d1s2 ppt-dominique usa

8/2/2019 d1s2 Ppt-dominique Usa

1/39

St rat egies for Pr ivat e Sect orEngagement and PPPs in Healt h

Public Policy toward the Private Health SectorIntroduction and Course Analytical Framework

April HardingDominic Montagu

Pat humwan Princess Hot el , Bangkok , ThailandMay 30 June 4, 2011


2/39

Teaching points

2

To understand why it is so difficult t o successfullyengage the private health sector

To introduce a framework for thinking strategically aboutprivate health sector policy

To provide a quick introduction to the m ajor policyinstruments for engaging the private sector


3/39

Outline

1. Why talk about & study private health sector

policy?2. Course framework

3. Challenges

4. Being strategic

3


4/39

The private sector in mixed health systems

The private sector plays a large role in health systems indeveloping countries and developed countries

But in developing countries it is typically overlooked and ignored

Well-performing mixed developed country health systems havein place a wide range of strategies and policy instruments whichguide the behavior of the private sector to contribute to healthsector goals

Developed countries can improve their health system performanceby using similar strategies

4


5/39

Source: Maynard 2005

France Germ any N et her lands UKHospitals Ownership

FinancingPub. & Priv.Public

Pub. & Priv.Public

Private (non-profit )Public

PublicPublic

PHC OwnershipFinancing

PrivatePublic

PrivatePublic

PrivatePublic

PrivatePublic

Specialist s OwnershipFinancing

PrivatePublic

PrivatePublic

PrivatePublic

Pub. & Priv.Public

Dental Ownership

Financing

Adult:Child: Public

Adult:Pub &PrvChild: Public

Adult:Child: Public

Adult: PrivateChild: Public

Adult:Child: Public

Adult: PrivateChild: Public

Adult:Child: Public

Adult:Pub. & PrivChild: Public

Drugaccess OwnershipFinancing

PrivatePub. & Priv.

PrivatePub. & Priv.

PrivatePub. & Priv.

PrivatePub. & Priv.

Ambulance OwnershipFinancing

PrivatePublic

Private (& P)Public

Private (& P)Public

PublicPublic

Public-private mix in Europe


6/39

Public Private Public Private

Large role of private sector : outpatient care, by quintile


7/39

Large role of private sector : outpatient care, by quintile andsource


8/39


9/39

Why talk about the private sector specifically?Because private sector is different

10

Analytics are different, because..

Behavior and incentives are different Instruments/ policies to influence are

different

Why else?

Because it is so often overlooked


10/39

Many reasons contribute to overlooking the private sector(CGD 2008 Survey)

11

Respondents identified key barriers to engagement with theprivate 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


11/39

Private sector can play critical role..

12

In achieving priority objectives..even for the poorWith respect to child health, TB, malaria, or maternal and child health

Place of birth, by wealth quintile: South Asia Place of birth, by wealth quintile: SEAsia


12/39

0 10 20 30 40 50

Waiting time

Doctors manner

Doctors skills

Nurses manner

Nurses skillsExplanation of care

Overall visit

Percent Sat isfied or Very Sat isfied

Private Public

Responsiveness: Private Sector Outperforms Public Sector

Andhra Pradesh (2000)

Large role and unlikely to diminish


13/39

Engage, but simplistically

14

Private sectoris there

Contractwith

NGOs


14/39

Private sectoris bad

Writemore

regulations

More simplistic approaches toprivate sector engagement

15


15/39

New evidence is challenging old thinking

Quality of Private and Public Ambulator y Health Care in Low and Middle Income Countries: Systematic Reviewof Comparative Studies. Berendes et al. 2011 PLoSMedicine

Although data are limited, qualit y in both provider groups seems poor, wi th t he private sector performing better in drug availability and aspects of delivery of care , including responsiveness and effort, and possibly being more clientorientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes forthe poor, including managing the increasing burden of non-communicable diseases.

The relative efficiency of public and private service delivery. Hsu. 2010. World Health Repor t Background paper39

The literature on relative efficiency levels between private and public delivery of healthcare shows inconclusiveevidenceThe debate of private vs. public seems anachronistic. Today the role of the private sector in the delivery ofhealth services is undeniable It is no longer a question of private vs. public but rather, what is the best and most efficient mix for the local context ?

