Центр сопровождения проектов государственно-частного партнерства. Pilot PPP projects in healthcare in Kazakhstan

Transcription

1 Центр сопровождения проектов государственно-частного партнерства Pilot PPP projects in healthcare in Kazakhstan

2 Construction and operation of general hospital with capacity of 300 beds at Kazakh National Medical University after S. D. Asfendiyarov in Almaty

3 Project Team MH&SD RK PPP AC KPMG AJZ Engineering PPP Advisory Center Mandated as a legal entity for advisory support of national and regional concession projects by the decree of the Government of the Republic of Kazakhstan on 30 April The mission to support the development of infrastructure in the Republic of Kazakhstan by providing advisory services on preparation and implementation of infrastructure projects including PPP projects.

4 Concept of the project Name of the concession project Project Grantor Concession Type Срок концессии CAPEX in constant prices (est.) Objectives of the project Construction and operation of a multi-disciplinary hospital at Kazakh National Medical University named after SD Asfendiyarov RSE in Almaty Ministry of Healthcare and Social Development of the Republic of Kazakhstan Design Finance Build Maintenance Operate (DFBMO) 20 years USD 100,7 mln. (30 882,8 bln. tenge in prices of 1 кв.2015 г.) Applying new technologies to improve quality of medical services to the population of the Republic of Kazakhstan Providing base for clinical training of students and retraining of doctors of KazNMU involving on the latest achievements of medical science Creating a base for scientific and clinical research in cooperation with foreign scientific communities

5 Location of object of concession Uralsk Aktobinsk Kostanay Astana Pavlodar Semipalatinsk Ust-Kamenogorsk Almaty N Karaganda Atyrau Taldykorgan S Aktau Kyzylorda Shymkent Taraz Almaty Distance from city centre: 12 km Concession object The object is to be located in the Nauryzbayskiy district of Almaty The object consists of a 300-bed hospital and clinics that can handle 300 visits per day

6 Strengths of the project Strategic importance for Government The project is in line with the Strategic Plan of development of healthcare of Kazakhstan up to 2020 and Perspective plan of the network of health care organizations of Almaty city for Economic advantages of Almaty In , the population of the city increased by 16.19%, while the real income of the population grew by 26%* Strong resource base Kazakh National Medical University benefits from 1454 lecturers, including 4 academicians, 172 doctors of science, 475 candidates of science. More than 1,600 medical professionals are graduated from KazNMU annually Ministry envisages high level of medical equipment of the university hospital

7 Trends in the development of Almaty The role of the private health sector is increasing in Almaty In 2009 to 2013 number of private outpatient organizations and doctors' offices in Almaty almost doubled from 168 to 293. competition among private and public organizations is expected to increase due to introduction of the insurance system This demonstrates the need for quality services and the confidence of patients in the planned hospital. Population, thous. people 1 642, , , , , Rate of natural increase,% 10,80 11,10 10,00 9,70 11, ACCORDING TO THE MARKETING STUDY OF MEDICAL SERVICES IN ALMATY OPTIMAL CAPACITY OF THE UNIVERSITY HOSPITAL IS 300 BEDS 71,00 Life expectancy at birth, years 73,70 72,80 71,70 74,

8 Structure of profiles and beds Profile Quantity Therapeutic 40 Cardiological 30 Neurologic 30 Endocrinological 30 Rheumatological 25 Ophthalmological 20 Traumatologic 30 Surgery 30 Interventional cardiology 15 Gynaecological 20 Rehabilitation of adults 30 TOTAL 300 Out-Patient Daily Department s Services Ophthalmologic Treatment Otolaryngological Treatment Proctologic Treatment Gynecological Treatment Therapy Surgery Consultations of doctors visits per day Therapist Gasteroenterolog Pulmonologist Nephrologist Rheumatologist Ophthalmologist Otolaryngologist Traumatologist Surgeon Cardiologist Neurologist Endocrinologis t Gynecologist Urologist Proctologist

9 Types of Support Services Types of Support Services Operating rooms, beds in intensive carebeds, in the recovery room Diagnostics Center Functional diagnostics and ultrasound: EKG, EEG, Doppler blood vessels Radiological diagnosis: CT, MRI, X-ray diagnostics, mammography Endoscopy Center for Laboratory Medicine The spectrum of research: 1. Immunological 2. Biochemical 3. Hemostasis 4. Hematology 5. Cytological 6. General hospital 7. Immunology 8. PCR analysis 9. Immunoassay

10 Schedule of pre-investment stage KPMG Risks Studies Social Studies Financial Studies Technical Studies BAFO* Legal Studies Marketing Studies Due Diligence Pre-qualification Kickoff Announcement of Tender Commercial close Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Development of the concession proposal Development of tender documentation and draft concession agreement Competition for the selection of the concessionaire 2017 * BAFO Best and Final Offer 10

