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PPPs in India: Expansion without Evidence

This is the second post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we discuss the state of PPPs in the health sector, and the need for greater evidence on performance and enablers.

Since Government’s endorsement almost 15 years ago as a potential solution to deficient health service delivery, healthcare public-private partnerships (PPPs) have proliferated across India. They represent a rare form of public-private collaboration in a system dominated by private provision, but inhibited by considerable distrust between the two sectors. In effect, public-private engagement for service delivery in India’s health system hardly moves beyond the micro-level realm of PPP transactions. More recently, however, government-sponsored insurance schemes such as PM-JAY are purchasing insurance-related services from private third-party administrators and health services from private hospitals, and represent a bold step forward in public-private engagement. In this post, we focus on PPP models oriented toward expanding service delivery in which state health agencies contract private entities to build and operate facilities or manage services heretofore delivered through the public delivery system. Despite the proliferation of these transactions, little is known about their scope and impacts.

We began analyzing the state of healthcare PPPs in India about a year ago, and quickly found that the evidence-base is thin. In India, states are constitutionally responsible for publicly-financed health service delivery. Our analysis of multiple tender documents, newspaper articles, reports and websites of state PPP cells reveals that over the past decade, state governments across India have primarily focused on infrastructure PPPs. A growing number of states are experimenting with service delivery PPPs . Many of these involve the contracting out of select clinical and non-clinical services, such as diagnostic services (ex: Bihar, Himachal Pradesh) and dialysis services (ex: Delhi, Andhra Pradesh). Some states, such as Karnataka, Meghalaya and Arunachal Pradesh, have outsourced management of some primary care clinics to NGOs. To a lesser extent, states have or are experimenting with contracting out hospital management and service delivery (see examples here and here). Data on the actual number of ongoing PPPs is difficult to obtain or validate.

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The impact of these PPPs in terms of quality of care, costs and alignment with public priorities is largely unknown. Some diagnostic and dialysis PPPs have reported positive performance (see here and here), possibly because their narrow scope makes them relatively easier to design, tender, manage and monitor. One model that has widely been panned as a failure is the “land for beds model”, in which land is leased to a private partner to build and operate a hospital at little or no cost, in exchange for meeting specific conditions, usually including designating a share of beds to the poor. A troubled joint venture between the Delhi Government and Apollo Group exemplifies the challenges of this approach. Amazingly, this form of PPP remains under consideration in other states.

Anecdotal evidence suggests that some private operators faced insolvency in part due to late payments from government agencies. Further, while PPPs are often employed to fill gaps in access and quality that the public sector cannot address through its own resources, contracts often lack critical details: performance indicators, accountability frameworks and standard operating procedures are generally missing. As elsewhere, the public sector’s low capacity for contract management in India may be the Achilles heel of PPPs.

The lack of good quality information and data on specific healthcare PPPs in India is concerning. States across India are moving forward with this agenda (see here and here), and many interesting engagements are underway; yet there is little to no rigorous evaluation or even monitoring of these initiatives. Much of the evidence to date is drawn from “light touch” case studies that often appear promotional in nature. Little is known about impacts, lessons learned, and how starting conditions and government and contractor capacities contributed to performance.

As a result, states are left largely to operate in the dark, with limited knowledge of what has worked elsewhere in India, and why. The often ad hoc nature of PPP transactions leaves them vulnerable to repeat past failures, and unable to systematically learn from successes. More and better information and analysis are needed to inform state and national PPP policies so that governments can move this agenda forward in a more informed way. Until then, we can’t be sure why some PPPs succeed while others fail.

Check out other posts in this series below:

Let Managers Manage: Raising Indian Public Hospital Performance

Let Managers Manage: Raising Indian Public Hospital Performance

This is the first post in our series, “Raising the Bar for Indian Healthcare”, which highlights the challenges and opportunities facing India’s healthcare delivery system. In this post, we discuss considerations for raising public hospital performance through greater autonomy.

