Dr Simon I. BeshirConsultant Cardiologist

NAMIBIA HEART CENTRERoman Catholic Hospital & Windhoek Central Hospital

8th December 2014

PRIVATE PUBLIC PARTNERSHIP

PPP in HEALTHCARE

Introduction

Overview of PPPs

Views on PPPs

Advantages and disadvantages

PPPs in other countries

Our Story

Lessons learned

PPP in HEALTHCARE

PPP in HEALTHCAREDEFINITIONS

A Public-Private Partnership = contractual agreement between a public agency and a private sector entity.

The resources of each sector (public and private) are shared in delivering a service or facility for the use of the general public.

In addition to the sharing of resources, each party shares the potential risks and rewards in the delivery of the service and/or facility.

PPP in HEALTHCARETYPES OF HEALTHCARE PPPs

Outsourcing non-clinical support services

Outsourcing clinical support services

Outsourcing clinical services

Private management of a public hospital

Private financing, construction and operation of a public hospital

More incentives for private sector to perform

New facilities available earlier

Increased levels of efficiency and innovation

Risks transferred to private sector

Forward spending commitments known and able to be planned for

PPP contracts can be very complex

Results assessment is often subjective

Public sector may be locked into contracts while health demands change

PPPs may not gain the population’s trust

>60 new hospitals built

All projects were delivered within the public sector budgets

Estimated that PPP projects cost 17% less than public sector projects – a saving of $4 billion on a $22 billion programme – the equivalent of 25 hospitals

PPPs have failed to win the people’s trust

First wave of 8 PPP (DBFO) contracts awarded in 2006

8th hospital: Valdemoro Hospital – includes Care Contract

€72 million investment – awarded to Capio

Care Contract includes full responsibility for local population

30 year concession – total value c. €1.3 billion

Highest burden of TB worldwide

State government contracted with NGO hospital to provide TB control services to 500,000 population

Better outcomes than Control Comparison: Cost per patient 10% lower ($88) 21% more TB cases found 14% better treatment success rate Cost per successful treatment 14% lower ($118)

Being extended across other parts of India (with ongoing independent evaluation)

OUR STORY – CARDIAC UNIT @ WCHNAMIBIA HEART CENTRE

VISION

Only 300-400 000 Namibians have a medical aid

The remaining 2 million rely on state health care

Some advanced methods of treating heart disease not available in Namibia (even at private facilities)

LET’S DEVELOP A HEART UNIT (CENTRE) THAT WILL PROVIDE THE WORLD STANDARD OF CARDIAC CARE TO ALL NAMIBIANS !!!

OUR STORY – CARDIAC UNIT @ WCHNAMIBIA HEART CENTRE

PREVIOUSLY

Some patients with heart disease transferred to RSA or Kenya at a very high cost

Most cardiac patients receive no or minimal therapy and faced suffering or death from heart failure, heart attacks or strokes

OUR STORY CARDIAC UNIT @ WINDHOEK CENTRAL HOSPITAL

Established and inaugurated by H.E. President Hifikepunye Pohamba in August 2008

First step towards the national heart centre was made

Some patients could receive heart treatment in Namibia

OUR STORY CARDIAC UNIT @ WINDHOEK CENTRAL HOSPITAL

GREAT SUCCESS BUT STILL SOME PROBLEMS Lack of qualified staff (especially doctors)

Inconsistent supplies of consumables > service interruptions

Inconsistent funding of the service

OUR STORY – CARDIAC UNIT @ WCH

GETTING A WELL QUALIFIED AND SKILLFULL DOCTORS State salaries for specialist physicians are below the levels of the trainees in the EU/UK/US Private physicians not keen to work at the state facilities (loss of income from private healthcare) BIG HURDLE ISSUE ……starting a new train is more difficult than jumping into a going one

OUR STORY – CARDIAC UNIT @ WCH Micro PPP CONCEPT Attract a highly qualified Consultants to work at the state hospital Allow them to conduct a limited private practice to supplement their income Set a performance standard for each consultant Define precisely the proportion of consultant ‘s time dedicated to the state unit

OUR STORY – CARDIAC UNIT @ WCH

PUBLIC INVESTMENT1. Consultant salary as per the national public service pay rates

2. Annual budget for the service provided + development

OUR STORY – CARDIAC UNIT @ WCH PUBLIC RETURN

1.Increased number of patients using the service2.Newly introduced treatments3.Less (or no) patients sent for the expensive therapy abroad4.Increased patient satisfaction – high quality care in Namibia5.Training of the young Namibian doctors and nurses = knowledge & skill transfer to benefit larger number of patients in the future

OUR STORY – CARDIAC UNIT @ WCH PRIVATE INVESTMENT

1.The time spent at the state hospital = loss of income in private practice (far exceeding the state salary)2.Know How 3.Unit management (ownership)

