PUBLIC -PRIVATE PARTNERSHIP FOR HEALTH CARE DEVELOPMENT

1. PUBLIC -PRIVATE PARTNERSHIP FOR HEALTH CARE DEVELOPMENT fi!LH fiajdfjss ixjO—kh i|yd rdcH yd fm!oa.,sl wxYhka fldgialrejka ùu by Dr A.K.S.B.DE Alwis Dr Luxman Edirisinghe `

2. Private & public mix (partnership) ProductionksIamdokh PublicrdcHPrivate mqoa.,sl Public rdcH Funding uq,H iemhqu Private mqoa.,sl

3. Aims of the partnershipiyfhda.S;djfha wruqK 1.Promote inter and intra-sectoral coordination and cooperation for health development.fi!LH ixjrAOkh i|yd jsjsO fCIa;% w;r iusnkaOSlrKh jrAOkh lsrSu 2. Mobilize more resources. jevsmqr iusm;a fhdod .ekSug 3. Reduce the service gaps. fiajd ysoeia wju lsrSug 4. Promote participation of community and other stakeholdersm%cd iyNd.S;ajh jevs lsrSug 5. Ensure the equity and quality. .=Kd;aul;djh yd idOdrk;ajh jevslsrSug 6. Reduce wastage of resources. iusm;a kdia;sh jevslsrSug

4. There are many references to partnerships To ensure the delivery of comprehensive health service, which reduce the disease burden and promote health it is proposed-Rationalized health network,(that include allopathic & indigenous as well as public & private servicesmrsmQrAK fi!LH fiajdjla u.ska frda. ;;ajhlg uqyqK §ug mj;akd l%ufjsoh Yla;su;a lsrSu Strengthened public-private partnerships to enhance efficient health service delivery.fi!LH fiajd iemhSu ldrAAhlaIu lsrSu i|yd rdcH-fm!oa.,sl fiajd w;r iyfhda.S;dj kxjd,Su To empower communities towards more active participation in maintaining their health it is proposed to achievefi!LH kxjd,Su i|yd m%cd iyNd.S;ajh iy;sl lsrSu Improved participation of civil society and non governmental organizations in promoting behavioral and life style changescSjk rgdjka yd mqoa.,sl yeiSrSus rgdjka hym;a lrjSu i|yd isjs,a iudch iy rdcH fkdjk ixjsOdk iyNd.S lrjSu To strengthen stewardship and management function of the health system.fi!LH fiajd l<uKdlrk l%shdldrlus jevs oshqKq lsrSu Strengthened coordination and partnerships with other sectors (Strategic framework for health development in Sri Lanka,2004-2005\April 2003)

5. Health care Priority areas of the GovernmentrdcH fi!LH ixrÌKfha m%uqL;djhka • Expand access to curative health care services through hospitals and other providers at the district level to move their services more accessible in poor and rural areas. wvq jrm%ido,dNS ÿIalr m%foaYj, ck;dj i|yd fi!LH fiajdjka flfrys m%fõYhka osia;s%la uÜgñka mq,q,a lsrSu • Expand the services to meet the needs of specific groups such as elderly, victims of war, displaced people, and specific health problems such as occupational health, mental health, estate health etc…jhia.;jQjka, hqO mSä;hska iy wj;eka jQjka jeks úfYaIs; lKavdhï j, fi!LH wjYH;djka iy jD;a;Sh fi!LH, udkisl fi!LH iy j;= ck;djf.a fi!LH jeks úfYaIs; .eg,q ksrdlrKh lsrSu i|yd fi!LH fiajdjka mq,q,a lsrSu • Development of health promotion programs with specific emphasis on outreach through the schedule.fi!LH m%jrAOkh i|yd ÿria: jevigyka ilia lsrSu • Health care financial options and partnerships fi!LH ixrÌKfha uQ,Huh úl,amhka iy odhl;ajhka • Human Resource Development. udkj iïm;a ixjO—Kh