Health Outcomes in Public vs. Private Settings in Low and Middle Income Countries: Systematic Review ofComparative Studie. Montagu et al. 2011

Outpatient care provided in the public sector has better outcomes than the same services provided in the privatesectorData on comparative outcomes of public versus private healthcare is very limited and no studies of any sorthave been conducted on this topic in low income countries.


16/39


Quality of Private and Public Ambulator y Health Care in Low and Middle Income Countries: Systematic Reviewof Comparative Studies. Berendes et al. 2011 PLoSMedicine

Although data are limited, qualit y in both provider groups seems poor, wi th t he private sector performing better in drug availability and aspects of delivery of care , including responsiveness and effort, and possibly being more clientorientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes forthe poor, including managing the increasing burden of non-communicable diseases.

The relative efficiency of public and private service delivery. Hsu. 2010. World Health Repor t Background paper39

The literature on relative efficiency levels between private and public delivery of healthcare shows inconclusiveevidenceThe debate of private vs. public seems anachronistic. Today the role of the private sector in the delivery ofhealth services is undeniable It is no longer a question of private vs. public but rather, what is the best and most efficient mix for the local context ?

Health Outcomes in Public vs. Private Settings in Low and Middle Income Countries: Systematic Review ofComparative Studie. Montagu et al. 2011

Outpatient care provided in the public sector has better outcomes than the same services provided in the privatesectorData on comparative outcomes of public versus private healthcare is very limited and no studies of any sorthave been conducted on this topic in low income countries.


17/39


World Health Assembly Resolution 2010 A63 :Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services

Called on all WHA member countries to:constructively engage the private sector in

providing essential health-care services


18/39

THIS COURSE ISABOUT MOVINGBEYOND THE OLDTHINKING

Learninghow toengage theprivatesector.

When it makes sense

Using proven instruments

Based on private sectorunderstanding

Knowing how private sectorresponse will contribute tosector goals

19


19/39

rding-Montagu-Preker Framework: Over view

Distribution(equity)

Efficiency

Quality of Care

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

PHSA Gather available information

Identify additional needs

In-depth studies

Activities

Hospitals PHC Diagnostic labs Producers / Distributors

Ownership For-profit corporate For-profit small business Non-profit charitableFormal/ Informal

Grow

Harness

Convert

StrategyAssessmentGoal Focus

PrivateSector

PublicSector

Restrict


20/39

Framework: Strategies

Source: Ada ted from Hardin & Preker Private Partici ation in Health Services 2003.

Grow Harness Convert

Government shifting fromfunding to purchasing

From NHS to socialhealth insurance system

could leverage privateresources to expand / improve servicescurrently provide bygovernment

Public-Private-Partnerships ininvestment, delivery, ormanagement

A well-functioning part ofthe private sector

could contribute moreby expansion, e.g.:

NGOs? ORS producers? Corporate hospitals? Diagnostic labs Pharmacies Midwives

A large existing privatesector with problems

Not participating indisease surveillance

Quality failings Monopolistic behavior

could be leveraged to Serve targeted

population Provide critical services

could be improved byactive management

Assure geographicdistribution & coverage P

r i v a

t e H e a

l t h S e c

t o r

S i t u a

t i o n


21/39

Framework: Instruments

Source: Ada ted from Hardin & Preker Private Partici ation in Health Services 2003.


Government shifting fromfunding to purchasing

From NHS to socialhealth insurance system

could leverage privateresources to expand / improve servicescurrently provide bygovernment

Public-Private-Partnerships ininvestment, delivery, ormanagement

A well-functioning part ofthe private sector

could contribute moreby expansion, e.g.:

NGOs? ORS producers? Corporate hospitals? Diagnostic labs Pharmacies Midwives

A large existing privatesector with problems

Not participating indisease surveillance

Quality failings Monopolistic behavior

could be leveraged to Serve targeted

population Provide critical services

could be improved byactive management

Assure geographicdistribution & coverage P

r i v a

t e H e a

l t h S e c

t o r

S i t u a

t i o n

Regulation Contracting Training/Information Social marketing

Social franchising Info. to patients Demand-side

(incl. Vouchers)

EQA / Accreditation

PPP transactions Enabling environment

improvement

Policy and Programmatic Instruments


22/39

HMP-Fram ewor k: Process



2: MatchGoal to PHS

Situation

3: SelectInstrument

4: ApplyInstrument

1: PHSA(evaluate)


23/39

Course Fram ework:



2: MatchGoal to PHS

Situation

3: SelectInstrument

4: ApplyInstrument

1: PHSA(evaluate)


24/39

Sample 1

Policies to reduce barriers to investment and/or registration of new private medical facilities

can be used to grow the private sector and soprovide benchmarking for government-providedcare, and opportunities for contracting out wheregovernment oversight capacity may be limited.

