JUNE 2013 PRIVATE HEALTH POLICY TOOLKIT FOR AFRICA Tools for Engaging the Private Health Sector PRIVATE HEALTH POLICY TOOLKIT FOR AFRICA Tools for Engaging the Private Health Sector ©2013 The World Bank Group 1818 H Street N.W., Washington D.C., 20433 All rights reserved. June 2013 Available online at www.wbginvestmentclimate.org This work is a product of the staff of the World Bank Group with external contributions. The information included in this work, while based on sources that the World Bank Group considers to be reliable, is not guaranteed as to accuracy and does not purport to be complete. The World Bank Group accepts no responsibility for any consequences of the use of such data. The information in this work is not intended to serve as legal advice. The findings and views published are those of the authors and should not be attributed to IFC, the World Bank, the Multilateral Investment Guarantee Agency (MIGA), or any other affiliated organizations. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to the Office of the Publisher, the World Bank, 1818 H Street NW, Washington, DC 20433, USA; telephone: 202-522-2422; email: pubrights@worldbank.org. About the Investment Climate Department of the World Bank Group The Investment Climate Department of the World Bank Group helps governments implement reforms to improve their business environments and encourage and retain investment, thus fostering competitive markets, growth, and job creation. Funding is provided by the World Bank Group (IFC, the World Bank, and MIGA) and over 15 donor partners working through the multidonor FIAS platform. ii Acknowledgments The preparation and publication of this toolkit were made possible due to the generous support from the Bill & Melinda Gates Foundation as part of their support for the World Bank Group’s Health in Africa Initiative. The preparation of this toolkit was led by April Harding of the World Bank Institute and Alexander S. Preker, of the World Bank Group. Bettina Brunner developed the content of this toolkit with a team from the WBI and IFC, including Hortenzia Beciu, Tazim Majwi, Ifelayo Peter Ojo, Connor Spreng, Bernard Olayo, Jorge Coarasa, Khama Rogo, Marie-Odile Waty, Cécile Fruman, Scott Featherston, Benjamin Herzberg, and Peter Berman. Barbara O’Hanlon of Strengthening Health Outcomes for Private Sector Delivery (SHOPS) and Dominic Montagu of the University of California at San Francisco were also instrumental in providing feedback and resources for the toolkit. The following individuals enhanced the toolkit by contributions of knowledge, documents, and time. We thank them for sharing their experiences: Herman Abels, Medical Credit Fund Ricardo Bitran, Bitran & Associates Catherine Connor, Abt Associates Inc. Annemarie de Man, PharmAccess Foundation Donika Dimovska, Results for Development Monique Dolfing, Medical Credit Fund Amanda Folsom, Results for Development David Goldman, RAND Corporation Gina Lagomarsino, Results for Development David Lee, Management Sciences for Health Marty Makinen, Results for Development Susan Mitchell, Abt Associates Inc. Frank Poen, PharmAccess Foundation James Rankin, Management Sciences for Health Meagan Smith, Banyan Global Nicole Spieker, PharmAccess Foundation We would also like to thank the dozens of government officials, private health practitioners, and members of civil society participating in private sector engagement workshops in Bali, Ouagadougou, and Mombasa whose feedback informed the content of this toolkit. iii Table of Contents Module 1: Why the Private Sector? ........................................................................................................................................................ 1 Step 1: The Private Sector Matters.................................................................................................................................................... 1 Step 1.1 Why the Private Health Sector Matters........................................................................................................................... 2 Step 1.2 Used by Consumers but Ignored by Governments ......................................................................................................... 2 Step 2: Stewardship and Engagement .............................................................................................................................................. 3 Step 2.2 Engagement with Faith-Based Organizations................................................................................................................. 4 Step 2.3 Partnership and Dialogue with the Private Health Sector ............................................................................................... 5 Module 2: The Policy Cycle .................................................................................................................................................................... 6 Step 1: Assessment........................................................................................................................................................................... 6 Step 1.1 Learning From Previous Assessments ........................................................................................................................... 6 Step 1.2 Conducting an Assessment............................................................................................................................................ 7 Etape 1.3 Develop Action Plan ..................................................................................................................................................... 8 Step 2: Policy (Re)Design ................................................................................................................................................................. 8 Step 2.1 Creating Public Private Dialogue .................................................................................................................................... 8 Step 2.2 Stakeholder Matrix ......................................................................................................................................................... 9 Step 2.3 Strategies for Working with the Private Health Sector .................................................................................................... 