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Structuring Public-Private collaboration in Health Care: Review of experiences and lessons
Marieke Verhallen



Structuring Public - Private collaboration in Health Care:
Review of experiences and lessons.


Marieke Verhallen, MPH
Public Health Consultants
Amsterdam


1. INTRODUCTION:

Background of the consultant:
Before starting it may be good to know my background and what my relationship is with the subject. After having worked in Cameroon for 8 years I joined Memisa Medicus Mundi, a Dutch health care development NGO which supports mainly, but not exclusively, private not for profit health care organizations over the whole world. During 11 years I was desk officer for a varying set of English and French speaking countries. An important aim was to improve the collaboration between Public Health Care systems and Private providers. As it proofed quite intricate I concentrated on this subject during my masters study and wrote my thesis about the potential of the contractual approach towards ensuring operational integration at district level. Since 1999 I am an independent consultant member of the Public Health Consultants Group in Amsterdam.

The Aim of the review:
To establish where other countries are in elaborating the partnership between the government / public sector and the private sector in Health and what can be learnt from their experiences to guide us in structuring and institutionalising this collaboration so that common goals in health can really be achieved.

Methodology used for the review:
a. Comparison to Dutch system as no gold standard exists:
Characteristics of that system: Government's role is policy setting, ensuring implementation by: securing financial arrangements, legislation, regulation, inspection and sanctions. With respect to service delivery: it only provides essential public health services.
Main providers are: not for profit hospital associations / foundations, private practitioners: generalists, midwives and specialists.
Health insurers: third party purchasers of services for their clients.
b. Documents from all the countries;
c. Email and telephone interviews with representatives of Public and Private organizations and external experts for Benin, Ghana, Tanzania and Zambia;
d. Interviews with main stakeholders at national level in Uganda;
e. International literature (World bank and WHO);
f. Own experiences.

Limitations:
a. Comparison to Dutch health system is flawed as certain elements are not comparable f.i. third party purchaser. As Ghana appeared the furthest many lessons stem from there.
b. Time was very short and thus the possibilities to interview in depth were limited and willingness to respond restricted;
c. The main focus had to be on Service providers excluding f.i. suppliers and support services: scope would otherwise become too large;
d. Private for profit representatives of the other countries could not be reached through the available communication methods and in Uganda they were not available at such short notice for interviews.
These limitations do mean that the review contains significant gaps, however, I do think that the lessons that emerge provide ample suggestions for the next steps in the process for the Uganda partners.

The presentation:
I hope this presentation will enable you all to define practical short, medium and long term objectives and strategies for the further structuring and strengthening of the public - private partnerships in Health.
To arrive there I will first give a brief overview of the situation in the other countries, then compare the main issues in the Uganda with the lessons of these countries to subsequently draw the main conclusions and recommendations.
After the presentation your questions and points for discussion will enable, I hope, the working group to determine the steps for the coming six month and the next year.

PREAMBLE

Definitions:
Partnership: being a partner in..., sharing an activity. In daily use this term has a strong connotation of the parties being equal.
Structuring: the way to organize the partnership; to arrange it carefully into an organized pattern / system;
Institutionalize: to establish the collaboration as part of the culture, social system or organization.
Conclusion: they all represent means to an end: to achieve certain common goals.
In health care common objectives, in order to improve the health status, are:
I.) improve coverage;
II.) improve quality;
III.) improve equity.

2. OVERVIEW OF THE STATE OF THE ART IN THE OTHER COUNTRIES

The public - private landscapes in all the reviewed countries is quite similar to that of Uganda: the private not for profit, mainly church related, providers contribute around 40% to 50% of the health services in the country with a relative higher presence in the rural poorer area's. The English speaking countries all have a history of a certain collaboration towards the national health policy implementation as the church institutions were provided with subsidies in awaitance of the extension of the public health system.
The private for profit is a relatively new but rapidly growing sector, which is not yet well legislated and organized. The traditional medicine sector has always been present in all countries. In most countries this sector is not (yet) considered in the strategies for Public - Private collaboration in service provision. In Zambia and Ghana legislation, registration and national representation are ensured. For Tanzania and Benin I do not yet have the information.

All countries are presently executing Health Sector Reforms induced by comparable problems, based on the same principles and aiming at similar improvements. All are adopting the Sector Wide approach, all policies and strategic plans mention improving collaboration between the Public sector and the Private sector as one of the main strategies to reach the three above mentioned goals.

