PUBLIC PRIVATE PARTNERSHIP

In Health Care by
Dr.H.Sudarshan Dr H Sudarshan

Public Private Partnership

P bli G Public Government t Private For Profit Private Sector & Not for Profit Sector NGOs, VOs) P fit S t ( NGO VO ) Privatisation: Partnership with Not for Private Sector i S t is not Privitisation t P i iti ti Partnership: It is not being Contractors for implementation of Government Programs. i l t ti fG tP Partnership in Ploicy formulation, Planning, Implementation, Monitoring evaluation, Implementation Monitoring, evaluation Training & Research

Need for PPP

Private Sector is an important player Partnership for strengthening Public Health System Duplication Limited resources Limited role of NGOs scale & distribution Learning from each other.

VGKK p y 1. Tribal Hospital at B.R.Hills with Ministry of Tribal Affairs & GOK 2. 2 Tribal ANM Program with GOK 3. Tribal Residential School with Ministry of Tribal Affairs Aff i & GOK 4. ITI with GOK 5. Technology Resource Center with CAPART

Karuna Trust
Our i i is for O vision i f a society in which we strive t i t i hi h t i to provide an equitable and integrated model of Health care, Education and Livelihoods by care empowering marginalized people to be self reliant reliant Our Mission is to develop a dedicated service Our minded team that enables holistic development of marginalized people through innovative people, innovative, replicable models, with a passion for excellence

Karuna Trust
Founded in 1986 Response to high prevalence of Leprosy in Yelandur- 21.4/1000 in 1987 to 0.2/1000 in 2005 Community based, people oriented, need based, culturally acceptable models using appropriate technology with minimum cost to the community

Public Private Partnerships

1. Entrusting 1 Entr sting Management of PHCs to VOs and Private Medical Colleges. Karuna Trust is managing 25 PHCs in Karnataka and 9 PHCs in Arunachal Pradesh 2. Tele Medicine project Asia Heart Foundation and Karuna Trust & Village Resource C Centres 3. Community Health Insurance 4. District Health Management 4 Di t i t H lth M t 5. Task Force on Health & Family Welfare 6. Good Governance i H lth K 6 G dG in Health Karnataka t k Lokayauktha

Past Experience of NGOs in Running Government PHCs & District Hospital

Maharashtra:
Mandwa Experiment of FRCH. Drs. Abhay and Rani Bhang Responsibility of running a District Hospital Ended after initial success

Rajasthan
Dr. Narendra G t running a PHC Did not succeed D N d Gupta i PHC: t d Got into litigation

Gujarath
Seva Rural by Dr. Anil Desai & Dr. Latha Desai Successful in running a PHC at Jagadia

PPP in Karnataka under IPP-9 Experience of Karuna Trust & Vivekananda Foundation
Karuna Trust:
Affiliated to VGKK, B.R. Hills, Yelandur Taluka, Chamarajanagar Dt. Rural & Tribal Health Working in remote, hilly & Forest area Total responsibility of Leprosy & Tuberculosis Control Program for Yelandur Taluka. Later, Epilepsy (Hotwater Epilepsy) & Mental Health.

Vivekananda Foundation:
A federation of Ten committed VOs working in g Karnataka, based in Mysore.

PARTNERSHIP PROCESS
Dialogue with people of the PHC area Recommendations of Gram Panchayat, Taluka Panchayat and Zilla Panchayat Members. Application to Zilla Panchayat Approval by the ZP Health Committee and resolution by the Zilla Panchayat. Panchayat Application forwarded to Commissioner of Health Government O d Si i G t Order Signing MOU with Di t ith Director of health Handing over of PHC by DHO to Karuna Trust

Partnership Process
Duration : Initial two years Renewal for 3 years , g q p Infrastructure: Land, buildings and equipment are handed over to NGO Human Resources: Government staff are given the choice to continue or take transfer to vacant positions. positions Rest of the staff are appointed by KT Financing: 75% of salaries (sanctioned posts only), d l ) drugs and administration R 25 000/ d d i i t ti Rs.25,000/-. Now 100% based on out come indicators