9 Step 3: Implementation...................................................................................................................................................................... 9 Step 3.1 Kenya Case Study........................................................................................................................................................ 10 Step 3.2 Guatemala Case Study ................................................................................................................................................ 10 Step 3.3 Republic of Congo Case Study .................................................................................................................................... 11 Step 4: Monitoring and Evaluation ................................................................................................................................................... 11 Step 4.1 Monitoring and Evaluation Overview ............................................................................................................................ 11 Step 4.2 Challenges of Public Private Dialogue Monitoring & Evaluation ................................................................................... 11 Step 4.3 Developing a Plan to Monitor Progress of Public Private Dialogue............................................................................... 12 Step 4.4 Public Private Dialogue Monitoring and Evaluation Tools............................................................................................. 12 Step 4.5 Indicators for Measuring Engagement.......................................................................................................................... 13 Step 4.6 Monitoring & Evaluation of Engagement Mechanisms.................................................................................................. 13 Step 1: Policy and Dialogue............................................................................................................................................................. 15 Step 2: Information Exchange ......................................................................................................................................................... 16 Step 2.1 Training and Information Flow to Providers .................................................................................................................. 16 Step 2.2 Private Sector Provision of Data to the Public Sector ................................................................................................... 17 Step 2.3 Private Sector Inclusion in Disease Surveillance Program ........................................................................................... 17 Step 2.4 Information Flow to Consumers.................................................................................................................................... 17 Step 3: Regulation ........................................................................................................................................................................... 18 Step 3.1 Regulation Costs and Benefits ..................................................................................................................................... 19 Step 3.2 Accreditation ................................................................................................................................................................ 19 iv Step 3.3 Self Regulation by Professional Bodies ........................................................................................................................ 20 Step 3.4 Private Health Sector Registry ..................................................................................................................................... 20 Step 3.5 Standardized Rules for Private Facilities ...................................................................................................................... 21 Step 3.6 Continuing Medical Education ...................................................................................................................................... 21 Step 4: Financing ............................................................................................................................................................................ 21 Step 4.1 Contracting................................................................................................................................................................... 22 Step 4.2 Social Franchising ........................................................................................................................................................ 22 Step 4.3 Social Marketing........................................................................................................................................................... 23 Step 4.4 Vouchers ...................................................................................................................................................................... 24 Step 4.5 Incentives for Providers................................................................................................................................................ 24 Step 4.6 Insurance ..................................................................................................................................................................... 25 Step 5: Public Provision of Services ................................................................................................................................................ 25 Step 5.1 Distribution of Public Goods ......................................................................................................................................... 26 Step 5.2 Functioning Referral System ........................................................................................................................................ 26 Step 5.3 Public Private Partnerships .......................................................................................................................................... 27 Module 4: Glossary............................................................................................................................................................................... 28 Module 5: Resource Links by Topic...................................................................................................................................................... 