Community, Civil Society, Public and Private Partnerships for

Health

Community, Civil Society, Public and Private Partnerships for

Health

Workshop on

“Community NGO Public Private Partnership: Designing the New Development Paradigm”

February 15, 2007 Jaipur

Dr. Siddharth AgarwalUrban Health Resource Centre (UHRC)

[formerly EHP India]

Presentation Outline Presentation Outline

• Need to partner with CSO, private, public sector and community

• Partnership with Civil Society Organizations and Public Sector and Community

• Partnership with Private and Public Sector and Community

• Multi-stakeholder partnership

• Challenges

• The way forward

• Lessons learnt

Need to partner with private, public sector

and community

Need to partner with private, public sector

and community

Maternal and Child Mortality in IndiaMaternal and Child Mortality in India

25%0.13 millionMaternal deathsProportion of globalEstimated NumbersAnnual Mortality

22%2.4 millionChild deaths

24%1.7 millionInfant deaths

30%1.2 millionNeonatal deaths

Reduction in MMR from 407/1 lakh live births (1998) to 100/1 lakh live births by 2015 (MDG)

Reduction in U-5 MR from 87/1000 live births (2003) to 41/1000 live births by 2015 (MDG)

0

20

40

60

80

100

020406080

100120140160

Under 5 Mortality * Infant Mortality * Neonatal Mortality *

Health conditions of urban poor are similar to or worse than rural population and far worse than urban averages

[Re-analysis of NFHS 2 (1998-99) by Standard of Living Index, EHP: 2003]

103.7

46.7

Rural Average

103.7

63.147

73.3

31.7

49.638.4

Urban Average Urban Poor

101.3

66

39.1

56.0

Nutritional Status

* Mortality per 1000 live births

Child Health and Survival in Rural and Urban AreasChild Health and Survival in Rural and Urban Areas

Source :USAID-EHP 2003.Standard of Living Index based reanalysis of NFHS-2 1998-1999.

* Mortality per 1000 live births

Mortality among Urban Poor Children in Rajasthan

Mortality among Urban Poor Children in Rajasthan

162.3

98.2

65.5

93.368.9

45.6

133.2

93.1

56.3

020406080

100120140160180

Under 5 Mortality * Infant Mortality * Neonatal Mortality *

Urban Poor Urban Average Rural Average

Source : USAID-EHP .2003.Standard of Living Index based reanalysis of NFHS2. 1998-1999.

Nutritional Status of Urban Poor Children in Rajasthan (under 3 years)

Nutritional Status of Urban Poor Children in Rajasthan (under 3 years)

62.5

27.1

46

15.1

51.9

22.3

010203040506070

Under weight for age Undernourished(Stunted) for age

Urban Poor Urban Average Rural Average

Perc

enta

ge

Poor Access to Health Services (Rajasthan)Poor Access to Health Services (Rajasthan)

23.6

43.8

17.5

0

10

20

30

40

50

1

Urbal Poor Urban Average Rural Average

Births whose mothers had minimum of 3 ante-natal visits

Perc

enta

ge

Source : USAID-EHP 2003.Standard of Living Index based reanalysis of NFHS 2. 1998-1999.

79

51.5

84.5

0102030405060708090

1

Urban Poor Urban Average Rural Average

ANC Services Deliveries at Home

Inadequate Public Sector Primary Level Urban Health InfrastructureInadequate Public Sector Primary Level Urban Health Infrastructure

• 61 UFWCs and 90 Health Posts, many run from hospitals, not proximal to slums

• In urban Rajasthan (13.2 million) there is one UFWC/HP for about 87,417 population

• PP Centres: 135 (many closed owing to discontinuation of Central funding)

• (Source: Annual Report on Special Schemes, Dept of Family Welfare, MOHFW, 1999-2000)

Community, CSOs,Public and Private Sectors Complement Each OtherCommunity, CSOs,Public and Private Sectors Complement Each Other

High physical and social access to the poor esp. of non qualified providers;

no mechanism to monitor quality

Poor quality of services at most Primary Care

centres and low social access

CSOs can effectively act as link between

community and service providers and improve

service utilisation

Low utilisation of public health care services

Limited willingness to serve the low profit

sections; weak emphasis on preventive care. High commitment to the poor among non-profit sector

