Building Public-Private Partnership for Health System Strengthening

1. Building Public-Private Partnership for Health System Strengthening Contracting out PHC – A case study from RahimYar Khan, Pakistan Neelofar Sami Aga Khan University Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010

2. Session Objectives • To present participants with the RYK case study as an example of PHC contracting • To explain the details of the Rahim Yar Khan contracting case

3. Country Profile • 6th most populous country in the world, with a population of over 160 millions. • 50 million people are resident of urban areas • Population growth of 1.9% per annum adds 3 million people every year • One third of the population lives below the poverty line • Gross Domestic Product is worth $168 billion • GoP spends 0.5-0.8% of its GDP on health • per-capita health expenditure is Rs. 750 to 800 ($10). 25% is contributed by the public sector and 75% through private out-of-pocket fee-based funding • emphasis to continue and strengthen the shift from curative services to preventive, promotive and PHC.

4. Public Health Sector Services • MoH is --- policy development/ strategic directions /M&E/technical support/ research /training • Provincial & district departments responsible for delivery/management of health services Through 3-tiered system • Primary---BHUs and RHCs form the core of PHC model • Secondary --- first and second referral facilities providing acute, ambulatory and inpatient care through THQs and DHQs • Tertiary care ---- comprising teaching hospitals

5. Private Health Sector • Majority of healthcare is financed out-of-pocket. • The private sector has developed considerably by capitalizing on demand. • people prefer private services for quality reasons but prefer public hospitals for inpatient care • Health care is provided by stand-alone clinics operated by individual providers with highest profits for investment

6. Distribution of Health Workforce/facilities by Public and Private Sector • Annual output of 5,000 medical graduates • 1 doctor/1400 persons (1:1000 WHO recom) Proportion of Workforce in Public : Pvt • Physicians----35:65 • Nurses--------70:30 • Midwives----35:65 No of Facilities • Hospitals---1000 &700 • Beds---------100,00 & 20,000 • Clinics------75000---all Pvt • Trust hospitals---580

7. RYK Case Study • Enormous amount of funds spent on BHUs, most of the BHUs are not operational • RYK has 4 tehsils. Population 3.68 million • Most BHUs in RYK not functioning properly • District government of RYK decided to work with Punjab Rural Support Program (PRSP) to manage 104 BHUs through contracting out • PRSP was given the government budget to run the RYK BHUs since mid-2003.

8. Process of Contracting Out The main provisions included: • district government to transfer control, management and use of buildings, furniture and equipment of BHUs to the PRSP • budgetary provisions relating to unfilled posts, medicines, maintenance and repair of buildings, equipment, utilities, stores, and office . • The financial provisions enable the RPSP to undertake financial redesign and make the BHUs run more effectively.

9. Process Continuted • PRSP to render accounts of management operations to the district government • district government was meant to relocate staff as requested by the PRSP. • All physical assets of BHUs were thus transferred to PRSP, to be returned at the conclusion of the contract.

10. Methodology • PRSP divided 104 BHUs into 3 clusters • One doctor/cluster appointed as team leader • 12 MOs already living at BHUs +23 new hiring • MOs were offered an interest-free car loan • Government of Punjab guaranteed their contracts remain secure if the PRSP pilot project did not work out. • salaries enhanced from Rs.12000 to 30,000 but private practice was strictly forbidden • Paramedics to be supported by Health Department

11. Methodology Continued • MOs in charge of entire clusters and they spend alternate days at the three BHUs • MOs to reside in a focal BHU within their cluster and look after emergencies after office hours. • paramedical staff not allowed to charge extra fees on the BHU premises. Just Rs.1 as fee • The MO is responsible for discipline of the cluster BHUs. • The BHU OPD to be conducted by the senior paramedic when the MO is visiting the other two cluster BHUs.

12. Methodology • Expedited delivery of medicines to BHUs • Physical Infrastructure of BHUs --PRPS made the actual clinics more functional but unable to manage paramedical residences

13. Results • 100 percent availability of doctors and medicines at each BHU and improvement in staff discipline • greater staff presence at the facilities has translated into a three-fold increase in uptake of services • no changes in the drug procurement system • increase the remuneration of the doctors managing BHUs and assured their residence in 33 BHUs, and they supervising PHC team

14. Difficulties • No control over quality of medicines • No control over paramedics who practice in private dispensaries • lack of motivation of BHU paramedics--- unfilled vacancies • Management issues