30 Figures Figure 1. The Private Health Sector........................................................................................................................................................ 1 Figure 2. Origine des soins par région.................................................................................................................................................... 2 Figure 3. Simple Model for Private Health Sector Contributions to Health Outcomes ............................................................................. 3 Figure 4. Engagement Domains Defined................................................................................................................................................ 4 Figure 5. Engagement Domains for Faith-Based Organizations ............................................................................................................. 4 Figure 6. What is a Health Public Private Partnership? .......................................................................................................................... 5 Figure 7. The Policy Cycle...................................................................................................................................................................... 6 Figure 8. Steps in a Private Health Sector Assessment.......................................................................................................................... 7 Figure 9. Steps in Policy Design Process ............................................................................................................................................... 8 Figure 10. Sample Stakeholder Mapping Matrix ..................................................................................................................................... 9 Figure 11. Strategies for Working with the Private Health Sector ........................................................................................................... 9 Figure 12. Results Chain for Safe Motherhood Voucher in Uganda .................................................................................................... 13 Figure 13. The Engagement Continuum............................................................................................................................................... 15 Figure 14. Best Practice in Policy and Dialogue ................................................................................................................................... 15 Figure 15. Best Practice in Information Exchange ................................................................................................................................ 16 Figure 16. Information Flows in Disease Surveillance Systems............................................................................................................ 17 Figure 17. Best Practice in Regulation.................................................................................................................................................. 18 Figure 18. Components of a Successful Accreditation Program ........................................................................................................... 19 Figure 19. Best Practice in Financing ................................................................................................................................................... 21 Figure 20. The Seven Steps of Contracting .......................................................................................................................................... 22 Figure 21. Geographic Evolution of Franchises .................................................................................................................................... 23 Figure 22. Referral System Flows ........................................................................................................................................................ 26 Figure 23. Key Types of Public Private Partnerships ............................................................................................................................ 27 Tables Table 1. Objectives and Expected Outcomes of a Private Health Sector Assessment ........................................................................... 6 Table 2. Private Health Sector Assessment by Country and Focus Area ............................................................................................... 7 Table 3. Action Plan by Stakeholder Group ............................................................................................................................................ 8 Table 4. Checklist to Monitor Progress Annually .................................................................................................................................. 12 Table 5. SMART Indicators for Gathering Performance Information ..................................................................................................... 13 Table 6. Costs and Benefits of Regulation............................................................................................................................................ 19 Table 7. Potential Advantages and Disadvantages of Self Regulation.................................................................................................. 20 Table 8. Models of Risk Pooling ........................................................................................................................................................... 25 Table 9. Best Practice in Public Provision of Services .......................................................................................................................... 