Creating First Class, Cost Effective Public-Private Partnerships (PPPs) for Southeast Asia Healthcare

Most SEA governments have been slow in addressing the need for significant investment in public hospital infrastructure and the public hospitals are often overcrowded and plagued with shortages of doctors, medical supplies and diagnostic equipment, which affects quality of healthcare. Additionally, hospital infrastructure tends to be concentrated around Tier 1 cities. This, together with increasing medical tourism is resulting in serious accessibility for SEA citizens. The healthcare market is undergoing transformation due to rising and ageing populations, changing demographic and medical tourism. To meet these issues, healthcare expenditure is expected to double over the next 5 years. PPPs present a huge opportunity for government and private sector organization to satisfy this demand.

Singapore, in particular, is facing the challenges of its ageing population and its government foresees doubling its healthcare expenditure from $4 billion to $8 billion in the next five years. To deal with this increasing burden in a sustainable way, the public healthcare sector is undergoing a major restructuring. Some industry leaders see Singapore as a potential future PPPs Hub in the SEA Region.

The UK was the first country in the world to develop the concept of PPPs for public services projects. Through partnership with the private sector, PPPs enable the delivery of efficient, cost-effective and measurable public services within modern facilities whilst minimizing the financial risk. Given the huge demand and complexity of the industry, what should governments & private sector organisations consider in order to create WIN-WIN PPP Healthcare projects?  How can private sector organisations capitalise on these golden investment opportunities? What are the lessons that Southeast Asian nations can learn from the UK’s experiences?

Join us at Creating First Class, Cost Effective Public-Private Partnerships (PPPs) for Southeast Asia Healthcare Workshop and explore the journey to create successful PPPs in Healthcare in the near future!

Key Highlights from Attending This Workshop:

• Explore the Journey to Create a Successful PPPs projects in Hospital Care/ Primary Care with interactive group discussions.
• Learn the pitfalls of PPPs and how to avoid them.
• Create a Practical A-Z Check List for your next PPP Healthcare Projects.
• Build a Feasible Control Parameter and Risk Mitigation Strategy to ensure a Win-Win Outcome.
• Case Studies for Best Practices in Regulatory & Contract Design
• UK Lessons: Learn from the First Country in the World to Develop the Concept of PPPs for Public Services Project. Canada, Ireland, Portugal, Australia, Japan and Sweden are all countries developing their own PPP models using UK expertise.

This workshop is targeted at government officials and private sector representatives actively involved in developing PPP for the healthcare sectors by the following industry profile:

• Financial Institution
• Government & Regulator
• Healthcare Investor
• Healthcare Provider
• Hospital Group
• NGO
• NPO
• Other agencies/ ministries where PPP (public-private partnerships) in healthcare is involved

Examples of Personnel Who Will Benefit from This Workshop:

• Business Development Managers
• CEO
• Chief Financial Officers and Controllers
• Contract Managers
• Credit, Risk and Investment Officers
• General Manager
• Infrastructure Directors
• Managing Director
• Medical Directors
• Operations & Facilities Management Companies
• Partnership Managers
• Procurement Managers
• Project Consultants/ Facility Managers
• Project Management Leaders
• Project Directors & Managers
• Project Financiers
• Project Technical Managers

Course Trainer has more than 28-years’ experience in healthcare and has gained worldwide experience across the full healthcare sector and at every level of the patient healthcare system and patient journey. With a focus on the quality of patient care, equity, well-being and in the effective and efficient use of scarce resources he has been providing Management Consultancy and Technical Assistance in supporting Governments and Policy makers to develop and improve the quality and efficiency of their national healthcare system.

He has worked with Development Agencies and the International Financing Institutions including, UKAID, USAID, UN, WHO, WB, ADB, AfDB, AUSAID (DfAT) EU and with the private sector providers and within public healthcare systems and patient facilities. He has held the position of Government Representative for Health, Health Advisor to Ministers, Health Advisor to the main agencies and has directly managed health facilities and led major health procurements and service transformational programs. 

He began his career in finance moving into the health sector at the time the UK’s NHS system began to move to a free market health economy but has since gained experience in more than 20 countries. His work had been predominantly within the reforms and transformation programs as the NHS in the UK is a centre for innovation as it continually drives forward on its quality and efficiencies agenda in the delivery of patient services.

