrastructure, including for medical
education and training
o Low productivity and efficiency of public health services
 The private sector already plays a dominant role in SSA, and it is
growing fast
 The private sector is poorly or under regulated and quality is very
uneven
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The private sector plays a dominant role in health
Public
Private
Health care expenditure by
financing agent
Percent
$16.7B
100%
Public
~40
Health care expenditure by provider ownership
Percent*
100%
Public
$16.7B
~50
For-profit
Out-ofpocket
~50
Other
private
Private
prepaid
Private
~5
~50
Data from the Business of
Health in Africa Report, IFC,
2007
Nonprofit
Traditional
healer
~5
Financing
agent
Social
enterprise
Providers
~65
~15
~10
~10
Private sector
providers
When measured on a usage basis:
• Private sector providers likely comprise larger share of market due to
under-reporting of non-profit and informal segments
• Social enterprises, non-profit and informal segments comprise larger
share of private sector due to smaller user fees and under-reporting
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Total investment demand is estimated at
$25-$30bn over the next ten years
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Opportunities and benefits of PPPs in Health (1/2)
Leverage the strengths and complement the weaknesses of both the
public and private health sectors
 Increasing overall financing by bringing private capital
 Improving access to health services
o For general or specialized health care or goods
o For targeted priority health services and goods
o For specific population groups or geographical areas
 Enhancing quality and efficiency of health services and goods (through
accreditation or empanelment, franchising or labeling, etc.)
 Introducing innovation and managerial improvement
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Opportunities and benefits of PPPs in Health (2/2)
 Introducing major institutional and systemic changes
o Allow the Government to evolve from provider of services to
regulator and commissioner of services
o Move from process to measurable outputs/results (long-term
performance-based financing)
o Bring an holistic approach by further integrating the private
sector into the health system (i.e., reducing fragmentation)
o Introduce competition
 Challenging the notion that private health care is for the rich, and
public health care for the poor. Rather than creating and exacerbating
inequities in care, PPPs can equalize care for all populations
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Challenges of PPPs in Health
Sources of
Obstacle
Examples
Public sector
• Skepticism of private sector motives
• Rigid/bureaucratic
• Non-inclusive approach
• Conflicting priorities
Private sector
• Mistrust of public sector
• Single minded, profit-oriented
• Competitive
Organizational
limitations
• Lack of data & knowledge on the private sector
• Lack of capacities to develop, implement and monitor
PPPs
Regulatory
environment
• Inadequate entry & registration and exit criteria,
heavy procedures
• Low enforcement capacity and low accreditation
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Pre-requisites for sustainable and well-performing
PPPs (1/2)
 A clearly and well identified need (identification of gaps)
 Strong willingness to work together in a real partnership
o Partnership means equity, trust and respect
o There should be mutual benefit (win/win situation, with
appropriate incentives for each partner)
o Transparency is key: PPPs players should clearly articulate their
motives
 Strong leadership and governance
o National medium to long term Health PPP policy/strategic vision
o Adequate regulatory framework in place with effective
enforcement
o Appropriate governance arrangements
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Pre-requisites for sustainable and well-performing
PPPs (2/2)
 Capacity of each partner to perform to the required standards (need
to set agreed measures at onset)
 Independent monitoring and oversight is critical for PPPs
 Quality of contract design and management
o Tariffs are set right, flexibility is introduced, penal provisions ad
terminations clauses clearly specified, etc.
 Financial sustainability ensured over the long term
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Support from the IFC-Bank Joint Health in Africa Initiative
Mission
Catalyze sustained improvements in:
(a) access to quality health-related
goods and services in Africa; and
(b) financial protection against the
impoverishing effects of illness,
with an emphasis on the underserved.
Goals