The recent rollout of PM-JAY – a government-subsidized health insurance scheme that aims to provide inpatient coverage up to 500,000 INR per year for India’s poorest families – signals the trajectory of India’s healthcare system. Building on the experiences of earlier state and centrally-sponsored insurance schemes, it solidifies the government’s expanded role as a purchaser of healthcare services. For India’s public sector hospitals, which are accustomed to mainly supply-side financing through line item budgets, this expansion of insurance revenue, together with the separation of healthcare financing from provision, will bring new opportunities, as well as challenges. Specifically, public hospitals will need greater financial and managerial autonomy if they are to respond to the incentives embedded in payment systems set by purchasers to control costs and provide high-quality services (see Chapter 12 of this useful resource for more information). The government’s 2018 New Strategy for India @75 calls for granting some autonomy to public facilities to enable effective use of claims money generated under PM-JAY to improve the care they provide. How India will guide and implement greater autonomy in public hospitals remains an open question.

Indian public hospitals have much to gain from new forms of governance and management. Most are directly operated by state health departments, and as a result, hospital managers have little decision-making authority over inputs or day-to-day operations, and political interference in human resource management is rife. Emerging evidence suggests that Indian hospitals are poorly managed, especially publicly-run facilities. Under these conditions, it is difficult to implement changes in support of quality and efficiency improvements. For both purchasers and patients, the result is often low-value care.  

Most successful autonomy-oriented efforts in India to date appear to have occurred in other sectors (e.g., Delhi Metro Rail Corporation, DMRC). Yet, recent evaluations have shed light on some highly successful healthcare examples such as GVK Emergency Management Research Institute (EMRI), which operates emergency transport services, and the Tamil Nadu Medical Services Corporation (TNMSC), which manages the ordering, testing and distribution of drugs and  medical supplies throughout the state of Tamil Nadu. India also has a long history of experimenting with autonomous hospitals. These have taken different legal forms, including legislated “autonomous” facilities at the central and state levels (e.g., All India Institute of Medical Sciences (AIIMS), Indira Gandhi Institute of Medical Sciences in Patna), and more recently, public-private partnerships (e.g., Mumbai Municipal Hospital).

Given these experiences, reforms that increase the autonomy of public hospitals have considerable potential in India – assuming accountability mechanisms are ratcheted up simultaneously to keep autonomous hospitals aligned with public priorities. Recognizing this, government has initiated steps in this direction. For example, under PM-JAY and some state-sponsored insurance schemes, public hospitals are allowed to retain payments received through insurance claims according to formulas set by the schemes.

Yet, there is a need for caution. Our extensive review of hospital autonomy experiences in India and globally revealed numerous possible pitfalls, as well as factors for success. What came through most clearly, however, was the need to ground any autonomy-oriented reform in the local (e.g., state) context, with strong understanding of enabling (and disabling) factors in the broader financial, institutional and political environment. This is a challenge in India, as past and ongoing hospital autonomy initiatives have not been assessed. Even for existing legally “autonomous” hospitals, little is known about effective decision-making authority, managerial capacity, performance or lessons learned.

 With limited data or information, it will be difficult for government to develop truly evidence-based policies or programs. There is a need to focus efforts on gathering critical evidence on existing autonomy initiatives before launching new ones, to support learning and continual improvement over time. 

Strengthening Quality Improvement & Leadership Skills to Drive Improvement on the Frontlines

Aceso Global has been working with the Inter-American Development Bank (IDB) on the Salud Mesoamérica Initiative (SMI). SMI is a pioneering public-private partnership between the Bill & Melinda Gates Foundation, the Carlos Slim Foundation, the Government of Spain, the IDB, the countries of Central America, and the state of Chiapas, Mexico. It is one of the most successful and thoughtfully designed results-based aid (RBA) models and we are excited to join and contribute to their effort, while also learning from their work.