6. Policy Issue: m%;sm;a;suh .eg,qj Strengthening of public - private partnership in development of health care delivery system in NWP of Sri Lanka. jhT m<df;a fi!LH ;;ajh kxjd,Su i|yd rdcH yd mqoa.,sl wxY j, iyfhda.S;djh Yla;su;a lsrSu Policy Vision :Harmonious Public Private- partnership contributing to highest possible level of health for the people of NWPjhT m<df;a ck;djg b;du;au by, ugsgfus fi!LH fiajdjla ,nd §u i|yd rdcH iy mqoa.,sl wxY j, ukd odhlFjh iy;sl lsrSu Policy Mission :To strengthen public -private- partnership in health care deliveryfi!LH fiajdj i|yd rdcH iy mqoa.,sl wxY j, iyfhda.S;dj ,n§u Policy Goal :To ensure the private sector participation in health care provision in NWP. jhT m<df;a fi!LH fiajdj iemhSfus§ mqoa.,sl wxYfha odhlFjh ,nd .ekSu

8. Internal factors • Health care provision in essentially needs multi-sectoral collaboration. fi!LH fiajd iemhSu i|yd w;HjYH f,ig jsjsO fCI;% j, odhlFjh u; mokus jSu • To reduce rising cost in health care provision. jevsjk fi!LH fiajd jshou md<kh lsrSu • To ensure the quality assurance in health care provision. fiajd iemhSfus .=Kd;aul ;;ajh wdrlaId lsrSug wjYH jSu • To ensure accessibility in health care provision. fi!LH fiajdj ,nd.ekSug we;s yelshdj iy;sl lsrSu • To ensure the cost effectiveness of health strategies. fi!LH Wmdh udrA. j, M,odhs;djh iqrlaIs; lsrSu i|yd • To ensure stakeholder participation in health policy implementation. fi!LH m%;sm;a;s l%shd;aul lsrSfuS§ jsjsO mdrAYjlrejkaf.a iyNd.SFjh iy;sl lsrSug wjYH jSu • To resource sharing for better service delivery. hym;a fiajdjka iemhSu i|yd iusm;a ksis whqrska fhdod .ekSug wjYH jSu • To achieve national health objectives. cd;sl fi!LH wruqK lrd ,.d jSug

9. Evidence from international health agenciescd;Hka;r fi!LH ixjsOdk j,ska ,efnk idÌsWHO policy direction focuses on six priority areas, f,dal fi!LH ixúOdkfha ih jeoEreï m%uqL;djhka • Health sector reform & health system development. fi!LH m%;sixialrKh iy ixjO_kh • Communicable diseases control. fndajk frda. md,kh • Promoting healthy life styles & reducing environmental risk factors, fi!LH iïmkak cSjk rgd m%jO_kh iy mdrsirsl wjOdku wju lsrSu • Integrating health services to enhance efficiency & effectiveness. ldrAhÌu;djh iy M,odhs;djh jeä lsrSu i|yd fi!LH fiajdjka wka;rA.%yKh lsrsu • Emergency preparedness & response. yosis wjia:djka i|yd iQodkïùu iy m%;spdr oelaùu • Partnership & coordination.iyfhda.S;djh iy iïnkaO;djh

10. Financial EvidenceuQ,Huh idOl • Cost of Health:fi!LH fiajdfõ nerlï • In 1994 World Bank assured that basic package for health should be US$ 13 per person (WB,1994). The Sri Lankan government has been spending around US$ 10 (Annual Health Bulletine,2000). • If Sri Lanka wants to subsidize the health system, the following new challenges should be addressedY%S ,xld rch fi!LH iqNidOkh iemhSfïoS uqyqKoshhq;= kj wNsfhda. • Increasing elderly populationsjeäjk jeäysá ck.yKh • NCD fnda fkdjk frda. • HIV/AIDStps whs jS tavsia • Unfinished work in communicable diseases & malnutritionksu fkdjQ fndajk frda. iy ukaofmdaIKh ms<sn| lghq;= • Dengue fvx.= frda.h 1991 § uQ,sl fi!LH fiajdjla iemhSu i|yd rgla jsiska wju jYfhka we fvd,rA 15la tla mqoa.,hl= i|yd jirlg jeh l, hq;= nj m%ldY lrk ,§ tfy;a tu ld,fha§ Y%S ,xldj ta i|yd jeh lrkq ,enqfjs we fvd,rA 10ls ^cd;sl fi!LH m%ldYh 2005&