Provision of subsidized and free health care for

the poor, equal focus on preventive measures

NGOs can effectively provide primary level

health services

Low community awareness about primary level healthcare services

Availability of modern technology –flexibility and

openness in approach

Weak planning and management systems –

rigidity

NGOs are close to community and have

better capacity of social mobilization for improved

utilization of services

Low satisfaction of Community with the

existing efforts

Many types of providers –85% medical

professionals private, non qualified providers widely

accessed

Constitutional mandate, Policy backup & wide

network

CSOs are concerned with health of the poor

Community desire for improved health

Private SectorPublic SectorCivil SocietyCommunity

NRHM lays strong emphasis on community, civil society, private and public partnershipsNRHM lays strong emphasis on community, civil society, private and public partnerships

• CSO-Private-Public sectors partnership to meet national public-health goals is one of the key strategies of NRHM

• Forms of partnership mentioned in NRHM relevant for increasing access to health services for the urban poor include:

– Contracting the management of UHCs to Civil society Organisations

– Contracting in private practitioners / specialists to public sector facilities / provide out reach services

– Contracting delivery of health services to unserved areas to Civil Society Organisations

– Social franchising / marketing

– Partnership with corporate sector

– Partnership with Community based organizations

– Enhancing capacity of community for better service utilisation

– Strengthening linkages between community and service providers through link workers (ASHA)

Civil Society, Community and Public Sector PartnershipsCivil Society, Community and Public Sector Partnerships

Outreach

10,000

Referral to Identified FRUs/Charitable Hospital

e.g., Arpana Trust manages a MCD health center in Molarbund, Delhi; Sumangli Seva Ashram, Shri Sharan Seva Samaja, Lions Club Trust and others (Bangalore), several NGOs in Chennai

Outreach

10,000

Outreach

10,000

Outreach

10,000

Outreach

10,000

Urban Health Centre

Government

1.Building2.Recurring costs3.Vaccines4.Other supplies5.Coordination

NGO Manages Govt./Municipal Urban Health Centre

CSO-Community and Govt. Partnership Approach # 1 CSOs Managing Health Centre from Govt. Premises

CSO-Community and Govt. Partnership Approach # 1 CSOs Managing Health Centre from Govt. Premises

Example Approach # 1.. Contd. Partnership between MCD, Arpana Trust and Community

Example Approach # 1.. Contd. Partnership between MCD, Arpana Trust and Community

• Arpana Trust runs a urban health center of MCD in an urban poor community in Delhi since July 2003.

• MCD, as part of IPP-VIII had constructed a health centre which was dysfunctional because of lack of staff and equipment

• Arpana Trust offered to run this health center and an MoU was signed for 5 years

• MCD provides the building, medicines and vaccines; Aprana Trust is in-charge of staff salaries, running expenses and community volunteers.

• Arpana Trust also mobilizes additional resources from corporate,individual and other donations.

• Arpana Trust has improved quality of services by– Providing diagnostic services at affordable prices– Providing services of part-time / visiting specialist consultants– Providing outreach services through mobile health vans

Outreach

10,000

e.g., Govt. of Assam’s partnership with Marwari Maternity Hospital (Guwahati), Govt. of Tamil Nadu’s & Chennai Corporation’s partnership with Voluntary Health Services

Outreach

10,000

Outreach

10,000

Outreach

10,000

Outreach

10,000

Government

1. Equipment costs2. Vaccine3. Other supplies4. Coordination

Referral for 2nd tier

services

CSO-Community and Govt. Partnership Approach # 2 NGOs Providing Health Services from Own Hospital

CSO-Community and Govt. Partnership Approach # 2 NGOs Providing Health Services from Own Hospital

Govt. contracts hospital toprovide outreach, OPD and

Referral services

Example Approach # 2.. ContdPartnership between Govt. of Assam and MarwariMaternity Hospital (MMH)

Example Approach # 2.. ContdPartnership between Govt. of Assam and MarwariMaternity Hospital (MMH)

• Govt. of Assam contracted MMH (a charitable hosptial) to provide outreach and referral health services in eight slums of Guwahati.