Ghana:
During 1997 and 1999 the Ministry of Health and the Christian Health Association started a deliberate and phased process that aimed at operational integration of, first of all, the CHAG hospitals into their districts through performance related contracts. Later the other level facilities will follow as well as other service providers.
- A Memorandum of Understanding between the national representing bodies was elaborated and based on that a format for the contracts between the Ghana Health Services (a new independent body responsible for health care delivery) and the district hospitals.
- Accreditation criteria and readiness criteria were formulated together;
- Of the 48 CHAG hospitals 45 are now recognized as Budget Management Centres;
- Though the MoU is not yet signed the hospitals have started implementation and in awaitance of the new budget allocation mechanisms the old allocation system continues.
- Fora for consultation and co-ordination as well as mediation are now functional at central level: Steering Committee for MoU and Stakeholders Meeting. A similar structure is foreseen for district level. The contracted units will be member of the statutory bodies in their districts and sub districts.
- Churches no longer feel their autonomy threatened.
- At district level the units start getting a share of un-earmarked funds (though due to other funding sources the balance between benefit and costs for accounting might questionable).
- The main problem at present is to get the district implementers to fully recognize the changed roles and functions.

Benin:
Here the partners come from further back: in the french speaking countries the two systems were basically parallel / independent systems: the churches were allowed to set up facilities but no formal functional or subsidy relation was installed. Over a six year period following lobbying from the National Non Governmental Hospital Association AMCES, some internal but more external pressure:
- Recognition of the role of the PNFP hospitals towards the realisation of complete district health services is now assured,
- A MoU and district contract formats have been elaborated, still to be signed;
- First experience with subsidies to start;
- A plan for the further elaboration of the collaboration in the coming 5 years has been set.

Tanzania:
Formerly this country had installed a predecessor to what we actually call the contractual approach: NGO hospitals were assigned the District Hospital function (DDH: district designated hospital) with allocation of the corresponding funding for recurrent costs. During the last ten years, due to severe budgetary restrictions and faltering policy vision the actual functioning as such eroded;
Since the beginning of the reforms new efforts to define the collaboration have been initiated, some pilot experiences are being tried but at the moment the process seems to have halted.
Obstacles seem to be:
- No clear vision has yet crystallised on either side in the sector nor in the wider environment;
- The present regulation by MoH is perceived as very restrictive ('police man like')
- Both sides seriously lack capacity;
- Questions regarding the degree in which the Christian Social Service Committee (CSSC) represents the different owners and implementing institutions (top down and bottom up)
- The past has given rise to rivalries and mutual mistrust which the present status quo seems to enhance.

Zambia:
In the context of HSR the purchaser - provider split was developed very rigorously: for central and district level and thus contracts were elaborated for each level. The collaboration with the PNFP health facilities was set in this perspective: the districts were to purchase services from them.
A MoU between government and churches was signed in 1996 but was not implemented as very soon afterwards the allocation formula and budget routing changed: districts are allocated a basket based on a weighted population formula for the non salary components.
At present the process is faltering:
- huge budgetary problems in health sector have lead to the development of a new strategic plan in 2000 which has just been started;
- lack of vision and capacity on both sides
- due to the former situation (free health services for all: the PNFP institutions received running costs at nearly the same level as public hospitals) the PNFP sector has not as such developed specific added value views and practices;
- the former system had brought with it an important mal- distribution and certain over capacity: politically difficult decisions are required and are not being made on both sides;
- questions regarding the degree in which CMAZ represents owners and institutions.

Ghana and Benin are set to start on their new road of collaboration, Tanzania and Zambia are still searching. Uganda has a precedence on them as it has already initiated a number of steps towards a sincere partnership.

3. EXPERIENCES IN COMPARISON TO THE SITUATION AND ISSUES IN UGANDA

3.1. CONTEXTUAL ISSUES

- History of Public Private Collaboration:
As in Uganda the church facility owners and managers and the government personnel of all these countries have a history together. This history coloured the culture and feelings by a certain sense of competition: the government strived for total coverage in pursuance of a social welfare state. The mission units where therefore seen as temporary and, when performing better as competitors, not in the least with respect to finances as most independent governments inherited the subsidy system.

In the years of dwindling resources (decreasing subsidies and decreasing external assistance) the PNFP units developed survival strategies which lead to a relatively higher independence but also to a relative isolation from the public health system (focus on curative care, decreasing preventative care, increase in user fees and / or other income generating activities). This is certainly true for Uganda and Tanzania.

This brief description of the history learns:
- there is little precedence of working in a co-ordinated manner together, the prevailing views are that there should be one hierarchical system;
- Through the years concerns have grown on both sides regarding:
- Dependability;
- Transparency and accountability;
- Reciprocal influence and consensus towards goals;
- Fairness of representation and allocation.

The Ghana partners confronted the feelings of mistrust at the start of their process in two ways: both recognized that they existed but that, as they needed each other, they committed themselves to a set of agreed principles on which the contracts would have to be based.
The Benin case, where this situation has always existed, shows that an increasing awareness, at both sides, of the common goals, interests and the high need to work together, can lead to finding solutions.

