Policy Bite : Public-private partnerships for PHC

January, 2016

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Policy Bite with Professor Amanda Howe, WONCA President-elect

Public-private partnerships for primary health care – what is the ‘bottom line’?

All governments have to decide how to meet the needs of their peoples, and most political elections are based on different beliefs as to how this can best be done. Fundamental issues about how to finance investment for health care and other public sectors require clear thinking and recurrent review of decisions made.

WHO(1) has been clear that whatever options are taken up, they need to result in “a well-functioning health financing system. …Countries must raise sufficient funds, reduce the reliance on direct payments to finance services, and improve efficiency and equity. … It is only when direct payments fall to 15–20% of total health expenditures that the incidence of financial catastrophe and impoverishment falls to negligible levels”.

In most countries, governments are turning to ‘public-private partnerships’ (PPPs) to complement state funding, and to deliver services. The variations of context and type of PPP make generalisations difficult – for example they may fund specific products like vaccinations, or hospital rebuilding programmes, or be providers of workforce . There are also complexities of terminology – for example, family doctors in the U.K. are largely self-employed and owners of their clinics, but are contracted to the NHS to provide taxation funded services free at point of use to patients: so is this a PPP, although our contracts are with the public sector?

Clearly, financing models have to be operated under appropriate governance structures, and to be likely to lead to health gain. A brief review of the literature finds that evidence syntheses and expert consensus is not yet clear as to whether models of PPP in service delivery improve the outcomes for patients. A European-wide evaluation of PPPs in health care (2) “did not find scientific evidence that PPPs are cost-effective compared with traditional forms of public financed and managed provision of health care” and were concerned that PPP projects lacked adequate disclosure and cost effectiveness. A specific example from India comparing different funding models concluded that “There is no remarkable improvement in the quality of services provided by PPP models”(3), Even when secured appropriately and proven to be effective, partnerships are ‘hard work’, both in financial and human resource investment(4), and can be a risk to reputation if significant conflicts of interest or unbudgeted costs are incurred. Risks with PPPs include loss of control, sustainability, and higher costs(5).

As clinical leaders in their setting at local, regional and national levels, family doctors need to be able to appraise and critique the suggestions and policies on which models of health care financing may work best for their patients. We know that the broad health needs of a community can be effectively met by a strong primary care team that combines curative care, preventive programmes, and ongoing chronic disease management for both individuals and groups of patients. PPP models are sometimes proposed to help fund the services we provide. If as family doctors we are involved with making any decision about a PPP , I suggest the following ‘checklist’:-

• National policies on PPP must address secondary and primary care sectors equitably

• Initiatives should be integrative rather than product- or disease- specific

• The PPP must be likely to support the overall building of capacity for effective primary health care – that is affordable, accessible, acceptable and of good quality(6)

• There must be sufficient independent expert advice to allow a strong business model / contract that shows transparent costings and outcome measures, with relevant liability clauses to protect professionals and ensure continuity of core services

• To avoid corruption, there must be due governance and transparent declaration of conflicts of interest; also declaration of profits and regular accounting for deliverables

• Models may / should include collaborative “ownership” of the project or service – this may be via financial, electoral, and stakeholder engagement mechanisms, or broader professional commitment / altruism, but must engage practitioners and motivate them towards positive patient care and quality improvement

• There is an important role for training in related public health, health economics, and ethics which can underpin these issues, but vital is exposure at an early stage to ‘real’ patients in their own setting which humanises the learning and develops patient centred care(7)

• Finally, one needs to avoid vested interests skewing the market and government policy.

This is a challenging area deserving further debate. There will not be simple answers, but hopefully we can agree some principles which inform our decisions and influence our actions – for the greater good!

Acknowledgement: I am grateful to Professor Mala Rao of Imperial College London for her comments and input.

References
1. Health systems financing – the path to UHC. WHO; Geneva: 2010. http://www.who.int/whr/2010/en/
2. EU Health and Economic Analysis for an Evaluation of the Public-Private Partnerships in Health Care Delivery across Europe. Expert Panel on effective ways of investing in Health for the European Commission. Brussels; 2014.
3. Is Public Private Partnership an Effective Alternative to Government in the Provision of Primary Health Care? A Case Study in Odisha Baig MB, Panda B, Das JK, Chauhan AS. Journal of Health Management 2014;16 :41-52.
4. Wildridge V. et al Literature review on partnerships. Health Information and Libraries Journal 2004, 21, 3–19
5. Bull World Health Organ vol.78 n.5 Geneva Jan. 2000 . http://dx.doi.org/10.1590/S0042-96862000000500015 - downloaded 29/12/15
6. http://phcperformanceinitiative.org/sites/default/files/PHCPI%20Technical%20Definition%20of%20Primary%20Health%20Care.pdf
7. Kelly L, Walters L, Rosenthal D. Community-based medical education: Is success a result of meaningful personal learning experiences?. Educ Health 2014;27:47-50