11. Y%S ,xldfjs rdcH wxYfha fi!LH i|yd jshou 1996-2015 Source: Sri Lanka Health Financing Scenarios, 2000 to 2015 This shows that public expenditure for health could rise from about 20 Billion Rupees in 2003 to between 70 & 173 billion Rupees in 2015. ta wkqj 2003È ns,shk 20la jq rdcH jshou 2015§ ns,shk 70-173 olajd jkq we;

12. Source: National health Accounts-2002

13. iuia: rdcH fi!LH jshous 1997 fkajdisl frda.S fiajd idhksl mqkre;a:dmk fiajd wdOdrl fiajd T!IO yd iemhSus ^ndysr frda.S& frda. ksjdrK yd m%cd fi!LH fiajd fi!LH mrsmd,kh l<uKdlrKh cd;sl fi!LH uq,H m%ldYh 2002

14. Source: National health Accounts-2002

15. iuia: rdcH fkdjk fi!LH jshous 1997 fkajdisl frda.S fiajd idhksl mqkre;a:dmk fiajd wdOdrl fiajd T!IO yd iemhSus ^ndysr frda.S& frda. ksjdrK yd m%cd fi!LH fiajd fi!LH mrsmd,kh l<uKdlrKh cd;sl fi!LH uq,H m%ldYh 2002

16. rdcH jshous j, m<d;a wkqj fjkialus

17. 1999 – 1999 jir j, fi!LH wdfhdack

18. Pd;sl fi!LH uq,H m%ldYh-2000 National Health Accounts

19. iuia: rdcH iy fm!oa.,sl fi!LH fiajdjka i|yd jshou 1990-99 Source: National health Accounts-2002

20. National Health Expenditures by Source as Share of GDP fi!LH jshou o< foaYSh ksYamdokfha m%;sY;hla f,i Source: National health Accounts-2002

21. Component of private Health Sector fm!oa.,sl fi!LH fiajdfjs wx.hka • Private hospitals and nursing homes fm!oa.,sl frday,a iy ud;D ksjdi • GPs full time (western & Indigenous medicine) fm!oa.,sl ffjµ jD;a;sljka ^ngysr foaYSh& • Private practice of government health workers(MS, Dental Sur. Paramedics) rcfha fi!LH ldrH uKav, j, mqoa.,sl fiajd • Private pharmacies -5000 fm!oa.,sl T!IO Yd,d • Private laboratories -450 ridhkd.dr • Private ambulance services .s,ka r: fiajd • Contracting out of government services rdcH wxYh fj; ,nd fok .sjsiqus .; fiajd • Insurance companies. rCIK wdh;k • Medical Manufactures /agents ffjµ ksYamdok ksfhdacs;hka f,I • Traditional healers iusm%odhsl iqj lrkakka • Quacks etc… iqÿiqlus fkdue;s ffjµ ‘ffjµjreka’ ^wOHCI-fm!oa.,sl ffjµ fiajd 2005&

22. Contribution of Private Health Sector in Sri Lanka fm!oa.,sl wxYfha odhl;ajh Source: CPCEH 2004

23. fm!oa.,sl frday,a - jhT m<d;

24. fm!oa.,sl wxYfha frday,a j, wdodhu Source: CPCEH 2004

25. fm!oa.,sl wxYfha jshou This shows that estimated private health expenditure to grow from 30 to 34 Billion Rupees in 2002 to between 98 & 291 billion Rupees in 2015. Source: CPCEH 2004 2002 § ns,shk 30-34 jk w;r 2015§ ns,shk 98-291 jkq we;

26. fm!oa.,sl frday,a j, we|ka ixLHdj 1990 - 2001 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004