- Private Sector characteristics that facilitate envisaging new ways of collaborating:
All the countries studied have till now concentrated on the Private Not for Profit Sector (church related). The reasons given are comparable:
- the size / volume of its existing and potential contribution to public health services;
- the fact that it is reasonably to well organized and has representing bodies at national level with which a dialogue can be started;
- the degree in which the vision and mission towards health care provision and role in public health system between the partners coincides in principle.

The comparison between Ghana and the other countries learns that success here is influenced by:
- the mandates allocated to the representing national bodies by owners and members combined with adequate internal structures to ensure communication and consultation;
- the degree of technical expertise at each level;
- the degree of interdependence between the partners (PNFP require funding and the government needs capacity);
- the perceived urgency to improve the existing situation:
Internal pressure: caused by the dissatisfaction with the prevailing situation:
- Governmental recognition that the present situation is failing to provide equitable health care access, is not responsive to peoples expectations and inefficient. And that public funds are not being used optimally (subsidy to non governmental parties and / or public expenditures).
- While the PNFP's want to contribute more consistently and comprehensively and urge for a more equitable system: users in their units pay more than in public units.;
External: pressure: from Development Partners combined with the level in which the local partners are dependent on them.

- Characteristics of other Private Sector parties:
There are few to no historical experiences in these countries with collaboration with private health practitioners. The first experiences and their impacts on public and private not for profit providers are rapidly influencing the climate (see skimming off income for first line units and hospitals, see also public and private employers supplementing their salaries).

Uganda has identified three private sub sectors and just recently a fourth has been added with which it would want to envisage partnerships:
- PNFP;
- PHP: private health practitioners;
- Traditional Medicine
- Non facility based Not for Profit Health Care Partners.
Each can again be subdivided into different subgroups, each presenting in theory specific opportunities for collaboration and partnership for shorter or longer term, for comprehensive contributions or for more specific contributions to public health goals and services.
In comparison to the characteristics of the PNFP's they all do present, at this point in time, additional obstacles to starting a dialogue:
- There are essential differences between the sub sectors from the perspective of their evolution and their institutional development;
- Size / volume of contributions to health care provision is not yet well known and mapped;
- They are hardly organized and have a very low degree of representation at national level;
- The degrees of technical expertise at each level varies greatly;
- Most are relatively independent from the public health system and the level to which they share interests and goals with the public health care providers or other private sectors varies enormously.
- The PHP's and Traditional Medicines groups still have to develop their views towards possible involvement in public health care provision.

Ghana opted for a gradual bringing on board of other sub sectors. It has just started the dialogue with the Private for Profit Sector and wants to use the experiences gained during the elaboration of the contractual approach with the PNFP sector in its deliberations with the private sector.
Benin has developed a set of objectives, strategies and activities to involve this sector in the coming five years.

3.2. POLICY AIMS AND STRATEGIES

- Health care policy
Comparable to the other countries Uganda's goals in Health Care are:
- Strengthening the capacity of the national Health System;
- Equitably and efficiently improve the health status of the population.

In line with these aims, the objectives for the Public Private Partnership have been set as:
- Increasing private sector contribution to the Public Health Agenda;
- Substituting where possible private for public provision;
- Reassessing mechanisms of existing subsidy to the private sector.

Uganda shares these, actually broad, aims with Tanzania and Zambia. Ghana instead, from the onset, formulated a more specific objective with respect to the way it wanted to involve the PNFP's: in view of their capacity the hospitals and next the lower level units are to be assigned delegated roles and tasks within the district health system.

The Uganda description of the District and Sub district Health System, which was elaborated at the same time as the present policy and strategic plan, seems to go much further as it indicates that delegation of roles and tasks to the PNFP would be the more specific aim. The system description namely states that PNFP units that are well placed to take the lead functions for a sub district should be assigned that role. This plan is already being implemented.
It would seem to me that a number of the issues of debate at this moment stem from the gap between the implementation of the sub district plan and the more short term arrangements that are being implemented towards the overall goal and objectives:
- f.i the discrepancy between the assignment of a broader function and the immediate objectives of the present grants (reducing user fees and starting harmonizing staff salary levels);
- considering and treating the PNFP Lower Level Units as separate from their sub district.

It would there fore be helpful to detail the policy and strategic aims more specifically in terms of the end situation which is desired. For the PNFP's this is implicitly already present and this implicit aim coincides largely with what the these partners would see as desirable with respect to their vision on health care and their concern to be able to cater more comprehensively and consistently for the poor.
For the other potential partners some implicit objectives could be assumed but there is a large variety of interpretations according to the persons you speak to. For the Traditional Medicine sector the short term objective is clearly set: legislation and regulation. Aims of co-operation are yet to be envisaged.

A more detailed and agreed policy for each sub sector will also allow to determine the intermediate steps, the adaptations to the system and to the arrangements required to gradually get there.