INFANT MORTALITY RATE (IMR)

IMR 80 70 60 50 IMR 40 30 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year IMR

UNDER-5 MORTALITY RATE

Under-5 mortality
100 90 80 U Under-5 morta ality 70 60 50 40 30 20 10 0
19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07

U-5 mortality

Year

PERINATAL MORTALITY RATE (PMR)

PMR 80 70 60 50 PMR 40 30 20 10 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year PMR

Indicators

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

State

1. Crude 1 Cr de Birth Rate 2. Crude Death Rate 3. I.M.R.

17.1

17.1

17.9

17.5

18

18.3

17

18

18

15.8

15

13

22

5.6

5.4

4.3

4.59

4.54

5.1

7.7

5.6

5.7

6.0

5.08

5.8

7.2

75.7

59.5

25.6

25.8

43.8

48.3

28

32

23.6

24.3

27.3

23.8

55 -

4. Still Birth Rate

37.8

21.2

5.1

Nil

10.8

10.6

11.3

10.6

36.0

21.6

27.6

10.2 33

5. Perinatal Mortality Rate M li R 6. Neo-natal Mortality Rate 7. Post Neo natal Mortality Rate 8. Child Mortality Rate (1-5yrs.) y 9. Under 5 rtality Rate (0-5 yrs.) 10. Maternal Mortality

67.7

42.3

15.3

10.3

21.7

21.2

17

21.1

10.5

8.1

25.0

17 25

70.3

48.6

20.5

20.6

32.8

29.5

8.5

2.6

5.2

17.8

2.5

10.2 24

5.4

10.8

5.1

5.2

10.9

18.8

14.4

16

18.4

4.2

4.2

6.8 -

12.4

10.6

5.3

5.2

7.5

9.8

16.3

5.5

6.7

2.7

3.0 -

88.1 88 1

70.1 70 1

30.7 30 7

31

51.3 51 3

58.1 58 1

44.3 44 3

37.5 37 5

28.6 28 6

31.0 31 0

30

26.8 26 8

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

Nil

228

Process Indicators - Gumballi PHC

199798
1

199899 86.1

199900 80.1

200001 83.1

200102 78.1

200203 61.9

200304 65.5

200405 65.5

200506 63.5

200607 66

200708 64.5

Stat e -

Birth Weight of Babies 2.5 kgs or more 2000 - 2500gms Below 2000 gm Pregnant Mother receiving ( (ANC(3visits) ( ) Deliveries by Trained birth attendant Institutional deliveries Immunization coverage Pregnant women Children Immunization Couple Protection Rate (Cumulative)

89.3

7 3.7 37

9.7 4.7 47

16.9 3

11.4 5.5 55

16 5.9 59

36.7 1.4 14

30.5 4.5 45

30.5 4.5 45

29.1 2

30.3 2.2 22

32.1 3.4 34

102

92

80

80

98

94.05

81.5

81.5

97.9

87.5

94

80

100

100

100

100

100

100

100

100

100

100

100

66

84.1

89

95.7

94.1

95.4

58

100

100

102

87

100

99.5 99 5

101

101

97

99.7 99 7

100

97.3

98

92

90

100

100

97

97

100

102

97

74

71.4

79

74.4

80

77.7

75

80

84.1

84

74.4

Monitoring & Evaluation

HMIS ANM 13 registers & 30 reporting forms from PHC! Soft wear for PHCs with IIM Bangalore. Monthly & Yearly reports from PHC Check list/format for Supervision Added a few more essential items Community Monitoring Independent evaluation by PFI & IHMR