11 Schedule of pre-investment stage 2 months 3 week 6 months 2 months 2,5 months Pre-qualification Initial discussion Estimation of conformity of criteria Competitive dialogue The development of competitive application, including a feasibility study Choosing of BAFO Negotiations with the participant whose bid as the best Receipt of applications to confirm compliance with the qualification requirements Participants who have passed the qualification are invited to competition Submission of applications Announcement of BAFO Announcement of the winner and the signing of the contract

12 Preliminary project concept Construction of flagship hospital and clinics on a concession basis An investor is invited to build the object, supply equipment, and provide technical maintenance The preliminary contract duration is 20 years Medical services in the hospital are to be provided by a state operator (on basis of KazNMU) Typical pack of other project agreements Financing agreement with shareholders Agreement with shareholders for the provision of subordinated debt Senior loan agreement Direct agreement EPC-contract Operation services contract Legal aspects The project is carried out in accordance with the Kazakhstan Law On Concessions The concessionaire is to design, build and operate a 300- bed hospital and clinics with a capacity for 300 visits per day (concession object) The Kazakhstan Ministry of Health and Social Development (MHSD) acts as a grantor 2-stage tender procedure: prequalification and bidding process Upon the start of operation the object is transferred to the state. The concessionaire obtains rights of use and ownership until the end of concession period At the end of concession period the concessionaire shall return the object to the grantor in an appropriate condition The grantor shall provide a land plot for construction and shall pay an availability payment

13 Organisational and legal structure Interaction agreement 2 Kazakhstan Ministry of Health and Social Development (grantor) Concession agreement Concessionaire Rights of use and ownership Partner university clinics The hospital is transferred to operational control Interaction agreement 1 Medical operator transfer to operational control Hospital and clinics (concession object) Medical services agreement GVFMS* Agreement Voluntary health insurance agreement Patients Department of the committee for the payment of medical services Insurance companies Notes: * GVFMS Guaranteed Volume of Free Medical Services

14 Payment mechanism (1/2) Availability payment Compensation for investment costs Concession management fee Compensation for senior debt service costs Repayment of the principal Interest payments during construction Bank fees during construction Security bonds bank guarantees Supply and maintenance of medical equipment: The maintenance of medical equipment (till the 1 st upgrade) Compensation of operational costs Compensation of concession object management costs to shareholders Repayment of the subordinated debt principal Interest payments on subordinated debt Shareholder s return on investment in the form of dividends Interest payments during operation Bank fees during during operation stage Maintenance services: Maintenance of the building, technical equipment, elevators Maintenance of the medical gas supply system Utility services: The maintenance of electricity, water, heat, lighting, air conditioning, IT systems General cleaning services, sanitation The cleaning of nearby areas Waste disposal, medical waste disposal Other services: Communication services (including the internet) Security services Disinfection Catering services for patients Laundry services Free car parking

15 Payment mechanism (2/2) Additional revenue of the concessionaire (not covered by the availability payment) Revenue from additional services Additional paid catering services Pharmacy sales Waste disposal services for other clinics (B- and C-class waste)

16 Preliminary cash flows. Construction stage Shareholders (Sponsors) Subordinated lender Shareholder s capital Subordinated debt Senior long-term debt Interest payments / fees under senior long-term debt Financing institution (Bank 1) Financing institution (Bank 2) Security bond fees Insurance costs Concessionaire Payment for construction works Taxes Insurance companies Kazakhstan state budget Taxes General contractor

17 Preliminary cash flows. Operational stage Shareholders (Sponsors) Subordinated lender Dividends, repayment of share capital Principal and interest repayments on subordinated debt Concessionaire Access fees Grantor Security bond fees Fees, principal and interest repayments on senior long term debt Taxes Kazakhstan state budget Insurance costs Financing institution (Bank 2) Financing institution (Bank 1) Insurance companies Partner university clinics Patients Payment under partner agreement Revenue from paid medical services Medical operator Department of the committee for the payment of medical services Payment of GVFMS* tariff Taxes Payments from Voluntary Medical Insurance Notes: * GVFMS Guaranteed Volume of Free Medical Services

18 General PPP project structure. Key project agreements Loan agreement The main document between the lenders and the private partner contains the project funding terms: the list and terms of all loan facilities under the project, requirements for drawdown and repayment, security, debt covenants, and early repayment terms, including early termination of the concession agreement Direct agreement Three-way agreement between the public partner, private partner and the lenders under which the public partner agrees to give the lenders a period of advance notice of the impending termination of the project arrangement This agreement also gives the lenders the opportunity to step in, either directly or through a nominee or representative, to remedy the termination event or to find another party who will be acceptable from the point of view of taking over the rights and obligations of the private partner under the concession agreement Direct agreement Lenders EPCcontract Construction contractor Loan agreement Public partner Concession agreement Private partner Shareholders Agreement with shareholders Service contract Operation contractor