He has worked at the forefront of health sector innovation in supporting quality improvement, in enhancing productivity and in developing effective management of healthcare services. He has been designing, developing and procuring commercial contracting solutions in Public Private Partnership programs across five continents.

Whilst PPP programs in health began with the Private Finance Initiative in the UK it was not until the Independent Sector Treatment Centre (ISTC) programme was developed that saw true PPP healthcare delivery on mass in the UK, with the exception of the Norwich hospital that began service delivery in 2001.  Derek was at the forefront of the ISTC innovation that was designed to rapidly introduce clinical and surgical capacity in the UK. I was involved in the development, procurement and management of 8 schemes across the UK.

He has since managed PPP programs in a UK overseas territory where his principle objective was to stabilise sector spend, develop on-island capacity and Medical Tourism. He has carried out feasibility studies in Africa including Zambia, Mozambique and Djibouti and supported governments develop and implement PPP programs in Asia, Middle East and Europe. He has led the development of the strategic framework for private sector participation in the delivery of healthcare in the Kingdom of Saudi Arabia.

He recently led an innovative Prime Provider PPP program (a consortium provider approach) with a complex SPV to deliver specific clinical services and an Alliance PPP program for Community and Rapid Response services, both these models was a first in the UK. The development of these programs drove forward changes to the regulatory framework.

He has been a member of the “Healthcare Expert Pool” of assessors for Grant Awards for the development of SME programs of the World Bank and UKAID. Health Systems Development has worked extensively within Cost Improvement Programs and undertaken Performance Analysis to enhanced VFM from Government investment.

Case Study 1: An Overview of MSK Services

There are over 200 musculoskeletal (MSK) conditions affecting millions of people nationally, including all forms of arthritis, back pain and osteoporosis. The ageing population will further increase the demand for treatment of age-related disorders such as osteoarthritis and osteoporosis. People with a need for MSK services require assessment, diagnostics and treatment which are delivered by a wide range of professional disciplines, predominantly orthopaedic surgeons, physiotherapists, other manual therapists, rheumatologists, pain management specialists, podiatrists and psychologists.

Background and drivers for change:

The Musculoskeletal National Framework (2006) described the inconsistencies in service provision across the UK and thus health inequality experienced by patients that was confirmed by clinicians.

This regional purchaser was reported as one of the highest spending health economies in the country. For 2009/10, it was ranked as the highest spending economy per 100,000 weighted population. The most recent programme budget information shows the health economy was ranked 14th highest nationally in terms of absolute expenditure on MSK per 100,000 weighted population. This equates to total 2012/13 MSK expenditure being 19% above national average based on a per weighted population basis

Purpose of the PPP procurement programme:

• Designed to deliver budgetary savings and reduce spend to a near average spend per capita
• To develop a PPP Prime Provider MSK service to leverage the management efficiencies and productivity of the private sector
• To design modern patient pathways which were fit for purpose

Achievement:

• Established an Accountable Care Prime Provider PPP service across a regional network of providers
• Reduced spend to near the national average from being one of the highest spending economies for MSK (efficiency savings of £14m over a 5-yr period)
• An outcomes based contract agreed
• Service development improvement plan implemented to guide the transformation of services and improve partnership working

Case Study 2: The Turks and Caicso Islands, a UK Overseas Territory, a PPP Hospital programme developed and implemented based on the UK model

An Overview of the Islands Position prior to the PPP Integrated Healthcare Program

Background:

The road system was in shambles; schools needed improvement; government offices were in dire need of repair; sporting facilities were non-existent and basically the Islands as a whole was crying out for infrastructural investment. At this time the Government’s Treasury was completely depleted of funds causing the Government to enter into negotiations for the sale of national assets to augment the Country’s reserves and provide funds to meet recurrent expenditure.

Decisions had to be made and the islands decided to use the UK’s PPP vehicle to address projects that had a revenue stream as they could be financed off balance sheet and not impact adversely on the Country’s ability to borrow. For those projects such as roads and schools that did not have revenue streams, the government borrowed directly for them.

Ongoing Situation:  The programme has received considerable and adverse public comments on Government spent on the hospital facilities:

There was a shared view that proper healthcare delivery for a country ought not to have as its driving component as a profit-making objective. The islands were able to square this approach in this regard by having the Government implement a national healthcare insurance program that would serve as the mechanism to fund the healthcare needs of all citizens and residents.

