april harding bali hyatt hotel, sanur, bali 21-25 june 2010
TRANSCRIPT
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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
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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
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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
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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??
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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?