25 v Foreword Sub-Saharan Africa, with only about 11 percent of the world’s people, carries 24 percent of the global disease burden in human and financial costs, according to “The Business of Health in Africa” (2007). Radical improvements are needed in health care systems across the continent to provide citizens with high quality, affordable, easily accessible health care. Encouraging the private health sector can be part of a concerted effort to expand access to health services and improve health system capacity, particularly for the poor. Governments need to proactively engage with the private health sector to correct restrictive policies, poor oversight, and lack of dialogue, which has plagued public-private interaction to date. The World Bank Group’s Health in Africa Initiative (HiA) is an innovative strategy that seeks to bridge this gap. HiA has three main components: providing equity and debt financing to private providers, supporting African governments with advisory services to better engage the private health sector, and improving the knowledge base. HiA is currently assisting governments and the private sectors in Burkina Faso, Republic of Congo, Ghana, Kenya, Mali, Nigeria, South Sudan, Tanzania, and Uganda. As part of improving the knowledge base on the private health sector in Africa, this "Private Health Policy Toolkit for Africa" gathers resources and tools about engaging the private health sector that were previously unavailable in one location. It outlines opportunities for developing, engaging, and supporting a well-managed and effectively regulated private sector to improve the region’s health. The toolkit provides a wealth of information on why the private sector is important to policymakers and on the key components of stewardship. Toolkit users can learn about the policy cycle and take a deep dive into engagement tools from accreditation to vouchers. We thank the partners and colleagues from the World Bank Group, academia, the private sector, and the development community who made this toolkit possible. We hope that policymakers will find this resource a useful, easily accessible addition to current findings on engaging the private health sector. Cécile Fruman Manager Infrastructure and Social Sectors The World Bank Group vi vii Preface There is growing recognition that the private health sector is a to involve the private sector to the extent needed to benefit significant source of health care in most African countries. health systems. Suspicion on both sides and a history of lack According to "Healthy Partnerships: How Governments Can of communication compound the difficulties of engaging with Engage the Private Sector to Improve Health in Africa" the private sector and can translate into restrictive policies (2010), the private sector share of total health expenditure in and poor oversight of the private health sector. Sub-Saharan Africa is on average 51 percent. Use of the private health sector in Africa is particularly strong among To address this information and communications gap, HiA groups that policymakers most want to reach, including the developed this "Private Health Policy Toolkit for Africa", which poor, women, children, and people with diseases such as gather resources and tools about engaging the private health tuberculosis, malaria, and HIV. sector that were previously unavailable in one location. The toolkit, available in both online and PDF versions, advances Since the late 1990s, the World Bank has spearheaded the collective knowledge about engaging private resources for initiatives to include the private sector as a partner in health the health sector in Africa from the development partners and sector reform, emphasizing contracting out, social insurance, academic communities. The tools presented include and public-private partnerships (PPPs). International aid checklists, case studies, templates, reports, slide organizations have also encouraged dialogue and partnership presentations, and videos. The contents were developed between the public and private health sectors including the through collaboration with Results for Development, U.S. Agency for International Development (USAID), the U.K Strengthening Health Outcomes through the Private Sector Department for International Development (DfID), and the (SHOPS), Banyan Global, Health Systems 20 / 20, and the German Agency for International Cooperation (GIZ). Major University of California San Francisco. Two surveys of key global health initiatives such as the Global Alliance for stakeholders in Africa, to inform the design and content of the Vaccines Initiative and the Global Fund to Fight AIDS, toolkit, were administered by staff members of the World Bank Tuberculosis and Malaria include private sector actors to Group (WBG) in 2010. improve efficiency and incorporate private sector models in program delivery. The tools presented in this report help readers design strategies and approaches for engaging the private sector in a In 2007, the World Bank Group published a seminal report health system. Topics are organized into five modules entitled “The Business of Health in Africa,” which highlighted outlining specific activities that can expand and tighten private the role of the private sector in health in Sub-Saharan Africa. health sector engagement leading to sustainable, pro-poor The report showed that the private sector (both for-profit and change. not-for-profit) can be an important part of the solution to Africa’s health care challenges when part of a publically led, Module 1: Why the Private Sector equitable health care system. Following this report, the World The first module defines the private health sector, Bank Group launched the Health in Africa Initiative (HiA) to engagement, and stewardship. While the private health sector help African governments harness the potential in the private has various definitions, for this toolkit it includes nonprofit and sector to better address Africa’s health challenges through the for-profit private hospitals, clinics, laboratories, pharmacies, generous support of the governments of France, Japan, the and the people working in them — doctors, nurses, midwives, Netherlands and the Bill & Melinda Gates Foundation and the pharmacists, and informal providers of health services. It also Rockefeller Foundation. encompasses producers and distributors of pharmaceuticals as well as health education institutions. Module 1 explains HiA has three main components: supporting African that engagement is the deliberate, systematic collaboration of governments with advisory services in better engaging the the government and the private health sector according to private health sector, providing equity and debt financing to national health priorities, beyond individual interventions and private providers, and improving the knowledge base. HIA has programs. Within a public economics framework, engagement activities in several African countries. They were designed in can be broken down into five domains: policy and dialogue, recognition that governments in Africa are under pressure to information exchange, regulation, financing, and public