World bank gives Tše­pong the thumbs up

Lesotho Times - - Front Page - Pas­cali­nah Kabi

THE World Bank has given Queen ‘Mamo­hato Me­mo­rial Hos­pi­tal (QMMH) (pic­tured) the thumb­sup.

How­ever, the bank has called on the govern­ment to re­solve chal­lenges fac­ing the Pub­lic-pri­vate Part­ner­ship (PPP) which gave birth to the hos­pi­tal to en­sure its fi­nan­cial sus­tain­abil­ity and main­tain im­por­tant health gains.

The in­sti­tu­tion was opened in Oc­to­ber 2011 to re­place Queen El­iz­a­beth II (QEII) Hos­pi­tal as the coun­try’s ma­jor re­fer­ral health­care fa­cil­ity. South Africa’s big­gest pri­vate hos­pi­tal group, Net­care, is the ma­jor­ity share­holder of the Tše­pong con­sor­tium, which won the bid to build and run the hos­pi­tal in 2009.

In the re­port re­leased last week, the World Bank notes QMMH and its fil­ter clin­ics pro­vide bet­ter ser­vices “in­clud­ing more ad­vanced med­i­cal tech­nolo­gies than were pre­vi­ously avail­able in Le­sotho”.

“Ma­ter­nal and child health re­sults have dra­mat­i­cally im­proved through the QMMH PPP net­work, which has greatly sur­passed health out­comes pro­vided by pre­vi­ous fa­cil­i­ties,” the re­port states.

“The over­all death rate at the PPP fa­cil­i­ties fell by 41 per­cent com­pared to QEII. Ma­ter­nal deaths at the fa­cil­i­ties fell by 10 per­cent, while there has been a 17 per­cent de­cline in hos­pi­tal deaths within 24 hours, in­di­cat­ing bet­ter ac­cess to life­sav­ing medicines, surgery, and emer­gency care.”

The health net­work, says the World Bank, is treat­ing far more peo­ple than pre­vi­ous fa­cil­i­ties with a 30 per­cent in­crease in the num­ber of pa­tients seen ev­ery day, 110 per­cent in­crease in to­tal an­nual out­pa­tient vis­its and 45 per­cent in­crease in de­liv­er­ies.

“The clin­ics and hos­pi­tal are fully ac­cred­ited by the Coun­cil for Health Ser­vice Ac­cred­i­ta­tion of South­ern Africa (COHSASA) — a glob­ally recog­nised ac­cred­i­ta­tion body — join­ing a small group of pub­lic health­care fa­cil­i­ties in sub-sa­ha­ran Africa that have achieved this recog­ni­tion,” notes the re­port.

“Other con­sid­er­able im

prove­ments in­clude:

lavail­abil­ity of most lab­o­ra­tory re­sults within one hour;

l84 per­cent of pa­tients are triaged within five min­utes of their ar­rival at the ca­su­alty depart­ment; limproved clean­li­ness of fa­cil­i­ties for less in­fec­tion-risk to the pa­tients, staff and vis­i­tors;

lbet­ter and ad­e­quate equip­ment for staff which re­sults in im­proved di­ag­noses.”

How­ever, the re­port also high­lights the chal­lenges fac­ing the PPP such as the “con­sid­er­able fi­nan­cial bur­den” the govern­ment is car­ry­ing to keep it op­er­a­tional.

“De­spite th­ese sub­stan­tial im­prove­ments, the health net­work is also fac­ing nu­mer­ous chal­lenges and has be­come a con­sid­er­able fi­nan­cial bur­den for the govern­ment of Le­sotho,” the re­port notes.

“Recog­nis­ing th­ese chal­lenges and find­ing ways to over­come them will be crit­i­cal to main­tain­ing im­por­tant health gains, while en­sur­ing its fi­nan­cial sus­tain­abil­ity for the govern­ment and peo­ple of Le­sotho.”

The World Bank notes that the PPP served a greater-than-en­vi­sioned pub­lic de­mand.

“Un­der the PPP agree­ment, Tše­pong agreed to treat up to 20 000 in­pa­tients and 310 000 out­pa­tients per year in ex­change for a lump­sum pay­ment.

“How­ever, th­ese num­bers have been ex­ceeded each year since the PPP be­came op­er­a­tional, with more than 27 000 in­pa­tients and nearly 350 000 out­pa­tients treated in 2015 alone,” the re­port says.

The PPP’S “bet­ter qual­ity of care” was in­di­rectly work­ing against it be­cause many pa­tients were by­pass­ing other hospi­tals, the re­port adds.