There was considerable emphasis given to the optimal delivery of primary healthcare as the Government saw this as being absolutely critical to the islands healthcare needs, but this did not materialize due to the financial crash and general downturn in the economy.

Tourists, cruise ship passengers and persons seeking to do elective procedures at the hospitals would have to pay the full rate for their healthcare needs and this aspect of the service would be profit driven. From this revenue stream, the Government would share in the income on a 50/50 basis and any other private patient income streams.

The overall cost for the hospitals was just under US $124 million. This was compared to facilities in Lesotho that cost US $120 million and Valencia which cost US $98 million. It ought to be noted though that the islands cost includes two fully equipped hospitals on two different islands unlike in the case of Lesotho and Valencia where one facility each was built for those respective cities. It should also be observed that unlike in Lesotho and Valencia, the islands have to import every single thing that is required for the construction and outfitting of these facilities. Furthermore you cannot understate the additional cost that is added on when the build has to meet very rigorous hurricane code and quality control requirements.

In 2009 when the hospitals were under construction, the Government was paying in excess of $20 million on treatment abroad patient care and a further $22 million for primary and secondary healthcare delivery through the civil service system.

Today, using figures published in the press of roughly $50 million (inclusive of the PPP’s unitary and clinical payments) for healthcare delivery within the PPP mechanism and primary care, the increase as a percentage in overall cost under this structure is rather modest in comparison to Lesotho’s.

When you factor into the equation that the GDP for Lesotho is approximately US $1,260 per capita and that of the Turks & Caicos Islands being in excess of US $23,600 per capita, having to pay a paltry $10 to access the system is mere pittance for the islands residents in comparison to the people of Lesotho.

The social benefits and the desire to keep families together seldom get weighed in financial analysis. But for a small island states such as TCI, it is usually the social good that gets factored into most of the Governments decisions for essential services

In assessing any country’s healthcare facilities however, it would be a mistake to look purely at the financial cost. One has to take into consideration what those facilities deliver, the social benefits of the entity, and the intangibles being contributed to making the country an attractive destination.

We're it not for the modern hospital facilities that the islands now have, the Country would not have easily gotten the Category One rating for its International Airport; and TCI would not have gotten the BBB+ Country Borrowing rating with Standard and Poors. There are countless stories of these hospital facilities generating tremendous goodwill for our Country.

Many times persons travel here from the UK, Canada and the United States and they are in awe of the modern facilities that the islands have. Many simply cannot comprehend that TCI have this caliber of facilities in our Country. Scores of Islanders have also had the benefit of getting medical procedures and healthcare treatment done at these very hospitals. Many of the medical procedures now offered would have been inconceivable back in 2003 but are now routinely offered in our Country.

Achievements:

The hospitals have generally been successful but not as successful as it they could have been if the relationships between the government and the provider had been one of true partnership working.  The challenge for Governments is maintaining progress and inspiring development:

Today:

Patients seeking treatment and spend on treatment abroad has significantly increased in the last few years, the health insurance board has requested emergency funding to support the fund and the on-going increase in spend on patients being treated abroad.

With the hospitals being built with significant expansion space in mind additional services have not been added as projected, patients seeking treatment abroad has increased because trust between the provider and government has long deteriorated.

The potential for the Government and Provider to plan and invest in improving the range and scope of on-island clinical services and to develop TCI as a regional hub of clinical excellence has not been explored or taken in these high-tech facilities.

Long-term contracts require long-term commitment and Governments must ensure that it has the right caliber of personnel, the appropriate governance structure in place and long-term partnership commitment for the whole program life cycle if it is truly to reap the full potential benefits of its PPP programme.

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To be confirmed.

• Southeast Asia will spend USD150 billion on healthcare in 2018
• Healthcare spending will exceed USD300 billion by year 2023.
• PPP models will be essential for the government and private sectors to be able to meet the increasing demand.
• UK National Health Service used PPPs for 25 years to deliver first class modern hospitals and primary care.
• SEA Governments are increasingly adopting the PPP models.
• PPPs create a great opportunity for new market entrants and market expansion for sustainable long term growth.