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Taking the pulse: The evolving health public-private partnership in Lesotho

Patricio V. Marquez's picture

Jean J. De St Antoine and Kanako Yamashita-Allen are co-authors of this post.

During a recent visit to Maseru, we met with staff at the 425-bed Queen ’Mamohato Memorial Hospital which opened in October 2011 and at one of three primary care clinics that have been running since 2010 as part of a Ministry of Health (MOH)--led public private partnership (PPP).  The PPP aims to facilitate access to quality health services in a poor country.   

The facilities operate as an integrated health network that provides services following a “continuum of care” approach, not only to the people of Maseru, but the hospital, as a national referral facility, also receives patients from the rest of the country.  No fees are paid in the clinics except for dentistry and radiology. Fees collected at the hospital are in line with the MOH’s fee schedule used in all public facilities in the country.  Fees are transferred to the MOH per existing national policy and do not fund the operation of the network.

Besides modern physical infrastructure and equipment, well-developed managerial systems connect the facilities providing unified goals, operational norms and incentives. While the overall budget, human resources and procurement of supplies are centralized under the hospital’s Operations Director, decentralized decision making and management guide the day-to-day operation of the clinics. And continuous training helps strengthen the knowledge and skills of doctors, nurses, and administrative personnel (training is also held periodically for medical staff from other facilities in the country).

Clinical guidelines help doctors and nurses make decisions on the services that are provided, when to refer patients to the hospital, and what drugs to prescribe. The ongoing development of computerized health information systems will further strengthen coordination of care across facilities by facilitating the online flow of patient information.   

Quality control measures, including performance assessment of doctors and nurses, are also in place.  Team rewards (e.g., vouchers for selected staff) are linked to the achievement of service and client satisfaction targets. The quality of clinical and non-clinical services is measured on a quarterly basis by an independent monitor, with penalties levied for non-compliance and actions agreed with Government for improvement.

Information provided by the staff shows high level of patient utilization of the clinics.  The hospital is operating at an occupancy rate of 70% and the average length of stay is about  5 days showing that proper coordination of care between the clinics and hospital reduces the need for lengthy and costly hospitalization (e.g., lab exams could be done in the clinics prior to admission to the hospital). The hospital is also seeing a greater survival of low birth weight babies due to availability of equipment and appropriate care. A 2011 survey showed that 75% of patients are satisfied with services received.

There are challenges. Managing a PPP contract is difficult, particularly to ensure that stipulated volume and quality of services in the contract are met. This requires that the government’s capacity to manage the PPP be continuously strengthened. 
At the end the visit we were not only impressed with what we saw and learned, but left with a feeling that the Lesotho PPP experience as it evolves further may offer some lessons that could be  adapted  to the specific reality of other countries considering health PPPs. 

Comments

Submitted by GPOBA on
The Global Partnership on Output-Based Aid (GPOBA) is providing a US$6.25 million grant to help subsidize the cost of specified services at the new hospital. In PPP operations like Lesotho, OBA can help make access to services more affordable for the very poor. It's one way of structuring results-based mechanisms and involves payment of a subsidy after the achievement of specified service performance or outputs. The service provider assumes the risk of pre-financing the agreed outputs. The independent verification of outputs –- a core component of OBA -- before subsidy is paid, helps ensure transparency and encourages efficiency.

Submitted by Patricio V Marquez on
Indeed the disbursement of the grant proceeds provided by GPOBA is linked to results achieved in the facilities. At all three filter clinics, the monthly average number of patient visits per day has consistently exceeded the initial forecast of 245 (low target) and even the high target of 295. Inpatient admissions at the PPP hospital are also above the target. These initial results are a good indication of acceptance, effective demand and actual utilization of ambulatory and hospital services.

Submitted by Rob Yates on
With any initiative as large as this, it is vital to assess the impact on the overall health system before drawing any conclusions about whether this could be a model for other countries. So whereas it would appear that the new tertiary hospital and its feeder clinics are popular and working well - what has been the budgetary impact of this additional activity? I seem to remember the claim that these new facilities would be “budget neutral” [ie they would cost no more than the previous hospital] was based on fairly modest utilization rates of the new facilities. Furthermore, my understanding was that any additional volume of services above the initial estimates would be reimbursed on a cost-per-case basis. If this was the case, then won’t this additional demand have resulted in significant overspend in the budget line for these services. This wouldn’t be so bad if the health budget has increased accordingly, but there has to be a fear that increasing expenditure on services in Maseru will be at the expense of primary health care services in the districts. Furthermore, has a benefit incidence been undertaken on who has been benefiting from the services provided at the new tertiary hospital. With it being located in the capital and if it is charging patient fees, it is highly likely that utilization will be skewed towards the better off and those people living in urban areas. In conclusion, despite signs of apparent success, might there not be a danger that with this PPP initiative donors are contributing to a reallocation of scarce public financing away from free primary health care services in poor rural districts, towards less efficient tertiary services which benefit the better-off living in the capital? I may well be wrong but it would be good to see the overall picture. Rob Yates https://twitter.com/yates_rob

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