• Govt. pays for referral and outreach services and also provides vaccines and contraceptives

• Initial contract was for one year (2002-03) and was subsequently renewed.

• This model requires little infrastructure, cheap and has potential to rapidly expand services to the unreached.

• This initiative has improved access to services (especially the floating population and migrants) and health outcomes in identified slums.

Partnerships with Private, Public Sectors and PeoplePartnerships with Private, Public Sectors and People

Nodal Govt./Municipal Dispensary

1.Vaccines2.Other supplies3.Coordination

2nd tier Govt./Private Centre

Slum2

3000 popln

Slum 3

3000 popln

Slum 4

3000 popln

Week 2

Week 4

Slum1

3000 poplnWeek 1

PPP: Approach # 3 Partnership with Public sector Private Doctors and Community

PPP: Approach # 3 Partnership with Public sector Private Doctors and Community

Week 3

Under the govt. immunization scheme there is provision of Rs. 1400 for 4 camps to be held in a slum per month

Referral from slums to Govt. Dispensaries or 2nd tier Govt/Private centre

Socially Committed Private Doctor[receives honorarium from Govt]

(about 3-4 hrs every Sunday)

District Urban RCH Unit Coordinates with private doctors, NGOs, nodal Dispensary,Coordinates periodic review

Social Mobilization by NGO• Identifies and trains link workers• Supports community mobilization• Supports outreach services• Builds linkage between community,

health providers

E.g. IPP VIII and CUDP 3 in 40 cities of West BengalEstimated cost per month: Rs. 25000; Cost per person : Rs. 2 per month

PPP: Approach #3 contdOther forms of Partnership with Private DoctorsPPP: Approach #3 contdOther forms of Partnership with Private Doctors

• Private doctors can provide health services in government healthfacilities on fee sharing/part time basis. Specialists can volunteer for few hours each month. [IPP VIII Kolkata and Delhi (Arpana)]

• Govt. referred cases (neonates, obstetric, childhood illnesses) are treated at Private facility which can be then reimbursed. [e.g. TN]

• Govt. can give “child health vouchers” to parents of newborns for series of services they can avail at private doctor’s facility [Kolkata, Udaipur]

• Once-a-week-OPD subsidy: Private Pediatricians (and others) can provide substantially subsidized services for the poor once a week for a specified time at their clinics [Meerut, Haridwar, many cities]

Government

1.Vaccines2.Other supplies3.Coordination

Referral to Identified FRUs/Charitable Hospital

Slum cluster 1

10,000 popln.

Slum Cluster 2

10, 000 popln.

Slum Cluster 3

10,000 popln.

PPP Approach # 4 .. ContdExample of Corporate supported Urban Health Efforts:

PPP Approach # 4 .. ContdExample of Corporate supported Urban Health Efforts:

Services provided : OPD, immunization, ANC, IUD insertions, health education, counseling, Referral and lab tests

Ranbaxy Mobile Health ClinicSocial mobilization and RCH Service Team

Estimated cost: Capital cost – 7.5 lac, annual recurring cost – 10 lac

• Supplement Health Investments and services needed to address urban health challenge

• Sharing of expertise pertaining to demand generation, marketing and management

• Advocacy for enhanced attention to health of urban poor population

PPP Approach # 4Partnership with

the Corporate-Public Sector and Community

PPP Approach # 4Partnership with

the Corporate-Public Sector and Community

CSR is not just charity; it is an integral part of doing business-View expressed by several leading Corporate leaders

Multi-Stakeholder Partnerships and ConvergenceMulti-Stakeholder Partnerships and Convergence

Ward levelCore Group

Ward levelCore Group

Total Coverage: 70, 000 slum population in 2 wards in Indore

Multi-stakeholder Coordination for Optimizing Resourcesto Improve Immunization (UHP Indore)

Multi-stakeholder Coordination for Optimizing Resourcesto Improve Immunization (UHP Indore)

NGOs & CBOs

Charitable organizations

Elected Representatives

Municipal Corporation(Zonal office)

DUDA [UIT]Local Resources

(Local Clubs, Schools)

Health dept

ICDS

Improves utilization of available services and enhances reach to vulnerable slums

• UHRC, facilitate coordination of the efforts of the municipal corporation, health department, ICDS, DUDA, local leaders, NGOs and a community based organization to provide immunization services in 24 slums of Indore.