PPP in Primary Health Care Total Management of Primary Health Centres

Karuna Trust Brand

Th MO, Staff Nurse, Pharmacist & Lab The MO St ff N Ph i t L b Technician must stay in PHC headquarter ANM and Male Health Worker should stay at the Sub-center head quarter 24 X 7 PHCs Availability of essential drugs through out the year. year People friendly PHC women friendly Cleanliness and Good maintenance No bribes

Features of PHCs run by KT

Taking total responsibility of the PHC population: No duplication People oriented community based, Cost-effective, p y , , culture & region specific primary health care. Effective Implementation of Reproductive Child Health New Born care and Essential Obstetric Care Effective implementation of National Health Programs: Leprosy, Tuberculosis Malaria HIV/AIDS Leprosy Tuberculosis, Malaria, HIV/AIDS, RTI & STI (Gonorrhea, Syphilis, Trichomonas), Disease Surveillance, Good Laboratory facility. Specialist services at PHC: Ob&G, Ophthalmologist, Physician, Pediatrician

Features of PHCs run by KT

Good Referral System: Transport for emergencies One of the staff accompanying the patient Mainstreaming of HIV/AIDS in PHC Addressing Specific problems: Sickle Cell Anemia & Hot Water Epilepsy. PHC Waste Management g Community-based Rehabilitation of people with disability Training house surgeons in Primary Health Care. FDA/SDC trained as Administrator of PHC

Empowerment of Rural Poor for better Health H lth

PRA/PLA and Micro-plan at every village form Village Health Committees (VHCs), Sub-center & PHC Committees. True Community Needs Assessment Accountability of PHCs to people through Community Monitoring Promoting SHGs & MSSs Micro-credit & Income generation, Anti-liquor & Anti smoking movement Convergence of Health, Nutrition, Drinking water & Sanitation. S it ti Involvement of PRIs: Gram Sabha, & Gram Panchayats Medical & Social audit of Maternal & Infant deaths Women friendly environment in the PHC & HMIS Gender desegregated data

Innovations
Tribal ANMs program: Training tribal girls as ANMs and posting them in the Tribal Sub-centers. One year course for 7th pass not recognized b N i C i d by Nursing Council. N il Now 18 months course f 10th th for pass. g g Introducing Dental Health & Cancer Control Program in PHC ANMs trained to take Pap Smears. Integration of Rehabilitation into Primary Health Care in addition to Preventive, Promotive & Curative health care. Telemedicine in Primary health Care Community Health Financing Promotion of Traditional Medicine 20 herbs for Primary Health Care. Integration of Ayurveda & Homeopathy (AYUSH). Promotion of Generic drugs and Rational drug use Introducing Mental Health Program including Low cost management of Epilepsy.

Telemedicine
Telemedicine in all PHCs in collaboration , with ISRO, NH and Amrita Inst. Tele-health C Coronary C Care U it at Ch Unit t Chamarajanagar j District Hospital with training of MBBS doctors in managing critical cardiac emergencies

Community Health InsuranceT.Narasipur Model

NGO & Government Collaboration Three Levels: Community Herbal Gardens - for common ailments il t Micro credit out patient SHGs - Micro-credit for out-patient care Pre-paid Insurance for Inpatient care Hospitalization H it li ti

Salient Features of Insurance

P Premium R 22 ( I Y i Rs.22 Year R 30/ ) per Rs. 30/-) person per year Premium costs shared by community, Milk p , , Co-operatives, SHGs,UNDP and GPs No exclusions - all age groups Hospitalization due to any illness Rs. 50/- paid to patient for daily wages lost and R 50/ t th hospital f extra drugs d Rs. 50/- to the h it l for t d per day of hospitalization

Features of Insurance
Ambulance Services and Referrals g Diagnosis & Treatment are also covered Maximum of 25 days of Hospitalization A Amount paid t patients every day through t id to ti t d th h the revolving fund at each Hospital NIC settles the claims once a week F APL th J For the Janarogya P li R 70/ Policy Rs.70/-, with exclusions - Private hospitals included