19 Construction and operation of outpatient hospital for 500 visits per shift in Kyzylorda city Moscow, November 3 rd, 2015

20 Construction and operation of outpatient hospital for 500 visits per shift in Kyzylorda city PROJECT OBJECTIVE Providing quality and available medical services of primary medical care of the population Kyzylorda and Kyzylorda region. ATTRACTIVENESS OF THE PROJECT Stable partner from government side represented by Akimat of Kyzylorda region Reimbursement of investment expenses Management fee Stable demand for medical services in the new, developing residential area RESULT OF THE PROJECT Outpatient hospital for 500 visits per shift in beyond the line part of the city Kyzylorda, residential area Al-Farabi. Access to medical services of primary medical care for the population of beyond the line part of the city. 2

21 Construction and operation of outpatient hospital for 500 visits per shift in Kyzylorda city Grantor Operating statements Location Concession period Investment volume (estimate) Akimat of Kyzylorda region 500 visits per shift, 2 shifts per day Kyzylorda city, residential area Al-Phatabi, Alshynbayeva-Ashirbayeva str. Up to 18 years ~3 billion tenge (10,8 mln.usd) Sources of reimbursement expenses and income provision of the concessionaire Reimbursement of investment expenses of the concessionaire Management fee Income from medical and non-medical services Type of concession Estimated type of Tender BTO («Design - Finance - Build - Transfer - Operate») Tender at the selection of the concessionaire without using the two-stage procedures Tender announcement July, 2016 Construction of object will be carried out according to design estimate documentation of outpatient hospital for 500 visits per shift in Kyzylorda city, developed by the order ofakimat of Kyzylorda region 3

22 Concession object location COH 5 Concession object COH 2 Residential are Al-Pharabi (population people) beyond the line part of the city часть города (population people) The private sector dominates. City outpatient hospital people attached City outpatient hospital people attached COH - City outpatient hospital Selected land parcel for construction 4

23 Overview of medical organizations in Kyzylorda city Public outpatient organizations in the city 6 outpatient hospitals, with two of them (outpatient hospitals 2 and 5) located in beyond the railway part of the city 8 medical ambulances, 9 medical centers, 1 rural health post Diagnostic center of Kyzylorda region Public hospital organizations, rendering similar ambulance services State hospital, children hospital, branch outpatient hospital «Railway hospital of medicine of accidents» JSC, Kyzylorda railway hospital, Regional medical center Private organizations 18 private medical organizations: ambulance services (physiotherapeutic procedures, treatment sessions on east and Chinese medicine and etc.), consulting services, laboratory services some of them have stationary beds, a day patient facilities none of those located in the region of planned outpatient hospital 5

24 Demand factors for medical services in beyond the railway part of the city Public outpatient hospital 5 and public outpatient hospital 2 are located in beyond the railway part of the city. City outpatient hospital 2, 500 visits per shift people are attached Located in the building, which is not standard and run-down (made from clay-straw material in 1957) City outpatient hospital 5, 650 visits per shift people are attached Served population who are not living in the majority in " beyond the line part " of the city The new outpatient hospital is planned as replacement of the existing city outpatient hospital 2 Planned number of attached people people Creation of the new state medical organizations in "beyond the railway part " of the city is not expected in the next 10 years The forecast number of the attached population: 1st year: people, 2nd year: people, 3rd year: people, 4th year: people, 5th year: people The predicted growth rate of the attached population to outpatient hospital is 2%* Estimation based on Healthcare department s data taking into account growth rate of the population "beyond the railway" part of the city and dynamics of number of the attached population of the operating outpatient hospitals. CONCLUSION THE DEMAND ON NEW OUTPATIENT HOSPITAL FOR 500 VISITS PER SHIFT IN NORTH-WEST SIDE OF THE CITY 6

25 Insurance payments Payment for GVFMC Paid services Institutional scheme The scheme of interaction of the parties during the post-investment period Вuild Тransfer - Operate Founder Creditor FUNCTIONS OF THE GRANTOR post-investment period transfer rights to possess and use concession object for the term of concession to the concessionaire payments of reimbursement of investment expenses and management fee project monitoring and control the quality of services provided under the concession agreement. Patients Financing FUNCTIONS OF THE CONCESSIONAIRE Committee of medical services payment Insurance companies Concessionaire RIE, Management fee Concession agreement GRANTOR (AKIMAT) financing and creating the object of concession rendering medical services and non- medical services maintenance of concession object, including routine maintenance and overhaul repairs of concession object ensuring security and safety of concession object, observance of standards of fire safety, management of medical waste and chemical means (including utilization) INCOME OF THE CONCESSIONAIRE reimbursement of investment expenses of the concessionaire Management fee Income from medical and non-medical services RIE Reimbursement of investment expenses GVFMC volume of medical care, guaranteed to citizens of Kazakhstan by State. 7

