April Harding

Bali Hyatt Hotel, Sanur, Bali21-25 June 2010

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To understand why it is so difficult to successfully engage the private health sector

To introduce a framework for thinking strategically about private health sector policy

To provide a quick introduction to the major policy instruments for engaging the private sector

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To understand why it is so difficult to successfully engage the private health sector

To introduce a framework for thinking strategically about private health sector policy

To provide a quick introduction to the major policy instruments for engaging the private sector

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Why talk about & study private health sector policy?

Course Framework

Challenges

Being strategic

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Outpatient Care

Hospitalization

Institutional Deliveries

Antenatal Care

Immunizations

Public-Private Sector Shares

Public Private

People Use the Private Sector for Services (India ‘95-96)

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Analytics are different, because…..

Behavior and incentives are differentInstruments/ policies to influence are

different

Why else? Because it is so often overlooked

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Respondents identified key barriers to engagement with the private sector as (in descending order): lack of knowledge and/or capacity in the public sector to do it resistance or lack of support by MOH staff and/or their unions lack of funding and/or funding mechanisms absence of a policy framework for collaboration/engagement resistance or lack of support at political level resistance or lack of support by donors/technical agencies

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For achieving priority objectives…..even for the poor

With respect to child health, TB, malaria….

Who Uses Public versus Private Health Facilities?

ARI: Dominican Republic

33.1 37.9 35.822.1

13.6

66.9 62.1 64.277.9

86.4

0

20

40

60

80

100

Poorest20%

Second Middle Fourth Richest20%

Perc

ent

Public Facility Private Facility

0 10 20 30 40 50

Waiting time

Doctor’s manner

Doctor’s skills

Nurse’s manner

Nurse’s skills

Explanation of care

Overall visit

Percent Satisfied or Very Satisfied

Public Private

Large role….and unlikely to diminish

Responsiveness: Private Sector Outperforms Public Sector

Andhra Pradesh (2000)

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Private sector is there

Contract with NGOs

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Private sector is bad

Write more regulations

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When it makes sense

Using proven instruments

Based on private sector understanding

Knowing how private sector response will contribute to sector goals

Defining Sectoral

Issues

• Outcomes

• Distribution/

Equity

• Efficiency

• Quality of Care

Public Sector

Private Sector

Source: Harding & Preker, Private Participation in Health Services, 2003.

PHSA

Gather available information

Identify add. needs

In-depth studies

Activities Hospitals PHC Diagnostic labs

Producers/ istributors

Ownership For-profit corporate

For-profit small business

Non-profit charitable

Formal/ Informal

StrategiesHarnessGrowConvert

Policy ToolsRegulationContractingTraining/InfoSocial marketingSocial franch.Info. to patientsDemand-side (incl. Vouchers)PPP transactionsEnabling

environment improvement

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Shifting from funding to purchasing (e.g. from “NHS” to social health insurance system)

As a means of involving a private actor in improving and/ or expanding public services delivery e.g. PPP transactions

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When a relatively well-functioning part of the private sector – could contribute more by expansion

NGOs? ORS producers?Corporate hospitals?Diagnostic labsPharmaciesMidwives

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Large existing private sector– With problems (to address) e.g. Not

participating in disease surveillance

– With potential (to mobilize) e.g. serving the population groups you care about; providing critical services, like diagnostics for AIDS and TB.

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Knowledge (already discussed)StrategyDialogue Getting beyond NGOsPS motivation & incentivesMuch & continued attention to

implementation

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Just like the public sector, good policy toward the private sector must be developed strategically.What goals? (disease? Pop’n group?

Region?)Which providers/ sellers/ producers?Which policy instruments??

Logical flow of thinking about private actors in health programs

Problem/goalspecified

Currentactivitiescharacterized

Evidence on policy instruments reviewed for effectiveness

Privateactorsimportantfor healthprogramdetermined

1 2 4 5 63

Where important actors and effective instruments exist, priority changes to health programs are identified

Relevant private actors identified

Desired changes identified

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In rich mixed-delivery health systems, a multitude of forums and mechanisms for communication (2-way!) between public and private actors exist.

In many developing countries – even those with large private sector, there is little communication.

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NGOs – are often easier for Gov’t to work with (goals aligned; less need for monitoring)

However, in most developing countries, NGOs are serving only a very small portion of the population…

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Health sector policymakers – aren’t accustomed to implementing policy which involves independent actors

They must be interested in participating (or reacting/ complying)

They must be able to survive (whether business or NGO)

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Not a “one-shot” deal

Requires resources (not a “hand-off”) and much capacity development

Generating behavior change of public officials requires “change management” not just directives

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Regulation (tomorrow)Contracting (today)Training/ Info dis. To providersVouchers/ demand-side support (tomorrow)Info dissemination to patientsSocial marketing/ commercializationSocial franchisingPPP transactions (today)Enabling environment improvement

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How do they work – the specifics? Whose behavior change is targeted?How is the change motivated?How will that change contribute to objective?

Which providers or producers is strategy effective at influencing?

What goals can they contribute to?

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What is the government’s role in implementing the policy?

What other policies will be needed?

What other actors will need to be involved?

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I hope I’ve given you some insights into some of the reasons engagement is so difficult. Probably you know more reasons.

We’ll use the framework again in the discussion of private health sector assessments.

We’ll be covering in more detail, several of the instruments which have been discussed.

Assessment is next

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Questions??

Comments?