Clarity on the end objective of the collaboration will enable government together with the partners to avoid that policy steps in other areas impact negatively on the possibilities to install the desired end objective. You may recall the recent debates regarding the recruitment of staff, the training schools etc.
In Ghana these kind of disputes have been largely avoided up till now by:
- specifically assigning the task of screening new policy steps by the Public Private desk;
- early consensus building in the Health Policy Advisory Board and in the Government - Private Sector Steering Committee.

- Overall National Policies:
The kind of collaboration that is being sought (the end objective) depends first of all on the national views and policies regarding the role of government. In most countries studied tend towards government ensuring the stewardship functions:
- policy setting: defining vision, directions and ensuring implementation;
- exerting influence: approaches to regulation / setting the rules and ensuring compliance;
- collecting and using intelligence.

The further elaboration of these functions determines in how far the overall environment is conducive to develop the various forms of public - private partnership.
To give one example: just last week one of the neighbouring countries passed a law of the Ministry of Commerce determining that independent every entity that exchanges services or goods for money is to be considered a business entity and there fore subject to the relating taxation. This means that non governmental health facilities are hence forth considered businesses. In other words: policies of other government departments have consequences for the development of the partnership.
In Ghana the same mechanisms, as used to adapt Ministry of Health Policies to the Partnership, are used to advocate for consistent overall policies.

- Decentralization:
Privatization and decentralization are the main strategies in use to decrease central government's role in execution to other parties. In decentralization there are two approaches: Ghana and Zambia have chosen for de-concentration while Uganda together with Tanzania have opted for devolution. As the latter means that the districts are accorded much larger decision making powers and a higher degree of autonomy this does have influence on the elaboration of the nature and methods of collaboration.
In this respect the Ghana Ministry of Health and the Ghana Health Services have an easier position: decisions at central level regarding strategies for implementation are binding. This also counts for Zambia.

Though the devolution of powers is not yet complete in Uganda, by principle and as a number of measures are already in place, there is already higher need to build consensus between Central Level, Ministry of Health, Ministry of Local Government, and the district authorities in view of ensuring partnerships in health are really implemented.
The present district set up does not foresee other parties taking up implementation roles as no structural representation is foreseen in the statutory bodies. In spite of that there are already numerous examples of good collaboration. However these seem to depend very much on the interpretations and good will of individual sector or district authorities.
The disputes concerning the grants to PNFP units find their origin in the difference of views of their roles in the district health system and thus feelings of being forced by central level.

- Selection of roles and functions:
Two important prerequisites to determining the possible roles and functions of other private partners in health care delivery are already in place:
- The division of functions and responsibilities at district and sub district level;
- The definition of the Minimum Health Care Package.
They are presently being complimented by:
- Protocols, standards and guidelines for quality assurance and control
- Costing on rational basis.

3.3. INSTITUTIONAL EMBEDDING

- Organizational set up chosen for policy implementation
A crucial issue for developing partnerships in health pertains to the way we look at a system. All the countries considered only have experience with one hierarchical health care system and organization. Though certainly the PNFP units have always been there they were always considered more or less as alien / temporary to the system. Earlier attempts at integrating them some how have failed due either to ignoring the different ownership or to failing to install durable institutional links at all levels (see f.i. DDH's in Tanzania).

Both in view of decentralization as in view of building lasting partnerships we are now asked to look at the system and organization of health care as, what WHO calls a 'Virtual System' or, my preference: a network organization.
This means units or entities of different ownership and with more or less partial overlap of interests and activities / services work together on an equal footing to attain those objectives that they do have in common.
To ensure that the relationships are constructive and that de-fragmentation is avoided other mechanisms of control are required than the old hierarchical command structure.

To make a network operate in a co-ordinated manner towards the common goal a number of essential tasks have to take place in dialogue between the partners. As this dialogue has to be continuous and structural it has to be housed at each level in existing institutions and / or in new ones. The tasks are:
- Information sharing;
- Consultation and Consensus building to reach agreement on policies, strategies and implementation;
- Co-ordination of activities and services;
- Joint monitoring and evaluation.

At central level a number of these tasks have already been installed:
- Information sharing through reports;
- Structural participation of the Private sector in the HPAC in view of consensus building towards implementation of the national policy and strategy;
- Active involvement in the Joint Mission: monitoring and evaluation;
- The instalment of a focal point in the Ministry: the Public - Private partnership desk within Health Planning Department: charged with liasing and elaboration of proposals for further structuring of the partnerships etc..

To be able to address in depth the issues specifically pertaining to the partnership, Ghana has also set up the Steering Committee for the implementation of the MoU and the Stakeholders meetings.

At district level here:
- information is sent upwards in the system by quarterly and annual reports, feed back mechanisms are not yet well established;
- nearly the only level at which structural dialogue takes place is at the level of the DHMT for those units that are in charge of a Sub district. The dialogue here, as far as I understand, for now, mainly pertains to the annual planning exercise.

