Working with the Non-StateSector to Achieve Public

Health Goals

Consultation on Priorities and Actions20-21 February 2006, Chateau de Penthes,

Pregny-Genève

Alex Ross and Dominic Montagu

Our environment

• Ambitious time-limited goals: MDGs, Universal Access,Bilateral programs– Translate into expansion of services– Population based– Coverage (to quality services)– Access -- overcoming barriers: equity, affordability, patient

satisfaction, stigma and discrimination, etc• Competitive marketplace

– New funding, but limited and for certain things– Politics: winners and losers

• Funding drivers– Donor practices

• NSS preferences: SWAps, Direct budget support– Global health initiiatives: requirements and opportunities– Performance based funding

Our environment

• Multiple providers have been around for a long time– Nothing new, but new combinations– Government subsidies– Increasing recognition of multiple providers– Poor public sector capacity

• Some health conditions more popular– The era of diseases of poverty: HIV/AIDS, TB, Malaria– Child health, safe motherhood, reproductive health– The ascension of health systems strengthening??

• Human resources

The Non-State Sectoras defined for this meeting

• Companies– Provision as core business– Provision to employees / community

• NGOs and FBOs• Clinics / individual providers• Pharmacies• Informal providers / drug sellers

“All providers outside of government management”

Some Claims about the NSS

Claim:

• Private sector is ‘outof control’

• Not properly trained• Money minded only• Don’t serve the poor• Private sector success

is public sector’s loss

Responses (that don’t work):

• Large scale regulation

• Massive training• Given them money• Ignore or chastise NSS

providers• Public sector defensive

How we got here

• Issues coming more frequently internationally• Montreux Challenge meeting on health systems identified

NSS as one of a number of critical topics• Health financing• Management• Non-state sector• Health workforce platform• Health Metrics Network• Essential Medicines

• WEF “building healthcare systems in sub-Saharan Africa• Forum on engaging the private sector for child health• National policy development (eg: Nigeria, Ghana, Uganda)

Incidence and Care of IDD among <5 in Africa

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

poorest 2nd 3rd 4th richest

Wealth Quintile

Wh

ere

tre

ate

d

0%

5%

10%

15%

20%

25%

30%

Incid

ence o

f illn

ess

Private sector serves all wealth strata

Source: Prata, Montagu, Jeffries 2005: analysis of DHS dataBenin, Burkina, Cameroon, C. Afr. Rep, Chad, Comorrow, Cote d’Ivoire, Ghana, Kenya, Madagascar, Malawi, Mali, Mozambique, Namibia, Niger, Nigeria, Senegal, Tanzania, Togo, Uganda, Zambia, Zimbabwe

Incidence and Care of IDD among <5 in Africa

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

poorest 2nd 3rd 4th richest

Wealth Quintile

Wh

ere

tre

ate

d

Private Facility

Public Facility0%

5%

10%

15%

20%

25%

30%

Incid

ence o

f illn

ess

Private sector serves all wealth strata

Source: Prata, Montagu, Jeffries 2005: analysis of DHS dataBenin, Burkina, Cameroon, C. Afr. Rep, Chad, Comorrow, Cote d’Ivoire, Ghana, Kenya, Madagascar, Malawi, Mali, Mozambique, Namibia, Niger, Nigeria, Senegal, Tanzania, Togo, Uganda, Zambia, Zimbabwe

NGOs are growing

Uganda Government financing to NGOs

Social Organization and NGO/Non-Profits in ChinaOrganization type 1999 2000 2001 2002 2003 2004Sos 137,000 131,000 129,000 133,000 142,000 153,000NGNCEs 6,000 23,000 82,000 111,000 124,000 135,000SO percent increase -9.0% -4.6% -1.6% 3.0% 6.3% 7.2%

Source: [Chinese] Ministry of Civil Affairs, Cited by [United States] Congressional-Executive Commision on China

Private for-profits are increasing (in Asia)

Private Clinic Growth in Indonesia '91-99

3000

3500

4000

4500

5000

5500

1991 1992 1993 1994 1995 1996 1997 1998 1999

Cli

nic

s

Change in treatment by hospital ownership in India 85-95

Private Clinic Growth in Indonesia 91-99

Global attention is increasing

Incidence of the term 'private' occuring in World Health Assembly resolutions, 1975-2005