reach international health targets such as the Millennium provision of services. Development Goals, but that most African governments cannot meet their health care needs alone due to financial Module 2: The Policy Cycle and human resource constraints at home. Efforts to leverage The second module describes how to engage with the private the assets of both the public and private sectors and mobilize health sector using the policy cycle, an idealized framework their resources can help scale up the delivery of essential that begins with assessment of the private health sector, interventions. continues with design and implementation of new policies for this sector, and ends with monitoring and evaluation of The HiA team discovered that a lack of information about the activities to determine impact. Along the way, toolkit viewers private sector’s role has hindered national policymaker efforts see how to conduct an assessment and develop an action viii plan. Module 2 identifies tools for stakeholder mapping, as public provision of services. For each policy tool, definitions, well as sample government declarations and decrees on the best practice, case studies, and links to subject-specific private sector, work plans and board / working group to adapt resources are provided. as templates for the policy design process. Module 2 explains the challenges of monitoring and evaluation and the steps in Module 4: Glossary developing a plan to monitor progress of public private Module 4 contains the glossary of terms for engaging with the dialogue with sample indicators and online tools. private health sector. Module 3: Engagement Tools Module 5: Links Module 3 covers the major engagement tools: policy and Module 5 has links to key policy reform tools by topic. dialogue, information exchange, regulation, financing, and ix Module 1: Why the Private Sector? Step 1: The Private Sector Matters Figure 1. The Private Health Sector Governments have a responsibility to guide the health system to deliver quality health care to populations, reduce health inequalities, improve access to health, and ensure adequate safeguards are in place. The private health sector is an important part of the health system in all countries, although its size varies from country to country. The private health sector includes private hospitals, clinics, laboratories, chemical shops, and pharmacies, and the people working in these establishments such as doctors, nurses, midwives, pharmacists, and informal providers of health services (figure 1). Private providers can be categorized into three groups:  Commercial for-profit, with the primary goal of generating a return on investment;  Social enterprises, which use a mix of market-rate and below-market financing, including donor funding, with a minimum expectation of financial return; and  Not-for-profit providers and faith-based organizations, that rely mainly on donations and grants with patients making minimal or no payment for goods and services. The private health sector also includes private insurance schemes, health training institutions, and producers and distributors of pharmaceutical Resources:  Working with the Non-State Sector to Achieve Public Health Goals [PDF 2.7 KB]  Health Governance: Concepts, Experience, and Programming Options [PDF 6.77 KB]  Report of The Regional Workshop on Building Public-Private Linkages to Advance Priority Health Services in Africa [PDF 1.25 MB]  The Role of the Private Sector in Health: A Landscape Analysis of Global Players' Attitudes toward the Private Sector in Health Systems and Policy Levers That Influence These Attitudes [PDF 464 KB] 1 Step 1.1 Why the Private Health Sector Matters Figure 2. Origine des soins par région The private health sector matters for many reasons. It constitutes a significant portion of available health care in low- and middle-income countries and thus cannot be ignored. The private health sector is the source of 80 percent of health care in South Asia and 66 percent in Southeast Asia; 60 percent in North Africa and Europe, and 34 percent in Latin America and the Caribbean (figure 2). The private health sector is heavily used by groups policy-makers most want to reach, including the poor, people with specific diseases such as TB, malaria, and HIV, and children and women. Figure 3 shows that the private sector's share in delivering services in Sub- Saharan Africa is fairly constant across income quintiles in Africa, viewed regionally. For country and regional presentations and data on Demographic and Health Surveys (DHS) from 48 countries showing use of the private health sector by wealth quintile, click here. Resources:  Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa [View on issuu]  Working with the Non-State Sector to Achieve Public Health Goals [PDF 2.7 KB]  A Landscape Analysis of Global Players' Attitudes toward the Private Sector in Health Systems and Policy Levers That Influence These Attitudes [PDF 464 KB]  Report Of The Regional Workshop On Building Public-Private Linkages To Advance Priority Health Services In Africa [PDF 1.25 MB]  Health Governance: Concepts, Experience, and Programming Options [PDF 6.77 KB]  Safe in Their Hands? Engaging Private Providers in the Quest for Public Health Goals [PDF 65 KB] Step 1.2 Used by Consumers but Ignored by Governments Private sector health services are used even in the poorest countries among the lowest income groups. A recent study found consumers give these reasons for consulting private sector providers:  Ease of geographic access, shorter waiting periods, flexible hours  Greater availability of staff and drugs  Increased confidentiality and higher technical competency  Perception that private providers are more caring and responsible to client concerns. Yet the private health sector is often ignored by governments due to the following factors:  Lack of information on private health sector activities since data collection in many countries omits the private health sector.  Attitudinal barriers from both sides.  Lack of dialogue in membership organizations that can serve to self-regulate members and thus offer governance, oversight, and transparency to the private health sector. Bridging the gap between the public and private health sectors is imperative because growth of private investment complements public investment to achieve a needed increase in access to health services and capacity of the health sector. 