• Regular meetings of these stakeholders are organized to discuss health related issues and provide services to all needy people.

• Bringing coordination among different stakeholders it aims to improve facility based immunization, outreach services and linkages of community with public and private sector providers for improving reach of healthcare services

• The overall purpose is to develop a replicable model and learn from this experience to apply in other wards and cities

Multi-stakeholder Partnership and Convergence Approach (UHP Indore)Multi-stakeholder Partnership and Convergence Approach (UHP Indore)

Challenges and OptionsChallenges and Options

IssueSkepticism among govt. officials in involving Private Partners including NGOs in health service delivery –

requires advocacy

OptionMutual trust between two sectors can be enhanced through

interaction/visits of Govt. officials to Private partner and NGO areas; and to places where PPP is functional.

Challenge 1Limited acceptance of PPP approach among

public and private counterparts

Challenge 1Limited acceptance of PPP approach among

public and private counterparts

Issue

Not many NGOs have the capacity to deliver health services independently

OptionThere is need to strengthen governments’ capacity to select

private partners and develop and monitor contractsCapacity building of NGOs to deliver health services is

essential

Challenge 2Effective mechanism for identification of appropriate NGO required

Challenge 2Effective mechanism for identification of appropriate NGO required

IssueBureaucratic constraints and lack of coordination across

government departments leads to delays in starting PPPPayment delays owing to long drawn procedures

affects operations of NGOsOption

Service or performance based payment rather than focus on processes; as well as maintaining private partners’

managerial autonomy improves outcomes.

Challenge 3Govt. and partner need to evolve the mode of functioning to streamline partnership

Challenge 3Govt. and partner need to evolve the mode of functioning to streamline partnership

Issue

PPP managed RCH services have often not lasted beyond project life (Andhra Pradesh, Bangalore)

Options

Approaches to sustain PPP beyond project funding need to be explored at the inception e.g. alternative funding, user fees, corpus

Partnership with NGOs helped sustain services after funding stopped

(Sumangali Sewa Ashram, Bangalore).

Challenge 4Sustainability of such partnerships beyond project funding is achallenge

Challenge 4Sustainability of such partnerships beyond project funding is achallenge

Lessons LearntLessons Learnt

Gentle Dialogue, Perseverant Efforts and Proper DocumentationGentle Dialogue, Perseverant Efforts and Proper Documentation

• Gentle and genuine dialogue, assessment of critical needs, joint development of plan to respond to needs, builds trust which is critical to success.

• Formal documentation within Govt. system– by way of letters of request, minutes of meetings, etc.

• Perseverant efforts to play catalytic/facilitator role: – Appreciate and begin with what Govt. stakeholders have – Involve decision makers at critical junctures– Identify and encourage champions within the govt.

system– Remain open to ideas/feedback, be flexible and

responsive• It is vital to initiate sustainability efforts early to

complement Govt/donor resources and sustain health improvements

HealthImprovements

PUBLIC SECTOR

SERVICES

PRIVATE/NON-GOVT AGENCIES

PEOPLE (SLUM COMMUNITIES/INSTITUTIONS)

The slum communities are essential partners in this effort to achieve optimal behaviors, penetration to most- vulnerable pockets, sustain health improvements

Include the “people” as key partners Include the “people” as key partners

Complement resources, strengths

Strengthening Comm

unity Capacity and

Linkages with Providers

Improved Supply andQuality of Services

Impr

oved

B

ehav

iour

san

d D

eman

d

Link

ed fo

r bet

ter a

cces

s

Let us work in

partnership to

build a healthy

and productive

tomorrow for

these children

Let us work in

partnership to

build a healthy

and productive

tomorrow for

these children