Mainstreaming of Traditional Medicine in PHC

Integration of single herbal remedies for routine ailments into PHCs 3 tier system Traditional Medicine, ANM and PHC Involvement of SHGs, schools and Mahila Vaidya Mitras Essential Drug List and STG for ISM PHCs

Promotion of low cost generic drugs and Rational Drug Use

Stocking and distribution of good quality, g g low cost generic drugs LOCOST & Biocon Biocare Pharmacies at Govt. Hospitals Govt Promotion of rational drug use Essential Drug List and Standard Treatment Guidelines Reforming the Drug Logistic Society

Mental Health
1. Mainstreaming M t l h lth i t 1 M i t i Mental health into Primary Health Care Management of Epilepsy and Mental illness. 2. MANASA A comprehensive system of p y care for homeless mentally ill people
Transit Centre Helpline Rehabilitation and reintegration with families

Karuna Trust Arunachal Pradesh

PPP for Primary Health Care in Arunachal Pradesh

PPP Started in the year 2005 One Primary Health Centre (PHC) in each district of the State will be managed and operated through a selected N G l t d Non Government Organization tO i ti (NGO)

Organisational Chart of Karuna Trust, Arunachal Pradesh T t A h lP d h

Community Dambuk ( (L/Dibang Valley) g y) Jengging (upper Siang) Sangram (Kurung Kumey) Etalin (Dibang Valley) y) Wakka ( (Tirap) p) Bameng ( (East Kameng) g) Mengio ( p (Papum Pare) ) Walong (Anjaw) Khimiyong (Changlang)

Joint Coordinator Coordinator

Programme Coordinator

Karuna Trust - Karnataka

Services to be provided by Karuna Trust

24 hours Emergency/Casualty Services. g y y OPD service for six days per week as per the timings specified by the State Government. 5 to 10 Bed inpatient facility. facility 24 hrs labour Room and Essential Obstetrics facility. Minor Operation Theatre facility. 24 hrs Ambulance facility. Make available essential medicines and Laboratory test facilities f iliti as per th d t il at S h d l B t th MOU the details t Schedule to the MOU. Implementation of National Programs Management of Sub-Centre attached to PHC. To provide all services free of cost. To maintain and run the PHC in a hygienic manner conforming to the standard norms of health safety. y

PPP in Arunachal Pradesh

D ti of the project Duration f th j t The duration of the project is for three years. Renewal/extension ? Performance Monitoring and Standards of Service Process indicators as per MOU PHC M Management C t Committee / Rogi Kalyan Samiti is also itt R iK l S iti i l responsible for guiding/monitoring the project At the State level, a Steering Committee chaired by Commissioner & Secretary (Health) monitors the project.

PPP in Arunachal Pradesh

Financing PPP Fi i
1. 90% Fund is released from the Government, towards meeting the cost of: Personnel, Drugs Personnel (Medicines), Reagents, Surgical Material, Health Care Consumables, Administrative Charges, Civil Works, Furniture Equipment (including Works Furniture, Surgical Equipment) 2. 10% from NGO sources towards the Project Cost. C t 3. Statement of Accounts audited by a Chartered Accountant are furnished to the government authorities in timely manner

Project Cost
Th project cost is Rs.29.37 l kh per PHC per The j t t i R 29 37 lakh annum Government contribution is agreed upon 90% of the budget i R 26 43 l kh per PHC per f h b d i.e. Rs. 26.43 lakh annum Karuna Trust has to contribute rest 10% i.e. Rs. 2.9 lakh per PHC

Then Then
Untidy dirty U tid & di t Dilapidated No Electricity Inadequate equipments, infrastructure and medicines Health services not regular Poor coverage of NHPs

and Now
Clean & Tidy Renovated Electricity El t i it provided id d Adequate equipments, infrastructure and medicines Health services available 24 X 7 Better coverage of NHPs.