Inform decision making among
public and private stakeholders

Improve regulation towards private
health sector and promote PPPs

Improve access to capital for the
private health sector

Increase risk pooling and human
resources for health
Approach
B. Technical
assistance and
advisory services
to governments
Synergies
A. Research,
C. Access to Debt
Analysis, and
Equity Financing
Information
to the Private
Dissemination
Sector (incl.TA)
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Health in Africa Initiative – Policy work at country level
Support on Governments’ request
First step: map public and private services and define needs gaps, build
dialogue and trust, and identify interventions aimed at improving the
policy, regulatory and operating environment and developing priority
Health PPPs
 Conducting private sector assessment as first joint activity under the
leadership of a joint steering Committee
 Holding consensus meetings to :
o Discuss assessment’s findings and identify gaps and challenges
o Recommend key interventions to improve the policy, regulatory and
operating environment and develop PPPs
 Adopting a 3-year Action Plan and integrating it into the national
health development plan
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Health in Africa Initiative – Policy work at country level
Second step: support implementation of the Action Plan along with
other IFC/advisory business lines and World Bank, and other donors
1- Policy and dialogue
 Establishing a Public-Private Dialogue Platform
 Developing a private sector policy, including PPP policy
 Organizing/structuring the private sector into alliances
 Improving the information flow between public and private sectors
2- Legal, regulatory and operating environment
 Reviewing the framework (legal statute, licensing criteria and
procedures, governance arrangements, etc.)
 Strengthening effective enforcement of such framework
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Health in Africa Initiative – Policy work at country level
2- Legal, regulatory and operating environment (… ctd)
 Improving access to financing (equity and debt)
 Strengthening managerial and operating procedures
3- PPPs in key health priority areas
 Establishing the governance arrangement (PPP committee, PPP unit,
independent monitoring system, etc.)
 Conducting PPP feasibility studies
 Building the institutional capacity to design, implement and monitor
PPPs
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Policy Work – In-depth country work
Mali
Kenya
 Country assessment and
engagement completed
 Reform agenda: PPD
Committee/PS Alliance;
Management of PHC; API
-adapting generic private
sector investment
facilities to health;
licensing
 Country assessment and
engagement completed
 Reform agenda: PS
Alliance; PPP unit;
policy/regulatory reforms;
licensing/ inspectorates;
NHIF and private health
insurance reforms; tax
reforms; PPP in primary
health and ambulatory
care
Burkina Faso
 Country assessment and
engagement completed
 Reform agenda: review
of all legal and regulatory
texts; enforcement of
regulations; PPPs in
reproductive health,
public health programs
and training.
Uganda
Ghana
Congo (Brazzaville)
 Country assessment and
engagement completed
 Reform agenda: Revised
PS policy; PS Alliance;
PPP unit; NHIS
accreditation;
regulatory/inspectorate
reforms; training
accreditation
 Country assessment
and engagement
completed
 Reform agenda:
policy/regulatory
reforms; PPPs in
emergency obstetrical
care, haemodialis, and
training.
 Country assessment
completed (with USAID)
 Engagement has
commenced
 Reform agenda defined:
New PS policy;
Regulatory/tax reforms;
Accreditation; NSHI bill;
Health Sector Fund; PS
Federation; PPP unit
 PPP transactions in
ambulance and hospital
management
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Policy Work – Specific opportunities being pursued
South Sudan
 Strong expression of
interest has been
received from MoH
 Joint WB/C3P/ HiA
missions done in
October and Feb
 Preliminary feasibility
done on PPPs in supply
chain, hospital mgt
and construction of
new referral/teaching
hospital
Nigeria
 NHIS reform and
health financing
reform project
approved and agreed
 Tender process has
commenced
DRC
Namibia
 University of Namibia
have expressed an
interest in developing
a school of medicine
through a PPP model
 Project development
underway
Botswana
 Early expression of
interest has been
received
 Follow up in Q2/Q3 of
FY11
 Gecamines requested
advice and assistance
on developing a
strategy for their
extensive hospitals
and educations assets
 Great PPP transaction
opportunities
 Project is currently on
hold due to IFC’s
dispute with
government
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Thank you
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