The Local Government Act of 1996 largely determines the statutory bodies at each level.
At this moment two problems appear in relation to institutionalizing the dialogue with other partners in health:
- the DHMT and the sub district are as such not recognized bodies;
- the description of the existing statutory bodies do not foresee representation of other parties than district political, administrative and / or sector representatives.

Additional obstacles are formed by the facts that the field of Private Sector Partners is very wide, they are not organized at lower levels and their presence in the districts varies largely per district. The differences between the other three sub sectors and the PNFP are important here as well. For them an added obstacle is the difference between the church structures and the health and district structures (RCC and the Church of Uganda is organized at diocesan level but these rarely coincide with districts and the other churches have more peripheral organization levels).

In Ghana the hospital managers of the district designated hospitals are statutory member of the district health committee. To organize the dialogue with the entire sector at this level Stakeholder meetings are foreseen at district level in the future.

The PNFP's and the district health care system
To illustrate how difficult it is two look in a new way at the health care system I can tell you that a number of the persons I spoke with hold the idea that the Bureau's are responsible for and have to supervise the LLU's. Two misunderstandings prevail here:
- the National co-ordinating bureau's are just that: they co-ordinate, facilitate and liais and the churches, the dioceses are the owners / responsible;
- the churches and the bureau's are in favour of the functional or operational integration, described before, and thus that these units should be part of the / take part in the dialogue and co-ordination mechanisms set in place at district and sub district level.
Supervision from national level and / or diocesan level should mainly aim at capacity building / strengthening and support information exchange.
The churches owners under the technical guidance of their bureau and unit managers have to make sure that they ensure internal cohesion and communication so that decisions are taken at the right level.

The district health system has two other important mechanism that aim at co-ordination and continuity of care:
- Supervision;
- The referral system.
They are powerful instruments but they need to be adapted to the network principles.

3.4. SUPPORT MECHANISMS

Participation in policy formulation and institutional embedding of the representation of the partner, answer to two of the important concerns described in the chapter on the contextual issues. The other ones still need answering both for the partnership to work as to support continuity and efficiency of the network system.

- Formalization:
The first support mechanism that allows to answer to the concerns of the two partners regarding dependability, mid term to long term certainty / protection as well as transparency and accountability is formalization.
With hindsight one can conclude that Ghana started from the point of view of formalization. However the process of elaborating the MoU and the contract formats in a participatory manner, based on the policy aim to delegate responsibilities, obliged them to determine next to all the essential issues, the main support mechanisms:
- accreditation and readiness criteria;
- budget allocation formula;
- reporting and accountability criteria and formats.
The added value here is that they have been developed in a consistent manner towards the policy aim and strategy and have clearly been agreed upon.

In contrast Tanzania's existing legislation and regulation system and recent changes in the external environment of health seem to severely restrict new initiatives for partnership with the private providers.

- Budget Allocation Formulae and Accounting requirements:
The experiences in Uganda with the present budget allocation formulae and accounting procedures and formats are giving rise to concern. The debate now focuses on different routings (via the Bureau's) or other forms (subventions). To my view and taking into consideration the Dutch, Ghana and Tanzania experiences, two principles should prevail:
- consistency with the policy aims in health care and in the functioning of the district;
- consistency with the aims of the partnership: fairness and equality.
A block grant with leeway for virement combined with reporting and accounting according to the priorities in health and the need for transparency does seem more fitting then.
The dis-balances that have grown in staff salaries and which have lead to unequal capacity at the LLU level (a situation Ghana experiences much less as the old grant in aid system ensured harmonizing of staff emoluments) should be taken into account.

- Accreditation, legislation and regulation:
Unfortunately not much new experience can be gathered yet from the other countries. In line with the principles of partnership and, if chosen, with the principles of delegation of responsibilities, these should first and foremost be seen as safeguards for both partners.
In the past they have been often seen as steering and controlling mechanisms. However in all the countries the existing legislation and regulation has often become quite defunct as capacity to inspect, follow up and, where necessary, sanction was rarely available.

Developing new standards, laws and regulation mechanisms should be a participatory process. Self regulation and liberal approaches fit better than a restrictive approach:
- They need to be consistent with the health and decentralization policy as well as with the aims of the partnership:;
- adherence is strongly enhanced if the partners are co-responsible;
- capacity to inspect and enforce will remain a problem in these countries for some time.
Internal and independent accreditation audits combined with fair and equal inspection and sanction methods will facilitate enforcement.

The Dutch system rests mainly on self regulation.
On the other hand our recent history also learns that a further orientation towards market theories in the health sector does endanger equity: at present we are battling with developments that tend to install a two tier where the rich can buy what the others will not be able to obtain.

