Building Public-Private Partnership for Health System Strengthening

Contracting out PHC – A case study from Rahim Yar Khan, Pakistan

Neelofar SamiAga Khan University

Bali Hyatt Hotel, Sanur, Bali21-25 June 2010

To present participants with the RYK case study as an example of PHC contracting

To explain the details of the Rahim Yar Khan contracting case

• 6th most populous country in the world, with a population of over 160 millions.

• 50 million people are resident of urban areas• Population growth of 1.9% per annum adds 3 million

people every year • One third of the population lives below the poverty

line • Gross Domestic Product is worth $168 billion • GoP spends 0.5-0.8% of its GDP on health• per-capita health expenditure is Rs. 750 to 800

($10). 25% is contributed by the public sector and 75%

through private out-of-pocket fee-based funding emphasis to continue and strengthen the shift from

curative services to preventive, promotive and PHC.

MoH is --- policy development/ strategic directions /M&E/technical support/ research /training

Provincial & district departments responsible for delivery/management of health services

Through 3-tiered system • Primary---BHUs and RHCs form the core of PHC

model • Secondary --- first and second referral facilities

providing acute, ambulatory and inpatient care through THQs and DHQs

• Tertiary care ---- comprising teaching hospitals

• Majority of healthcare is financed out-of-pocket.

• The private sector has developed considerably by capitalizing on demand.

• people prefer private services for quality reasons but prefer public hospitals for inpatient care

• Health care is provided by stand-alone clinics operated by individual providers with highest profits for investment

Annual output of 5,000 medical graduates 1 doctor/1400 persons (1:1000 WHO recom)Proportion of Workforce in Public : Pvt Physicians----35:65 Nurses--------70:30 Midwives----35:65

No of Facilities Hospitals---1000 &700 Beds---------100,00 & 20,000 Clinics------75000---all Pvt Trust hospitals---580

Enormous amount of funds spent on BHUs, most of the BHUs are not operational

RYK has 4 tehsils. Population 3.68 million Most BHUs in RYK not functioning properly District government of RYK decided to work

with Punjab Rural Support Program (PRSP) to manage 104 BHUs through contracting out

PRSP was given the government budget to run the RYK BHUs since mid-2003.

The main provisions included: district government to transfer control,

management and use of buildings, furniture and equipment of BHUs to the PRSP

budgetary provisions relating to unfilled posts, medicines, maintenance and repair of buildings, equipment, utilities, stores, and office .

The financial provisions enable the RPSP to undertake financial redesign and make the BHUs run more effectively.

PRSP to render accounts of management

operations to the district government district government was meant to relocate

staff as requested by the PRSP. All physical assets of BHUs were thus

transferred to PRSP, to be returned at the conclusion of the contract.

PRSP divided 104 BHUs into 3 clusters One doctor/cluster appointed as team leader 12 MOs already living at BHUs +23 new

hiring MOs were offered an interest-free car loan Government of Punjab guaranteed their

contracts remain secure if the PRSP pilot project did not work out.

salaries enhanced from Rs.12000 to 30,000 but private practice was strictly forbidden

Paramedics to be supported by Health Department

MOs in charge of entire clusters and they spend alternate days at the three BHUs

MOs to reside in a focal BHU within their cluster and look after emergencies after office hours.

paramedical staff not allowed to charge extra fees on the BHU premises. Just Rs.1 as fee

The MO is responsible for discipline of the cluster BHUs.

The BHU OPD to be conducted by the senior paramedic when the MO is visiting the other two cluster BHUs.

Expedited delivery of medicines to BHUs Physical Infrastructure of BHUs --PRPS

made the actual clinics more functional but unable to manage paramedical residences

100 percent availability of doctors and medicines at each BHU and improvement in staff discipline

greater staff presence at the facilities has translated into a three-fold increase in uptake of services

no changes in the drug procurement system

increase the remuneration of the doctors managing BHUs and assured their residence in 33 BHUs, and they supervising PHC team

No control over quality of medicines No control over paramedics who practice in

private dispensaries lack of motivation of BHU paramedics---

unfilled vacancies Management issues