SMI aims to reduce maternal and child health inequalities through an RBA model that is in alignment with the priorities established by the governments of the region. The SMI model is based on four basic concepts[1]:

1.       Countries have to work within the poorest 20% of their populations, selected based on Poverty Incidence Data;

2.       SMI funds can only finance evidence-based, cost-effective and promissory interventions for maternal and child health;

3.       All projects are co-financed by SMI and countries (50% average cost-sharing) and must be executed using the SMI results based aid model; and

4.       All results are externally verified by an independent third party through both household and health facility surveys. If countries meet 80% of their goals, they receive 50% of their original investment to use freely within the health sector.

Specifically, Aceso Global is tasked with designing an innovative learning program for middle managers to support Quality Improvement (QI) efforts in the eight SMI countries. The program breaks from more traditional training styles that use didactic lecturing  and aims to reach behavior change and competency development with interactive and experiential learning techniques. The curriculum focuses not only on the “hard skills” of measuring and improving quality of care, but also on “soft skills” like leadership, team building, communication, coaching and continuous learning that are essential ingredients for any change process. It is firmly grounded in the local realities of the SMI countries and uses case studies, experiential learning and peer-to-peer exchanges to convey contents over the course of the ten-month training.

The competency development program equips middle managers with the necessary skills to coach frontline primary healthcare providers on QI. It also contributes to the larger transformation agenda that SMI and country leaders are pursuing to fundamentally shift the way that care is delivered, to put quality at the center of organizational culture, and to move towards a true learning system that accepts failure and is relentless in the pursuit of innovation and improved performance.

Aceso Global is also developing a unique evaluation strategy for the learning program that examines changes in leadership, organizational culture and skill development, deploying customized evaluation instruments that will gauge the extent to which hard and soft skills have been mastered. The purpose is to yield standardized, comparable data on leadership behaviors and organizational contexts that influence the successful implementation of QI initiatives and ultimately lead to improvements in maternal and child health.

This project falls under Aceso Global’s quality portfolio, which addresses quality of care across the health system by: (1) collaborating with country leaders to put quality of care culture, measurement, improvement and innovation at the center of national healthcare agendas; (2) working closely with providers and stakeholders on the frontlines to shift the culture around quality of care and improve the use of quality data; and (3) integrating quality data with national health information systems, including supporting or developing quality dashboards. Our portfolio approach echoes some of the key takeaways from last year’s wave of reporting on global quality of care, including the Lancet Commission’s High-quality health systems in the Sustainable Development Goals era: time for a revolution, the OECD, World Bank and WHO report, Delivering Quality Health Services: A Global Imperative for Universal Health Coverage, and finally the Institute of Medicine’s Crossing the Global Quality Chasm, for which Aceso Global CEO and Founding Director Maureen Lewis was an expert reviewer.

 

For more information, please contact: Sarah Mintz, smintz@acesoglobal.org

[1] Salud Mesoamerica Initiative Program Description, Progress and Results, May 2016

Aceso Global Annual Report 2018

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Aceso Global published its Annual Report 2018, which showcases the organization’s considerable growth over the last year, and its continued commitment to addressing fundamental structural issues in healthcare globally.

Aceso Global’s Annual Report 2018 highlights the many activities, projects and engagements the organization undertook in its third year. These ranged from designing a Network Model for Brazil’s public healthcare system, to supporting UNAIDS in their sustainability efforts in Mozambique, to participating in conferences around the world as distinguished panelists and keynote speakers. The Report also provides a financial overview, illustrating the organization’s growth.

“Across our diverse activities and projects, our focus has been on systematically working with our clients to respond to their most pressing needs, ensure quality and assist in devising creative solutions,” says CEO Maureen Lewis.