- Incentives:
An often forgotten area in ensuring social services is the role of incentives. A lot can be said about them but for now I would want to restrict it to:
- Policy aims can be supported by installing incentives that are consistent with them and which enable the partners to invest in the services (tax exemptions, financial responsibilities leeway to develop innovative approaches and services). This is probably most applicable to developing partnerships with the Private Practitioners;
- In commercial literature and more and more in international health care views, autonomy and accountability are seen as incentives: thinking of the concerns on the side of government and PNFP's it could be helpful to look at these issues from the perspective of incentives to perform better and to work more closely together.

- A Deliberate Process:
The Ghana experience teaches us a set of lessons that are overriding but greatly supportive to developing the partnership. The process to elaborate the MoU between the Ministry of Health and the CHAG as well as the and contract formats for the designated district hospitals was planned and phased with an important symmetry between the two partners:
- Agenda setting;
- Alternating function of initiator and driver;
- Adequate and prior allocation of mandates for decisions committing the partners;
- Use of own capacity and developing the additional capacity and skills required: negotiation, formulation of tools like contracts (structural capacity building / temporary technical assistance);
- Funding for the transformation costs from their development partners.

The process itself allowed the partners to know each other better and allay most of the concerns during the deliberations. The hiccups that they did have learn that such can be endangered by external and internal influences of which personal capture proved the most crippling.

This formalization process was proactive rather than the Tanzania one were incremental changes according to the most acute problems has greatly complicated relations and thus halted the process.
Between Ghana and Zambia another important difference is apparent: in Zambia the changes were implemented in one sweep in stead of gradually. The gradual approach of Ghana ensured that transition safeguards were in place limiting frustrations and tensions to the minimum.

3.5. CONCLUSIONS

  • Theory is still limited, experiences are being gained but not yet sufficient to bank on.
  • Basically there are still only two views on collaboration with private sector:
    1. Parallel systems: only touching incidentally and when government wants;
    2. One organization: Others have to be absorbed into it.
  • Important paradigm change: health care system is not one organization but a network of actors from different denominations
  • Know and Recognize PSP's, what do they have in common
    AND what are their essential differences are
    Identity and autonomy
  • PSP's to be clear on policies, roles, contributions and limits
  • Recognize that the sub sectors are different and only partly have overlapping interests with government and with each other: need to draw on the common interests and see autonomy as incentive towards;
  • Important to keep the objectives in focus: otherwise collaboration becomes end in it self bringing with it all the strain of tensions with respect to old sores and sharing of resources.
  • There is a need to have a strategic vision and framework to guide comprehensive and consistent elaboration from both sides:
    - health sector does not operate in isolation: other sectors need to share vision;
    - counts for both sides;
  • There is a need to have a focal point within the ministry
  • Together with recognized fora for information sharing, consultation, consensus building and monitoring at technical level and decision making level / central and decentral;
  • It is a process: planning, phasing, pacing and built in improvement cycle
  • Policy or central level should not run too far ahead of implementing level ie bring them along;
    Important to remember: organizations and systems form one side of the coin but the people form the other, ie how things should work versus knowledge, skills and attitudes of staff that have to make it work.
    - ie Preferably the latter should be involved in policy making at least through consultation and feedback so that they can 'carry' the decisions;
    - Secondly training should precede implementation: shared training experience strengthens bonds before the start.
  • Monitoring and evaluation should be foreseen from the beginning to ensure that learning from the experiences is built in and frustration levels are kept at minimum.

Last but not least: Partnership is two way thing based on equality between the parties: equal obligations and equal rights and open attitude to negotiation.

What is rarely stated in documents was expressed by several of the persons I spoke with these days: there is an added value for collaboration and partnership building in health:
Different collaborating partners bring with them: countervailing powers, checks and balances, and they generate positive internal advocacy for weaker sections of users. In fact it should be a phase towards a system where the user is also a partner!

4. RECOMMENDATIONS

What could the Ugandan Health Care system look like in 10 to 15 years from now?
I honestly believe that, if the actual commitment can be maintained and the present views and plans continue to be developed constructively, Uganda will then have a system where all the different partners, starting from the communities to the various private players and from district providers and authorities to national public health authorities work hand in hand to improve the health of all Ugandans and stimulating each other to strive for the best possible performance.

To reach there the following medium term and short-term steps may prove helpful:

Short Term, within the system:
1.) It is increasingly becoming clear that the process of developing partnerships requires time according to where the partners are. The Private Health Practitioners and Traditional Medicine groups require support to strengthen their organization.

In the meantime the development of the process with the PNFP could be brought a number of steps forward if the PPP desk and the main stakeholders could concentrate on this process in the coming months. The prior relations and the advances made in the Strategic Plan ask for some steps to be taken soon.