“As Le­sotho pro­vides uni­ver­sal health cov­er­age for its cit­i­zens, peo­ple pay the same fees for care at QMMH and its clin­ics as they do at any other hospi­tals in the coun­try. Given the choice, peo­ple are seek­ing to be treated through the PPP health net­work,” states the World Bank.

This was com­pounded by in­ad­e­quate pri­mary care fa­cil­i­ties and num­bers of spe­cial­ists, equip­ment and sup­plies apart from QMMH and its pri­mary care clin­ics, the bank adds.

“From the be­gin­ning, IFC (In­ter­na­tional Fi­nance Cor­po­ra­tion) and the govern­ment of Le­sotho recog­nised that pro­vid­ing sig­nif­i­cantly im­proved health ser­vices through the net­work would in­crease pa­tient de­mand at the fa­cil­i­ties.

“So the health net­work PPP was de­vel­oped in par­al­lel with an ini­tia­tive to re­fur­bish pri­mary care fa­cil­i­ties across the coun­try with the Mil­len­nium Chal­lenge Cor­po­ra­tion (MCC).

“How­ever, there was a sig­nif­i­cant gap be­tween the health net­work PPP and th­ese im­proved fa­cil­i­ties com­ing on­line, lead­ing many pa­tients to seek treat­ment through the PPP fa­cil­i­ties. To­day, even though the health in­fra­struc­ture has been im­proved out­side of Maseru through the MCC fund­ing, there are in­ad­e­quate num­bers of spe­cial­ists, equip­ment and sup­plies, which con­tin­ues fu­el­ing de- mand for ser­vices through QMMH and its pri­mary care clin­ics.”

Other chal­lenges in­clude an in­ad­e­quate re­fer­ral sys­tem which has re­sulted in pa­tients “self-re­fer­ring” to QMMH, the re­port con­tin­ues.

“It is es­ti­mated that roughly 70 per­cent of all cases treated at QMMH by­pass pri­mary care. This means there is no ef­fec­tive sys­tem to fil­ter pa­tients and treat non-se­vere cases at pri­mary level,” the re­port says.

“The cost of treat­ing th­ese ex­tra pa­tients has a di­rect im­pact on the health bud­get.”

In ad­di­tion to a long­stand­ing dis­agree­ment be­tween the part­ners con­cern­ing the base price upon which yearly in­fla­tion ad­just­ments should be cal­cu­lated, the in­creased re­fer­rals to South African hospi­tals at the govern­ment’s ex­pense is an­other bone of con­tention, the bank says.

“In the orig­i­nal con­tract, there is a list of eight ex­cluded ser­vices, which no­tably in­cludes all in­va­sive car­diac care and can­cer treat­ment. Since 2011, QMMH staff have re­ferred pa­tients show­ing up with th­ese symp­toms to pub­lic hospi­tals in Bloem­fontein, South Africa,” it states.

“How­ever, the PPP con­tract does not es­tab­lish a clear, prac­ti­cal pro­ce­dure for ‘au­tho­ris­ing’ such re­fer­rals by the Min­istry of Health, and so Tše­pong has not in­formed the min­istry of many of th­ese re­fer­rals. As a re­sult, there is now a back­log of un­paid re­fer­rals to the South African hospi­tals which were not ex­plic­itly ap­proved.

“This has be­come an is­sue be­tween the part­ners and must be re­solved for the part­ner­ship to con­tinue to pro­vide the greatly im­proved health ser­vices, which were pri­mary goal of the govern­ment of Le­sotho from the out­set.”

The World Bank ad­vises the par­ties to ad­dress the mat­ters un­der dis­pute as a mat­ter of ur­gency.

“The PPP con­tract sets out clear dis­pute-res­o­lu­tion pro­ce­dures, and those need to be ap­plied, in­clud­ing eval­u­at­ing op­tions for rene­go­ti­at­ing some con­trac­tual clauses to make sure that the PPP scheme re­mains fis­cally sus­tain­able,” says the global fi­nan­cial agency.

“To help ad­dress th­ese is­sues, the World Bank Group is in dis­cus­sions with the govern­ment of Le­sotho about pro­vid­ing tech­ni­cal as­sis­tance on con­tract man­age­ment.

“This ini­tia­tive would sup­port the Min­istry of Health in day-to­day con­tract man­age­ment, help the two part­ners sort out con­tract dis­putes, and, if needed, sup­port con­tract rene­go­ti­a­tion to en­sure the sus­tain­abil­ity and con­tin­ued ef­fec­tive­ness of the health net­work PPP in de­liv­er­ing sub­stan­tial health ben­e­fits to the coun­try.”

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