DOWNLOAD THE ANNUAL REPORT HERE

Innovative Financing and its Role in Global Health

There is often confusion surrounding discussions on innovative financing in the context of global health. This summary of a past CUGH conference session on the subject clarifies what is meant by global health specialists when they debate “innovative payment mechanisms” and challenges associated to it. Aceso Global’s CEO Maureen Lewis opened the session with a presentation on the emergence of new actors in global health financing and the shifts in donor priorities away from disease specific programs towards more integrated programs, which could be financed by innovative financing mechanisms. Click here for the full post.

The Revolution in Quality of Care: What Will it Take?

The recent WHO/OECD/World Bank report on Delivering Quality Health Services fills a much needed gap in defining and explaining the importance of quality of care in the attainment of Universal Health Care (UHC). Essentially, the message is: without quality, what is the point of health care investments? Along with access, quality is the sine qua non of health services.

The report’s careful explanation of quality of care and requirements for achieving progress in this area lay out imperatives for countries choosing to take on the challenge of raising quality of care in health care delivery. And while the list of actions is long, it reflects both gaps in data and evidence, and the hard road ahead in closing the gap. Unfortunately, the summary of available evidence and data is thin and limited largely to South Asia, specifically India, and a handful of African countries, complemented by OECD examples on the quality front. Finally, while not mentioned in the report, quality improvement initiatives have often been partial, focusing on one part of the system, such as maternal and child health, while ignoring the need for a culture of quality, a set of core indicators and, critically, some means of ensuring sustainability of initiatives.

As articulated by the OECD (Francesca Colombo remarks), while quality is complicated, some initiatives can be simple and straightforward. Building blocks, such as checklists for surgery or tracking selected adverse events in hospitals, offer a path toward quality improvement that are straightforwardly simple and worth adopting. Others, such as a quality culture and robust data systems, entail greater investments and longer time frames. But all of the requirements and suggestions entail a shift in the way that health care is delivered, and a greater reliance on data. More importantly, and absent in the report, are the roles of incentives and accountability in health care.

The importance of incentives, both financial and non-financial, cannot be underestimated in driving toward a quality culture. Similarly, without accountability, change is unlikely and, where it occurs, unsustainable. Multiple experiences suggest as much. The seminal Institute of Medicine report, To Err is Human, outlined the abysmal state of US health care quality, despite virtually universal hospital accreditation, highly trained staff and significant resource investments. Quality isn’t automatic. In response to the report findings, the weight of public payers, mainly Medicare, forced change through setting clear incentives, and ensuring accountability, e.g., defining performance, rewarding good results and following through on consequences for not meeting data, process improvements and outcome targets. Much progress has been achieved as a result.

Similarly, Atul Gwande’s project on a surgical checklist for “essential birth practices” in India implemented a 28-item checklist accompanied by hands-on collaboration with providers over an eight-month period to test the benefits of using a simple tool for reducing medical errors associated with childbirth. Despite valiant efforts, the checklist system showed no impact.  However, there was no incentive for providers to consistently use the method and, more importantly, they were not being held accountable for outcomes.

The quality agenda remains imposing, but as the WHO/OECD/World Bank report makes clear, embracing quality at the national level offers the only serious route to achieving UHC. And while the report reflects a tour de force on a policy and technical level, implementation issues raise the stakes further. Many of the report’s recommendations offer a menu of options, and countries will need to determine what to prioritize. However, the importance of structuring quality initiatives to ensure adoption and sustainability on a national scale calls for specific actions to drive shifts towards quality, specifically:

  • defining, collecting and using data to capture progress in improving quality in service delivery at all levels of the system;
  • establishing incentives to encourage collection of (correct) data, analysis of performance and use of the data at all levels to monitor performance and measure quality improvements; 
  • financial and non-financial incentives aimed at providers to encourage adoption and mainstreaming measures to raise quality in service delivery; and
  •  harnessing the data to allow supervisors across the system to hold providers and staff accountable for the quality of services.

While simple to describe, these shifts translate into dramatic changes in how health care is delivered, financed and monitored. That part of the quality agenda remains far from simple and straightforward, but captures the essence of quality improvement in context of low- and middle-income countries.