OUR STORY – CARDIAC UNIT @ WCH PRIVATE RETURN

1.Opportunity to define and to develop a national heart service2.Opportunity to introduce advanced methods and treatments . . i.e. personal growth, prestige, experience 3.Ability to earn extra income from the limited private practice

OUR STORY – CARDIAC UNIT @ WCH 2012 - SERVICE ASSESSMENT

Performance analysis of the Cardiac Unit (2012)•No of patients treated ( outpatients, operations, etc) annually•Portfolio of treatment methods (CABG, stents, pacemakers)

Costing analysis of the Cardiac Unit (2012)•Salaries (doctors, nurses, technical staff)•Capital costs (equipment)•Consumables used for the procedures

BUDGET BASE

VISION & GOALS – 5 YEAR PLAN

NAMIBIA Approx. 2,000,000 population (state patients)

vs

UK/EU/US PERFORMANCE STANDARDS number of cardiac procedures per million population annually

=

NUMBER OF CARDIAC PROCEDURES TO BE DONE IN NAMIBIA

OUR STORY – CARDIAC UNIT @ WCH

IMPLANTING PACEMAKERS & OTHER DEVICES

OPENING THE BLOCK HEART ARTERIES WITH BALLOONS & STENTS

OUR STORY – CARDIAC UNIT @ WCH

PERFORMING OPEN HEART OPERATIONS SUCH AS BYPASS SURGERY or VALVE REPLACEMENT

OUR STORY – CARDIAC UNIT @ WCH

VISION & GOALS – 5 YEAR PLAN

INNOVATION & DEVELOPMENT •New treatment methods

•Clinical research

•Clinical data management system

VISION & GOALS – 5 YEAR PLAN

New treatment methods RENAL DENERVATION THERAPY TO TREAT

HIGH BLOOD PRESSURE

VISION & GOALS – 5 YEAR PLAN

ROBUST DATA MANAGEMENT SYSTEM

VISION & GOALS – 5 YEAR PLAN

VISION & GOALS – 5 YEAR PLAN

ANNUAL BUDGETTING PROCESS

1.ACTIVITY REPORT FOR THE PREVIOUS 10 MONTHS

2.PROPOSED FURTHER DEVELOPMENT/EXPANSION

3.UPDATED COST PER ITEM

4.PROPOSED BUDGET FOR THE COMING YEAR WITH MOTIVATIONS & JUSTIFICATIONS

5.FINANCE DEPT. OF MHSS EVALUATION

6.FINAL BUDGET SUMBITTED TO MOF

7.NEW BUDGET RELEASED USUALLY IN APRIL/MAY

PAYMENT MECHANISM

A SINGLE SUPPLIER OF THE CARDIAC UNIT SELECTED BY A TENDERResponsible for all the supplies for the UnitSingle point of contact for the cliniciansBulk purchases – good pricing – good value for moneyDeadlines and clinical support stipulated in the contract

1.AN ANNUAL VOLUME OF SUPPLIES ESTIMATE BASED ON PREVIOUS YEAR ACTIVITY + PROPOSED EXPANSION

2.QUARTERLY REQUESTS SUBMITTED BY THE UNIT LEAD TO THE SUPPLIER VIA THE HOSPITAL MANAGEMENT

3.WHEN APPROVED THE SUPPLIES DELIVERED TO THE CENTRAL CLINICAL STORES & INSPECTED FOR COMPLETNESS

4.SUBSEQUENTLY PAYMENT RELEASED TO THE SUPPLIER

PRIVATE PARTY RESPONSIBILITY

1.Clinical leadership of the Cardiac Unit2.Staff training3.Unit management4.Performing complex cardiac procedures5.Training of the junior medical & nursing staff6.Setting up goals and targets for the unit7.Putting together the annual activity report of the unit8.Bringing innovation and new developments9.Budget proposal – justfication.

GOVERNMENT RESPONSIBILITY

1.Unit funding (staff salaries, annual budget)

2.Analysis of the annual activity report

3.Review and justification of the proposed budget

4.Supervision of the unit ( via senior hospital management)

CARDIAC UNIT @ WCH - OUTCOMES

LESSONS LEARNED

1.The Vision & Realistic Goals are essential

2.Micro-PPP can achieve Macro-RESULTS

3.Open minded approach - don’t let a stupid rule to stop a good project

4.Robust data collection is necessary to avoid abuse of public money

5.Key players must be selected well !

THE FUTURE

OPTIONS

1.Continue the current system = micro PPP

2.National Heart Service – Country Wide Project = true PPP

3.Outsourcing of the Cardiac service fully to a private facility for a fixed fee per patient

4.Reverting back to a full state based care

Thank You