27. Percentage distribution of private hospital beds by province, 2001 m,d;a wkqj mqoa.,sl frday,a we|ka m%;sY;h -2001 Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004

28. Private sector admissions as a share of total admissions in the country mqoa.,sl frday,a fkajdisl frda.Ska uq,q osjhsfka fkajdisl frda.Skaf.a m%;sY;hla f,i Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004

29. fm!oa.,sl wxYfha fiajd iemhSu 1992 - 2001 fkajdisl ndysr Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004

30. iuia: fkajdisl frda.S ixLHdj – fm!oa.,sl wxYh 1990 - 2001 fkajdisl frda.Ska we;=,;a lsrSu Source: Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004

31. iuia: ndysr frda.S fiajdjka – fm!oa.,sl wxYh 1990 - 2001 mqoa.,sl wxYfha we;s ndysr frda.Ska Source:Ministry of Health IPS-Private hospital survey 1998, CPCEH 2004

32. Current situation in partnership • iyfhda.S;djfha jrA;udk ;;ajh • No proper legal frame workukd kS;suh mokula ke; • No coordination between two sectorswxY foflys iyiïnkaO;djhla fkdue; • Private sector institutions are not registered in health departmentmqoa.,sl fi!LH wdh;k rcfha ,shdmosxÑ lr fkdue; • No feedback mechanismsjsOsu;a ixksfjSok l%ufõohla fkdue; • No monitoring mechanismswëÌK ms<sfj;la fkdue; • No participation in health planning & implementation • fi!LH ie,iqï lsrSfï iy l%shd;aul lsrSfï iyNd.S;ajhla fkdue; • No quality assurance mechanism for private sector • mqoa.,sl wxYfha ;;ajmd,k l%uhla fkdue; • No sharing of resources for the benefit to community • fmd\q iïm;a mrsyrK l%ufõohla fkdue; • 6. Wastage and Duplication of workslghq;= oaú.=Kùfuka iïm;a wmf;a hdu

34. Possible causes for weak partnership \qrAj, iyfhda.S;djhg fya;= 01. Lack of tradition in collaboration between two sectors.tjeks iïm%odhla fkdmej;Su02. Objectives are differ tlu wruqKla fkd;sîu 03. The weak information system. ÿrAj, ikaksfõokh04. Lack of capacity in public sector to manage and regulate relationship with private sector. mqoa.,sl wxYh iu. iïnkaO;d meje;aùfï oÌ;d rdcH wxYh fj; fkd;sîu05. Political pressure. foaYmd,k n,mEï 06. Pressure from trade unions other stakeholders in health.jD;a;Sh iñ;s we;=,q wfkl=;a mdY_jlrejkaf.a n,mEï07. Mistrust. wúYajdih08. Weakly organized private sector in the country.mqoa.,sl wxYh ;=, ukd ixúOdkh ùula fkd;sîu

35. cont….Possible causes for weak partnership 09. Strong public confidence on government health system (socio-cultural influences). rdcH wxYh flfrys we;s oeäúYajdih 10. Weaknesses of private sector in maintaining quality assurance mechanism and fulfilling social responsibilities as expected by the people ck;d wfmaÌdjkag wkqj fiajh ie,iSug mqoa.,sl wxYh wiu;a ùu 11. Dependency of private sector on public sector for human resources mqoa.,sl wxYh rdcH wxYfha udkj iïm;a u; hemSu 12. No legal framework for partnership kS;s iïmdok fkd;sîu 13. Less public interest. ck;d Wkkaÿj wvq nj 14. Unsuccessful out comes from partnerships in other sector fjk;a wxYj, rdcH-mqoa.,sl iúnkaO;djhka widrA:l ùu

