The Right for Health & Private Public Partnership in care delivery

1. The Right for Health & Private Public Partnership in care delivery Issues to be considered by policy makers SDU‐UK&I Spring Conference 16th & 17th June 2012 DrIbrahim M Abdel Rahim

2. UN Declaration of Human Rights Article 25 • Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services … Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection ---

3. WHO Constitution - Declaration of Principles WHO constitution first signed 1948 Please take note of definition of health The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. ---

4. WHO Constitution - Declaration of Principles. How to make governments accountable? Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures. ---

5. WHO Constitution - Declaration of Principles. How to assure global health security Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. ---

6. ALMA ATA DECLARATION Almata PHC Declaration 1978 . How close are we to The health for all goal? The existing of gross inequality in the health status of the people particularly between developed and developing countries, as well as within countries (advantaged and poor segments), is politically, socially and economically unacceptableand is, therefore, of common concern to all countries. ---

7. HEALTH SYSTEM CONCEPTUAL FRAMEWORK Social Determinants of Health SYSTEM BUILDING BLOCKS GOALS OF HEALTH SYSTEM Information Support Service Delivery Responsiveness Leadership & governance Coverage Provider performance Health workforce Health Quality & Safety Financing Health technology Efficiency Financial protection Equity ---

8. Irrespective of the Financial arrangement or the mode of care delivery Population Good Health outcomes Equity in Access to Health These are the goals of national health delivery system Quality of Care & Responsiveness Affordable cost ---

9. Definitions The Public health delivery sector: defined as all health facilities owned, controlled and financed by various levels and agencies of government. The private delivery sector is a residual category not under the direct control of the government Within the private sector itself, additional classification: The private for profit and private not for profit, faced-based organization, traditional & non-traditional, etc. Partnership: “a relationship based upon agreements, reflecting mutual responsibilities in furtherance of shared benefits.”1 ---

10. Status of private care delivery in the EMR region? Has established role in infrastructure development, pharmaceutical and non clinical services. Role in care delivery reached sky rocketing rates in recent past (more 70% of ambulatory care in some EMR countries). Some of the reasons include poorly funded and managed public delivery systems providing poor quality care, population growth and marketing practices … etc Most of the delivery modalities are unregulated individual vendors (including dual practice) and small inpatients faculties with limited capacity. PPP may offer an opportunity and a leverage to streamline, regulate and positively engages Private Sector.

11. While performance of each sector depends on context & varies case by case yet: Public vs. Private comparison ---

12. Key types of public private partnerships and collaboration in health sector • Contracting out: (activities supported from Public funds) • Service delivery contracts • Management contracts • Construction, maintenance, & equipment contracts • Hybrid contracts (e.g., large IT infrastructure or service) • Leases of facilities/assets • Concessions( activitieson new inputs from private partner) • Government guarantees/other fiscal incentives (loans) • Other Government incentives Land prices , taxes, amenities • Private Financing Initiatives • Other types, typically without government guarantees, i.e. • Divestiture/privatization • Free entry • Other (e.g. provisions for health saving accounts) • Sample benefits: • Efficiency • Quality • Cost- and risk-sharing • Improve access

13. Prerequisites for PPP to aligned with interests & goals of health/social sectors Adherence to Legal and regulatory frameworks Transparencyand Accountability Partnership built on well founded Public policies (no policy without a policy dialogue) Commitment to the notion of “Public Goods“ Mutual Understanding of terms & obligations Sharing of Resources, risks and benefits Respond to Consumers and Community needs & expectations ---

14. Due to understandable differences in interests, goals and approaches to work, the results from PPP are not always rosy: “In 2008, the Ontario Auditor General concluded that the Ontario government could have saved $50 million in the Brampton Civic Hospital P3 project if a public procurement process had been chosen. The Auditor General called for the costs and benefits of all feasible procurement alternatives to be evaluated before entering into a P3, and value-for-money assessments should have relevant and clear criteria.” brief on PPP by British Columbia Government ---

15. Health care delivery, The Market & Health Financing: Health is a commodity whose value could not be easily monetized (estimated in monetary terms) or traded. Health care is an imperfect field for market forces or mechanisms to work. “i.e asymmetric information exist between consumer & provider” “market failure” Occurrence of liability “ill health” is unpredictable and when it occurs is unevenly distributed. A wide based (universal) system for pooling risks and resources is needed for attainment of socially & ethically acceptable health and financial outcomes. Pre-paid systems of financing are necessary for equitable access while out of pocket payments at point of service delivery lead to unacceptable consequences.

16. Push some households into poverty Reduce expenditures on other basic needs May cause households to forgo seeking health care and suffer illness Health policies should target reducing out-of-pocket expenditure Out-of-pocket health expenditure Risk of financial catastrophe 16

17. Each year Millions suffer financial ruin when they use health services are the world Due to absence or inadequacy of social health protection systems: • Globally around 150 million suffer severe financial hardship each year. • 100 million are pushed into poverty because they must pay out-of-pocket at the time they receive health care.

18. Risk of severe financial hardship and impoverishment drops substantially with out-of-pocket spending less than 20% of total cost of care Share of out-of-pocket spending on health care Source: WHO, Health Financing Policy unit database, unpublished

19. EMR Shareof out-of-pocket expenditure (%) in – 2010 Per capita total health expenditure (US$) – 2010 Source: WHO NHA Website PAL Sudan Sudan 19

20. HealthCare Financing Reform & Universal Health Coverage • A World Health Assembly Resolution in 2005 urged countries to develop their health financing systems to: • Ensure all people have access to needed services without the risk of financial hardship linked to paying for care. • Aspiration to attain UHC was in WHO's constitutions of 1948; in the Alma-Ata declaration of 1978

21. The way forward is in adopting policies based on population right for health, equity in health through committmentto universal coverage and health care delivery based on primary health care

22. Thank you

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