0

5

10

15

20

25

30

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

Year

Inci

den

ce

Innovative strategies are being explored

Source: Janovsky and Peters Innovations 2005

Country Contracting

Delegationto LocalHealthAgency

User FeeExemptions

Subsidiesto Poor

PerformanceIncentives

ReorganizeHealth

Workers

Socialmarketing

CommunityEngagement

Cambodia 1 1 4 1 1 2 1 3 4

Ethiopia 4 2 3 2 3 4

Ghana 3 3 3 4 2 2 2 2

Indonesia 4 4 2 3 3

Kenya 4 4 3 3 3

Mali 3 3 3

Mozambique 2 1 3 3

Myanmar 3 2 3 3 3

PNG 4 3

Tanzania 1 4 2 3 3 4

Uganda 3 4 4 1 3 3

Vietnam 3 4 4 4 2 3 4KEY

Not applicable - no plan

1 Pilot only at outset

2 Pilot plus plan for full-scale at outset3 Phased implementation without pilot4 National scale at outset

Change in private expenditure on health vs. total % of expenditure on health that is private, 1998 - 2002

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Change in pvt financing going in both directions

Change in private expenditure on health vs. total % of expenditure on health that is private, 1998 - 2002

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Change in private expenditure on health vs. total % of expenditure on health that is private, 1998 - 2002

Afghanistan

Bosnia and Herzegovina

Democratic Republic of Congo

Gambia

Sierra Leone

Colombia

Mozambique

Guinea-Bissau

Thailand

Niger

Chad

MauritaniaEquatorial Guinea

Cameroon

Angola

Mauritius

Chile

Botswana

Senegal

Algeria

Indonesiac

Myanmar

Central African Republic

Burkina Faso

Cambodia

Poland

Romania

Republic of Korea

Rwanda

Sao Tome and Principe

Malawi

United Republic of Tanzania

Syrian Arab Republic

Grenada

Saint Vincent and the Grenadines

Mali

Mongolia

Dominican Republic

Morocco

Haiti

Monaco

Italy

Bahamas

Benin

Portugal

Vanuatu

Sudan

Barbados

Switzerland

United Kingdom

Swaziland

Malta

Albania

Azerbaijan

Maldives

Tonga

Lebanon

Iran, Islamic Republic of

Samoa

Lao People's Democratic Republic

El Salvador

Malaysia

Bhutan

Brazil

Egypt

Cuba

Cyprus

San Marino

Nepal

Bahrain

Cook Islands

Qatar

Lesotho

Belgium

IcelandDenmark

Japane

Marshall Islands

New Zealand

Saint Lucia

Greece

Guinea

Kyrgyzstan

Serbia and Montenegro

Djibouti

United States of America

Solomon Islands

Austria

Guatemala

France

Micronesia, Federated States of

Niue

Oman

Germany

Russian Federation

Nicaragua

Cape Verde

Nauru

Kiribati

Democratic People's Republic of Korea

Saint Kitts and Nevis

Tunisia

Czech Republic

Australia

Nigeria

Sweden

Ukraine

Finland

Pakistan

Honduras

Canada

Fiji

Slovenia

Zambia

Uganda

Spain

Ghana

Mexico

Norway

Jamaica

Kenya

Ireland

Latvia

Madagascar

Netherlands

Armenia

Panama

Kazakhstan

Palau

DominicaCongo

Côte d'Ivoire

Saudi Arabia

Slovakia

Ecuador

Namibia

Papua New Guinea

Eritrea

Libyan Arab JamahiriyaSri Lanka

The former Yugoslav Republic of Macedonia

Ethiopia

Peru

Seychelles

TurkmenistanAntigua and Barbuda

Bolivia

Brunei Darussalam

Uzbekistan

Kuwait

Lithuania

Philippines

Viet Nam

United Arab Emirates

Croatia

Costa RicaTimor-Leste

South Africa

Zimbabwe

Belize

Hungary

Argentina

Republic of Moldova

India

China

Comoros

Bangladesh

Luxembourg

TurkeyIsrael

Tajikistan

Guyana

Paraguay

Jordan

Yemen

Venezuela, Bolivarian Republic of

Trinidad and Tobago

Andorra

Belarus

Uruguay

Togo

Estonia

Singapore

Liberia

Tuvalu

Bulgaria

Georgia

GabonSuriname

Iraqd

Burundi

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…and unrelated to system importance of pvt financing

Interviews with many stakeholders

• Context• Critical issues• Emerging issues• What Activities are needed?• What outputs should be produced?

Summary

• Focus on Service Delivery– Education, financing, pharmaceutical

production etc. put in ‘parking lot’

• Focus on important but neglected or newand relatively uncharted policy andoperational challenges

Eight issues

1. Scaling up2. Stewardship & Policy3. Regulation4. New NGOs5. Local Capacity6. Data7. Quality8. Informal Sector

Three Clusters

1. Scaling up2. Stewardship & Policy3. Regulation4. New NGOs5. Local Capacity6. Data7. Quality8. Informal Sector

• New entrants intoservice delivery

• Old challenges, butnew approaches

• Scaling up