Grow

Harness

Convert


25/39

Sample 2

Social marketing and social franchising

both offer opportunities to leverage existing resources inthe private sector and use them to expand access tosubsidized good or services of public-health benefit.

Grow

Harness

Convert


26/39

Sample 3Grow

Harness

Convert

Government devolvement from the direct provision of medical care services may sometimes lead to a planned divestiture of ownership and care provision.This can take several forms:

1. The new private owners may be contractually obliged tocontinue providing public health services under contractto government using the formerly public assets ( PPPtransaction )

2. The new owners may be permitted but not obliged toprovide public health services ( privatization )


27/39

Sample 4 (rare)

The risks associated with informal care provision

in particular with the widespread sale of antibiotics andantimalarials over-the-counter, by untrained retailers, ledthe government of Cambodia to outlaw the operation of non-registered medical shops and informal drug sellers at the

start of 2010. The effects of this were..

Grow

Harness

Convert

Restrict


28/39

Challenges

Knowledge (already discussed) Strategy

Dialogue Getting beyond NGOs PS motivation & incentives

Much & continued attention to implementation

29


29/39

Challenge #2: Strategy

30

Just like the public sector, good policy towardthe private sector must be developed

strategically. What goals? (disease? Popn group? Region?) Which providers/ sellers/ producers? Which policy instruments??


30/39

Logical Framework Strategy Selection

Problem/ ObjectiveDefined

RelevantPrivateActors

Identified

CurrentActivitiesAssessed

DesiredBehaviorChanges

Identified

Strategy forChangingBehaviorSelected

StrategyImple-mented

1 2 4 5 63

Health seekingbehavior oftarget populationgroup analyzed

Tools include

utilizationsurveys;focus groups

Major privateactors identified

Providerpracticesanalyzed

Tools include:provider

interviews/ surveys Gap identified

bet. current &betterbehaviorsoutlined

Gap from Step 3used toenumeratedesired behaviorchanges

Mostappropriatestrategyto elicitdesired

behaviorsselected

Implementa-tionobstaclesidentified

Plan outlined forovercoming

challenges Details andlogistics ofimplementa-tionfinalized

Health problemspecified, e.g.:o Low

immunizationo Poor TB

outcomeso Lack of

services inrural areas

Targetpopulationgroup identified(e.g., children,TB patients,rural)


31/39

Challenge #3: Dialogue

32

In rich mixed-delivery health systems, a mult itude of forums and mechanisms for communication (2-way!) between public and

private actors exist.

In many developing countries even those with large privatesectors, there is little communication.

Public Actors

Private Actors


32/39

Challenge #4: Moving beyond NGOs

NGOs are often easier for the governmentto work with

goals aligned less need for monitoring

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

the population

33


33/39

Challenge #5: PS incentives & motivations

Health sector policymakers arentaccustomed 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)

34


34/39

Challenge #6: Attention to implementation

35

Not a one-shot deal

Requires resource s (not a hand-off) and much capacity

development

Generating behavior change of public officials requireschange management not just directives


35/39

Thinking strategically about policy instruments

36

1.Regulation (when/who)

2.Contracting (when/who)

3.Training/ Info dis. To providers (when/who)

4.Vouchers/ demand-side suppor t (when/who)

5.Info dissemination to patients

6.Social marketing/ commercialization (when/who)

7.Social franchising (when/who)

8.PPP transactions (when/who)

9.Enabling environment improvement (when/who)


36/39

The Policy Instruments: What to be thinking about

37

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

Which providers or producers is strategyeffective at influencing?

What goals can they contribute to?


37/39

Policy Instruments: What to think about

38

What is the governments role inimplementing the policy?

What other policies will be needed?

What other actors will need to be involved?


38/39

In lieu of conclusion

39

o I hope Ive given you some insights into some ofthe reasons engagement is so difficult. Probablyyou know more reasons.

o Well use the framework again in the discussionof private health sector assessments.

o Well be covering in more detail, several of theinstruments which have been discussed.

o Assessment is next


39/39

In lieu of conclusion

Questions??

Comments?

d1s2 ppt-dominique usa

Documents