2.) The planned intensive sensitisation of the PNFP owners, District Authorities and the General Public to the broad aims of the collaboration and partnership will certainly facilitate understanding and collaboration from these sides. In view current perceptions it will be important to explain clearly that the aims of the HSSP can only be achieved when the different providers can be enabled to work together.

3.) The PNFP bureau's, owners and managers should ensure adequate representation of the population in their hospital governing boards and unit management committees to facilitate better communication with the communities and enable them to recognize the facilities as theirs.
Strengthening the capacities of the units for reporting and negotiation at the (sub) district level is also urgent.

4.) Experiences are showing that internal and external policies and developments impact on the possibilities to develop the partnership. It is really a cross cutting issue. Mechanisms for early alerting, consultation and consensus building would allow to avoid problems afterwards. There are three possible approaches: adding the task to the PPP desk, or ensuring that the PNFP and others are well represented in the other working groups. Another possibility is to mainstream the partnership subject, like it has been done for gender.

5.) The present formats to account for the PHC grant surpass the capacity at the Lower Level Units. If a simplified format could be elaborated in collaboration with the MoH, representatives of the DDHS and representatives of the bureau's, taking the available capacities in to account, this would greatly alleviate the burdens and speed up the process for all concerned.

With other departments:

6.) The present process to access the PHC grants gives rise to significant problems for the Lower Level Units and for the following levels. If a simplified process could be accommodated by the MOLG financial regulations this would largely allow to limit frustration all around.

7.) As a number of implementation steps are already on the way at district level (PNFP units taking the lead for a sub district) the elaboration of institutional representation in the main statutory bodies (recognized decision making bodies like the district planning committee) would seem imminent to ensure adequate consultation and co-ordination. It will certainly also strengthen the perception that the entities form one system together.
As solutions within the Local government act may need to be sought, time will be required to get this representation in place.

As the field of directly involved PNFP's and NGOs is quite diverse a single representation would not seem feasible for most districts. An intermediate solution would be to form per district a formal stakeholder advisory group which can discuss with the district health director, select a representative and forward and receive minutes to ensure the institutional dialogue.

Medium Term:

Internal

1.) The policy for the partnership between the PNFP and the public health partners needs to be refined and harmonized so that the specific objectives or the end situation towards which all want to direct their effort becomes clear.
If this policy can be developed in dialogue and collaboration with the main stakeholders it can contribute to mutual understanding and foster feasibility.

At the same time it can be a learning process in view of developing similar policies for the other private sectors.

2.) The Ministry and the PNFP partners should then prepare for the formalization process by building capacity for negotiation and contract development. If necessary, they should also adapt their internal communication procedures for consultation and timely decision making.

3.) The detailed policy will then serve as the basis for the formalization process.
It should be noted that, in view of the devolution of powers to the districts, the Local Government act will have to be taken into account and / or an additional level should be foreseen.
The Memoranda of Understanding and service contract formats will need to have a duration of around three years to allow for the foreseen gradual implementing of policy and funding harmonization as well as the gradual development of capacity.
Both should also allow for exemptions clauses in view of religious principles and capacity inadequacies.

4.) Particularly important issues to be negotiated in the context of formalizing the collaboration are:
- The tasks to be delegated i.e. accepted;
- funding mechanisms that correspond with the tasks, the intended health outputs and the fiscal decentralization.

5.) Developing the accreditation criteria for units, the management and professionals can be done during the process or directly after. A factor of influence here is whether different parties need to be involved.
Development of objective criteria for the units / facilities will facilitate the weeding out of units that are too near to each other.

With other departments:

6.) Subsequently the self-regulation system and procedures can be developed in dialogue.

7.) Next the legislation and regulation system can be adapted.

8.) The detailed policy and formalization process will show which further institutional embedding is required. A plan can then be developed with the main stakeholders to develop and / or strengthen it.

9.) A similar phased approach will be required to develop the partnership with the other sub sectors. In accordance with the capacity at the ministry and PPP desk as well as the level of organization of the sub sectors this can be undertaken in parallel or after the establishment of the full partnership of the PNFP.
NB.
In conclusion: the process will require quite some capacity and transition costs from the Ministry and the partners, which should be taken in account before starting on this structural road to a pluralistic system that can really enhance the performance of the Strategic Health Plan efforts and contribute to a sustainable system.

5. SOURCES

BENIN:
- "Projet d'Accord Cadre entre L'Association des Oeuvres Médicales Privées Confessionnelles et Sociales au Bénin (AMCES) et le Gouvernement de la République du Bénin"
- "Projet de Convention Spécifique entre la Direction départementale et L'hôpital";
- The log frame of the Strategic Health Plan for 2001 - 2005 of Benin concerning the Public - Private collaboration;
- Email interview with Dr. F. de Paepe, director of AMCES;
- Personal observations of Public Health Expert, L. Bijlmakers, who participated in the last health care review.

