Public-private partnership or sale of doctors?

Ana Pavlovska-Daneva

A few months ago we heard that Macedonian citizens will be provided with healthcare services in the field of pediatric cardiovascular surgery, through modern legal mechanisms of interweaving or interconnection of public and private healthcare. Great. In management science, it is called a public-private partnership. In the Anglo-Saxon system is known as “contracting out”, in European-Continental law these are contracts called administrative contracts.

What is the point of these agreements or partnerships? Those services that the state is obliged to provide to its citizens (such as healthcare services) and which are expensive and require exceptional expertise in personnel and special technical equipment (such as children’s cardiovascular surgery), it can – if there is no capacity to deliver them itself – transfer them to a private entity (such as the private healthcare institution, the Zan Mitrev Hospital). And that’s not bad. On the contrary. It’s good. It’s good for everyone. Sick children will have surgery at home, in their own country. The surgeries will be carried out in a hospital equipped with the necessary equipment and in conditions that doctors, children, and their parents deserve. The country guarantees a top expert team in its public healthcare, people in which it has invested, in their education, in their development, in their professional upgrading, in their academic titles and statuses. To these experts, the state guarantees safe and good working conditions in order to keep them in public healthcare because they are indispensable to its citizens. In the end, all expenses for these surgeries will be paid by the Health Insurance Fund.

Why is the law very important in such agreements and partnerships? Why should a good idea, a will or a decision of the state, in the case of the Ministry of Health, be “legitimized” or put in a legal framework called a management contract? To prevent abuse. Intentional or unintentional. Predictable or unpredictable. The contract should regulate everything, every detail of the work, the rights and obligations of both entities: the state and the private clinic. And of course, the agreement must contain penalties, punishments, but also other solutions for possible non-compliance with contract obligations. Any violation of the agreement entails harm and negative consequences primarily for the citizens, for the sick children, for their parents etc.

Hence, this type of public-private partnership agreements are complex masterpieces that are prepared for months by a whole team of experts – in this case, lawyers, economists and doctors, representatives of the Ministry of Health, representatives of the Health Insurance Fund, attorneys at the medical team and advocates of the interests of the private facility – the Zan Mitrev hospital.

What is it that the contract must contain? Duration. How many years of activity does the country give to the private facility. Because these contracts are not permanent. In that period (5, 10, 15 years) it has to prepare to create capacities within its own framework, so that in the public healthcare it will continue its own activity. And the other way around. The private entity must not give up this activity during that period of time, just because it has become disadvantageous or something like that. They must take care and protect the rights and interests of our citizens.

Furthermore, the agreement should include assessments how much of the cost of the service will be borne by the state budget (will be paid by the Health Insurance Fund) and how much of it will be allocated to cover the costs of the private entity. Of course, the contract will also contain provisions that will allow for the earnings of the private co-contractor. Otherwise, why would Zan Mitrev, or any other healthcare private institution, sign such an agreement with the Ministry of Health and divert its resources?

Of course, through the contract, the state protects public interests as well. Thus, such contracts require not small, on the contrary huge amounts of financial guarantee by the private entity. Therefore, in case it decides to break the agreement, the state stays protected. It activates the guarantee and with this money continues to carry out the activity itself, or give it to another private entity. This is just one of the many modalities of entering contract clauses to protect public interests. On the other hand, the private entity can sue the state in court, it can win the dispute and be compensated, but its activity (the children’s surgeries in this particular case) must not be tolerated. They must not be stopped.

It is equally important that, with this agreement, the state would be allowed to disable the outflow of its personnel, its experts sending it to “temporary work” in the private facility. So, if already a public-private partnership has arranged a building and equipment from a private entity, and services (surgeries) are provided by a medical team employed in public healthcare, then the contract will regulate the amount of the salary of the medical staff, as well as all other allowances and privileges, since it is in the interest of the state that this staff remains in public healthcare and then when the activity returns again within the Clinical Center, these doctors and nurses continue to carry out the same activity there. And, of course, to provide interns and new staff. The salary of the public healthcare personnel in the private hospital that is a partner of the state does not even have to be paid by the private entity. Salaries may remain budgeted for the exact number of child heart surgeries that are covered by the Fund. But in the Zan Mitrev hospital children who are not covered by our budget (foreign citizens), by paying a market price for the service, can then have surgeries, and then all this would be additional earnings for our surgeons and nurses, as well as for the private hospital itself. Many models of such contracts are possible. But there must be a contract!

There’s an old saying – to know who is drinking, and who is paying. To keep count. So that we can have satisfied citizens / patients, but also satisfied private sector interests that are necessary in every healthcare system. And not just healthcare, of course. For a professor, surgeon, doctor of medical sciences to perform surgery in good conditions, but also to teach students, to create more successors, more professional surgeons for us, for our children.

Let’s see what is contained in the public-private partnership contract of our Ministry of Health. Nothing, as it seems. I sincerely wish to be wrong, to not know, that I am mistaken, but my impression is that there is no such contract at all. It does not exist.

How else can the termination of the children’s cardiac surgeon from the Clinical Center be interpreted? What is a public-private partnership agreement that provides for public healthcare physicians’ dismissal and their transfer to a private sector? It’s not a public-private partnership. It is an ordinary outflow of the best public healthcare personnel in private hospitals. With the country’s blessing, and it will pay the surgeon to perform the surgeries in a private clinic, and not the state clinic!? This is one strange partnership. What is this partnership if the surgeon-professor or assistant professor must, at any rate, have to resign from the state medical faculty where he is teaching, and allegedly perform surgeries in a private hospital because the state is a “partner” with that hospital. Then the state faculty should also be involved in the partnership, right?

Where is it regulated who will determine the priority list of operations? Where is it established that the surgeon and other members of the public healthcare team may not be dismissed or resign during the period agreed to delegate (transfer) the activity of the state to the private hospital? Where are the rights agreed, but also the obligations of the private entity? Financial guarantee for uninterrupted and continuous performance of the activity? Their indemnity? And, many other important issues, where are they regulated?

Views expressed in this article are personal views of the author and do not represent the editorial policy of Nezavisen Vesnik