Bameng PHC
380 km. from Itanagar in East Kameng district The mud road from Seppa to Bameng is very often blocked by landslides y

Then Then

now

Financing Primary Health Care Thithimathi & Gumballi 2006-07

No. 1 Salaries 2 Medicines Purchase 3 Admin & Maintenance Expenses Total Thithimathi ZP KT Total 729,331 2,400 731,731 75,000 54,887 129,887 Gumballi ZP KT Total 587,433 15,000 602,433 50,000 202,772 169,079

25,000 169,698

194,698

25,000 612,433 71%

33,650 251,422 29%

58,650 863,855 100%

829,331 226,985 1,056,316 79% 21% 100%

Medicines, Surgicals, Lab Chemicals supplied to PHCs

No. Items Period Thithimathi 1/4/1998 1/4/98 1/4/99 1/44/00 to 1/4/99 to 1/4/00 to to to to 31/03/99 31/3/00 31/3/01 31/3/99 31/3/00 31/3/01 Gumballi

1 Medicines 245,193 149,523 256,801 116,100 125,647 92,402 Family Planning Pills & 2 Devices(Oral pills, condoms & cuT) 27,700 24,300 25,300 6,648 11,500 9,500 3 Surgical items 5,827 8,865 2,038 4,314 11,389 5,762 4 Lab chemicals 4,731 4,460 10,255 925 2,700 2,250 Total 283,451 187,148 294,394 127,987 151,236 109,914 283 451 187 148 294 394 127 987 151 236 109 914

Partnership Constraints
The Gumballi PHC h d t f Th G b lli had to face diffi lti with th P i t N difficulties ith the Private Nursing i Home at the Taluka Head quarters Felt threatened as they would loose business. Some of the old staff of PHC 1. 1 Corruption at District Health Office to sanction the Grants and to collect Medicines. 2. Long delays in releasing the Grants - 6 to 12 months 3. Vested interests made one of the ZPs pass resolution to withdraw the PHC. Discrimination between Government run PHCs & NGO run PHCs 1. Though it was 90% by Government and 10% by VOs in reality it became 75% & 25%. VOs had to struggle to raise their share. Rs.5,000/- for Administration & no budget for repairs & Maintenance. Thanks to NRHM funds (75,000/PHC)

Constraints/limitations of VO
1.Human R 1H Resources: Shortage MBBS doctors and turn over St.Johns Medical College 2 year posting ANM Shortage: Started ANM school Poor Quality : Capacity building & Motivation Q y p y g 2.Financial Resources: 75% & 90% budget, No funds for Monitoring, Supervision & Capacity Building. Fund raising for NGO contribution 3. Self imposed limitations: Part of Govt system drugs, total responsibility, less opportunity for innovations, Very remote, difficult, poor infrastructure PHCs to prove that with less resources you can provide better services.

Karuna Trust PPP in India

Karnataka State 25 PHCs & 2 PHCs through other NGOs (5 lakh Population) 2 Hospitals of VVNL also managed by KT under PPP Arunachal Pradesh 9 PHCs A dh Pradesh Adil b d 2 PHC Andhra P d h Adilabad PHCs Maharashtra with FRCH Orissa State 10 PHCs

PPP in District Health Management

Capacity Building for District Health Plan Implementation of Health programs Monitoring & Supervision Health Management Information System Community health insurance Asha training and Supervision g p Community Action and Monitoring

Task Force on Health and Family Welfare

The Task Force constituted by the Chief Minister
GO No HFW 545 CGM 99, Bangalore dt.14-12-1999 dt.14 12 1999

The terms of reference were to make recommendations for:

Improvement of Public Health; Stabilization of the population; Improve management and administration of the Department; Changes in the education system covering both Clinical and g y g Public Health. And to monitor the implementation of the recommendations.

GOOD GOVERNANCE IN HEALTH

BY Dr. H.Sudarshan Ex-Vigilance Di t E Vi il Director

THANK YOU