36. Outcome of weak partnership.ÿrAj, iyfhda.S;djfha m%;sM, • 01. Uncoordinated activities. wixúOdkd;aul l%shdldrlï The health authorities have no information on private sector investments or activities and private sector, therefore not involved in national health policy formulation and their contribution towards implementation of national health strategies are not significant. • 02. Waste of resources from both sectors due to duplication or overlapping of investments. iïm;a wmf;a hdu • 03. Lack of sound quality- assurance mechanism in private sector. mqoa.,sl wxYfha ukd ;;aj md,khla fkd;sîu • 04.Increasing cost to the government in health care provision. rdcH wxYh wkjYH úhoula oerSu • 05. Reluctance from donor agencies m%;smdok imhk wdh;k ukafoda;aidyS ùu

37. Policy options in public-private partnershipm%;sm;a;suh úl,am 1. A national policy should be developed to allow private and other non- government sectors to actively participate and contribute in optimum manner to achieve national health objectives in maximum cost effective manner. rcfha ueosy;aùfuka m%;sm;a;s ilia lsrSu’ 2. Policymakers should achieve this task with the participation and consultation with all internal and external stakeholders of health. ish,q odhl;ajhka iu. tl.;djhlg meñKSu 3. Formulation of guidelines and protocols for partnership, including modalities for monitoring. fldgialrejka ùu ms<sn|j ish,q kS;s iy Wmfoia iïmdokh lsrSu 4. Orientation of private and other non-government sectors on national health policies and strategies. wfkl=;a rdcH fkdjk iy mqoa.,sl wxY rcfha fi!LH m%;sm;a;s iy Wmdh udrA. ms<sn| oekqj;a lsrSu Development of consensus among all stakeholders on partnerships. mdY_jlrejka w;r wfkHdkH wjfndaOhla we;s lsrSu Cont..

38. 6. The areas of possible partnerships should be identified, both in central and peripheral level. fldgialrejka ùu wjYH wxY yÿkd .ekSu 7. Address to the barriers for partnership. ndOl yÿkd .ekSu 8. Capacity building and sharing of information in both sectors initially and provision of necessary assistance to the private sector for its development and participation. mqoa.,sl wxYfha iïm;a ixjO_kh i|yd iydh oSu 9. Formulation of coordinating committees in national and peripheral level. cd;sl iy m%dfoaYSh kshdul lñgq msysgqùu 10.Formulation of legal frame works for partnerships. kS;s iïmdokh lsrSu 11. Operational research to evaluate the existing and identified areas of partnership. ióÌK u.ska l%shdldrlï we.ehSu

39. Areas where public- private sector partnerships could be establishedrdcH-mqoa.,sl iyfhda.S;djh we;s l<yels fldgia * Joint policy formulation bodies and coordinated implementation of national health strategies. cd;sl fi!LH m%;sm;a;Ska l%shd;aul lsrSu * Supportive services, Cleaning\Transport\ Training\ Security Wmldrl fiajdjka ^msrsisÿ lsrSu/ m%jdykh/ mqyqKqj/ wdrÌl fiajd& * Sharing of information f;dr;=re fnodyod .ekSu * Coordinated curative activities. taldnoaO m%;sldr fiajd * High tech laboratory & curative services wë;dlaIksl ridhkd.dr iy m%;sldr fiajd * Long-term care oS._ ld,Sk m%;sldr * Community based care m%cd fi!LH fiajd * Rehabilitation mqkre;a:dmkh * Coordinated investments. taldnoaO wdfhdackh * Training of human resource for private sector. mqoa.,sl wxYh i|yd udkj iïm;a ixjO_kh * Quality assurance mechanism ;;ajmd,k l%ufõo

41. Possiblestakeholder reactionwfmaÌs; m%;spdr 1. Possible antagonism by trade unions jD;Sh iñ;s úfrdaO;d 2. Political sensitivityfoaYmd,k m%;spdr 3. Cooperation or resistance by health care managersfi!LH l<ukdlrKfha m%;sfrdaOhka 4. Low Interest from private sectormqoa.,sl wxYfha WodiSk nj 5. Possible resistance of private sectormqoa.,sl wxYfha m%;sfrdaOh • Support from donor agenciesm%;smdok imhkakkaf.a iyfhda.h • Resistance from the public uyck úfrdaO;d

42. THANK YOU