GHANA:
- The presentation of the MOH representative, Dr. C. Bentsi and CHAG representative, Dr. Yao Yeboah, during the Medicus Mundi International Partner Consultation, Dar Es Salaam, 1999;
- Telephone interview with Dr. C. Bentsi, head of the Public - Private Unit in the MOH;
- Email interview with Dr. Buckle, Executive secretary National Catholic Secretariat;
- Email interview mr. Ch. Acquah, project officer CHAG;
- Email interview Sr. M.A. Tregoning, diocesan health care co-ordinator Sunyani Diocese;
- 'Consolidating the Gains: managing the challenges' the 1999 Health Sector Review.

TANZANIA:
- Telephone interview with Dr. E. Nangawe, head of the Health department of CSSC;
- Personal observations of the Health Sector Advisor, Dr. G. Steenbergen, Royal Netherlands Embassy;
- Personal observations of Public Health Consultant Dr. J. Koot, member of the present review team;

ZAMBIA:
- Report Joint Mission, January 2000, volume one and two.
- Draft National Health Care Strategic Plan 2001 - 2005;
- Email and telephone interview with Dr. V. Musomwe, senior planner Ministry of Health;
- Telephone interview with Health sector Advisor, Dr. R. Peeperkorn, Royal Netherlands Embassy;
- Email and telephone interview Executive Secretary CMAZ, Dr. Ch. Biempa;

UGANDA:
Documents:
- National Health Policy, September 1999;
- Health Sector Strategic Plan, 2000/01-2004/05;
- Current Issues in Sector - wide Approaches for Health Development, Uganda Case Study, WHO, 2000;
- District Public Health Care System Study, Government, January 2001;
- Fiscal Decentralisation in Uganda the Way Forward, Government, January 2001;
- Report for DANIDA on the Ugandan Health Care Swap, Oxford Policy Management, February 2001;
- Terms of Reference and Work Plan Public - Private Partnership Working Group and Desk 2000 - 2001;
- Aide Memoire Joint Mission, October 2000;
- UCMB Mission Statement and Policy, 1999;
- UCMB Strategic plan 2001 - 2005 and Operational Plan 2001 - 2003;
- UPMB Annual report and Statutes.

Interviews:
- Ministry of Health:
- Director General for Health Services, Professor F. Omaswa;
- Director Department of Planning and Development, Dr. H. Kyabaggu;
- Head of the PPP desk, in Department of Planning and Development, Dr. Ch. Kirunga;
- Technical Advisor PPP desk, Dr. C. Forni;
- Ministry of Local Government: Commissioner Local Authorities Inspection, Mr. Th. M. Nkayarwa;
- Ministry of Education, Commissioner Technical, Vocational and Business Education and Training, Mrs. R. M. Lematia;
- Health Service Commission: Chairman Dr. G.W.S. Kamya, Deputy Chairperson, Mrs. Ch. Kabugo, Permanent Secretary, Mrs. J. R. Kisakye; member mr. M. Masereka;
- Medical and Dental Practitioners Council, Registrar, Mr. J.C. Ndiku;
- Ministry of Finance and Economic Development, Mr. St. Rice;
- Consumers Association, three representatives;
- UCMB, Executive Secretary, Dr. D. Giusti and Assistant Executive Secretary Dr. P. Lochoro;
- UPMB, Executive Secretary, Mr. St. Mutyaba; Head of Administration, Mr. B. B. Sabiiti; Primary Health Care Co-ordinator, Mrs. G. Nakazibwe;
- UMMB, Executive Secretary, Dr. Ismael Ndifuna;
- AMREF, Country Director Uganda and Rwanda, Dr. P. Ngatia;
- CUAMM, Country Co-ordinator, Dr. Stefano Santini;
- World bank, Dr. P. Okwero;
- DFID, Mrs. R. Cooper;
- EU/EDF Health programme, Mr. W. Brunger;
- Ireland Aid, Mrs. N. Brennan and Mrs. S. Lake.

INTERNATIONAL DOCUMENTS:
- WHO, Report 2000 and various articles of ICO regarding contracting;
- Palmer N., The use of private sector contracts for primary health care: theory, evidence and lessons for low and middle-income countries, WHO Bulletin, 2000.
- Draft Handbook on good practices relating to Non - Governmental Organizations, World Bank, 2000.
- Options Consultancy Services Limited and London School of Hygiene and Tropical medicine, Working with Private Sector Providers for Better Health Care, an introductory guide, 2001.
- World
- Health Policy and Planning, December 2000, articles of various authors on Regulation in Health Care.
- Mills A. and others, Private Providers in Developing Countries, London ZED Books, 1997.
- Walsh K., Public Services and Market Mechanisms, Competition, Contracting and the New Public Management, Macmillan Press 1995.



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