26 Outpatient hospital services Primary health care services Therapist, pediatrician, general practitioner, obstetrician-gynaecologist, psychologist, case worker, midwife Consulting at specialist doctors surgeon, ENT specialist, cardologist, rheumatologist, neuropathologist, infection disease doctor, endocrinologist, ophthalmologist, traumatologist, otolaryngologist, traumatologist-orthopedist Laboratory diagnosis All-clinical trials; Hematologic researches; Biochemical researches; Immunological researches; Serological researches; Histopathology and cytology Instrumental diagnosis Functional diagnostics: Electrocardiography (electrocardiogram), Elektroentsephalografphy (EEG), Ultrasonic diagnostics (ultrasonography); Radio diagnosis: X-ray diagnostics, mammography Procedures and manipulations Physioprocedures Day patient facility (10 beds) 8

27 Project planning timeline Risks studies Social studies Financial studies DBAFO Commercial Close Technical studies Legal studies Marketing studies Due diligence and coordination Tender announcement Introduction of CO Kick off Selection of the private partner Negotiations May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Development of Concession proposal Development of Tender documentation and draft of Concession agreement 2017 Tender procedures 9

28 Tender procedures timeline 2 month 10 days 2 month 2 month 6 month Clarification of Tender conditions Estimation of prequalification requirements Choosing Best Concession Offer Negotiations with participants, whose offer defined the Best Financing close and organizational works of concessionaires Introduction of Tender offers Potential concessionaires receive the admission to participation in Tender Announcement of the best Concession offer Announcement of the winner and signing the contract Beginning of construction As part of the tender documentation participants will be given a concession proposal and design and estimate documentation. The Potential concessionaires can also participate in competition with their own land plot. 10

29 Construction and operation of general hospital with capacity of 300 beds at Karaganda State Medical University in Karaganda city

30 Multidisciplinary Hospital with 300 beds at Karaganda State Medical University in Karaganda city Repayment of a body and percent on the senior debt Reimbursement of own capital Object location Karaganda city, Republic of Kazakhstan Financing institution (Bank) Shareholders (Sponsors) Concession scheme Build -Operate Transfer (BOT) or Build -Transfer Operate (BTO) Concession agreement Cooperation agreement Students Estimated activities of the Concessionaire within the concession project financing, construction and equipment, medical activities, renovation of the equipment Committee of the state property and privatization of RK (Committee) Ministry of healthcare and social development of RK (Grantor) Transfer of rights of possession and use of Concession object Concessionaire Teaching staff Payment for clinical site KarSMU Reimbursement of investment expenses Payment for medical services GVFMS Private VMI

31 Road-map of PPP in healthcare in Republic of Kazakhstan

32 The action plan of public-private partnership in healthcare in the Republic of Kazakhstan Program of development of PPP in RK for provides for creation of social infrastructure by PPP. In sectoral strategic documents, such as Healthcare development program in RK for , Strategic plan of MHSD RK for Standard of a state policy on PPP in healthcare of the United Nations Economic Commission for Europe (UNECE) recommends development and adoption of the detailed program document - the Road map on introduction of PPP in health care (PPP Delivery Plan). Detailed and realistic plan of action and pool of selected projects at the national level can become a major factor of attraction of private and domestic investments into healthcare. Formation of an effective Road map includes a number of extensive analytical works which are at the moment not carried out and aren't begun. Road map of PPP in healthcare in the Republic of Kazakhstan will be developed

33 The action plan of public-private partnership in healthcare in the Republic of Kazakhstan Basic templates in part to monitoring of concession projects, the interface of the agreement between the concessionaire and medical operator, systems of penalties and deduction within contracts PPP, systems of indicators to which there have to correspond services of the concessionaire Base template of service contracts and contracts of transfer to trust management, providing conditions under which efficiency for the state party is reached Pool of bankable projects On all chosen projects the payment mechanism Economy of funds for stages of development of the PPP projects Improvement of quality of development, increased chance of successful tender Promotion of the pool of PPP projects to the market, market sounding events

34 Thank you for your attention! PPP Advisory Center, LLC Republic of Kazakhstan, Astana, st. Dostyk, 18, a business center Moscow, 16 Floor Telephone: +7 (7172)