2 Resources:  Working with Private Sector Providers for Better Health Care: An Introductory Guide [PDF 1.2 MB]  Trends and Opportunities in Public-Private Partnerships to Improve Health Service Delivery in Africa [PDF .5 MB]  Private Sector Engagement in Sexual and Reproductive Health and Maternal and Neonatal Health [PDF 502 KB] Step 2: Stewardship and Engagement Engagement is the deliberate, systematic collaboration of the government and the private health sector according to national health priorities, beyond individual interventions and programs. The World Health Organization's World Health Report 2000 describes stewardship as oversight of "the entire health system", private as well as public. Engagement with the private health sector is part of the broader concept of stewardship, or overall government responsibility for the health sector. Figure 3. Simple Model for Private Health Sector Contributions to Health Outcomes This toolkit's focus on public- private engagement is based on the understanding that through engagement, improvements in the operating environment will positively influence contributions of the private sector to improve the health system overall (figure 3). Resources:  Engaging All Health Care Providers in TB Control: Guidance on Implementing Public -Private Mix Approaches [PDF 3.83 MB]  Private Sector Involvement in HIV Service Provision [Website]  Public Stewardship of Private Providers in Mixed Health Systems [PDF 2.56 MB]  Engagement with the Private Health Sector [PDF 337KB]  The Role of the Private Sector in Health: A Landscape Analysis of Global Players' Attitudes toward the Private Sector in Health Systems and Policy Levers That Influence These Attitudes [PDF 464 KB] Step 2.1 Engagement Domains Based on a public economics framework, engagement with the private health sector can be broken down into five domains: policy and dialogue, information exchange, regulation, financing, and public provision of services (figure 4). For more information on engagement domains, see Healthy Partnerships: How Governments can Engage the Private Sector to Improve Health in Africa. 3 Figure 4. Engagement Domains Defined Step 2.2 Engagement with Faith-Based Organizations Figure 5. Engagement Domains for Faith-Based Organizations In many regions, faith-based organizations (FBOs) play a key role in health service delivery. Government's affinity for and engagement with FBOs can be explained by: -The perception among policy makers that the public sector and FBOs share similar social goals, are committed to public health goals, and are motivated to serve the poor. -Faith-based associations of providers tend to be well- organized and provide policymakers with a clear point of contact. Government engagement with FBOs can also be challenging due to lack of resources, duplication of efforts, and lack of strong reporting systems. Figure 5 shows how FBOs fit into the engagement domains. Resources:  Faith-Based Organizations: How Can Governments Work with FBOs to Strengthen the Health Force? [PDF 393 KB]  Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa [View on issuu]  Africa Christian Health Associations Platform [site web] 4 Step 2.3 Partnership and Dialogue with the Private Health Sector Figure 6. What is a Health Public Private Partnership? Public Private Partnerships (PPPs) are defined by the Health in Africa Initiative as a broad partnership between private contractors and the Government, in which the public sector contracts (usually on a long-term basis) with the private sector for the provision of a public service (figure 6). Public-Private Dialogue (PPD) is a process enabling the government and private sector actors (not-for-profit and for-profit) to exchange views and share their perspectives on health sector issues of common concern and interest. PPD can be structured or ad hoc, formal and informal, wide-ranging or focused on specific issues. Resources :  Supporting the Development of PPPs in Health-The Health in Africa Initiative [PDF 708 KB]  Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery in Africa [PDF .5 MB]  A Zebra or a Painted Horse? Are Hospital PPPs Infrastructure Partnerships with Stripes or a Separate Species? [PDF 293 KB]  Designing PPPs in Health [PDF 1.5 MB]  Public-Private Partnerships And Public Hospital Performance In São Paulo, Brazil [site web]  World Health Organization Resources on Working with the Private Sector [site web]  Her Majesty's Treasury: Public Private Partnerships [site web]  The Private Sector within a Public Health System: The German Example [PDF 1.4 MB] 5 Module 2: The Policy Cycle Figure 7. The Policy Cycle This Module describes how to engage with the private health sector using the policy cycle, an idealized framework which starts with assessment of the private health sector, and continues to policy design, implementation and evaluation. In this Module, Step 1 discusses assessment, Step 2 focuses on strategic design, Step 3 explains implementation, and Step 4 discusses monitoring and evaluation (figure 7). Step 1: Assessment Table 1. Objectives and Expected Outcomes of a Private Health Sector Assessment The first step in the policy cycle is country analysis, which is commonly called the private health sector assessment, or PHSA. The PHSA helps policymakers understand how the private sector works and fosters objective dialogue between the government and private sector stakeholders on how to enhance the private sector's role in health. Table 1 shows the objectives and expected outcomes of a PHSA. Step 1.1 Learning From Previous Assessments Perhaps the best tool for learning how to perform private health sector assessments (PHSAs) is to review PHSAs previously conducted, which usually include:  Terms of Reference (TOR)  Assessment methodology  Survey instruments  Stakeholder analysis  Workshop agendas  Case studies  Assessment bibliography View assessments by focus area conducted by the World Bank Group, the United States Agency for International Development, and other donors in table 2 below. 6 Table 2. Private Health Sector Assessment by Country and Focus Area Country Focus Area Bangladesh General, Maternal / Child Health Burkina Faso (French) General China Primary Care Congo (English, French) General Ghana General, Primary Care Indonesia General, Maternal / Child Health, TB Kenya General, Health Financing Malawi General, private health provider mapping Mali (English, French) General Morocco General, Family Planning / Maternal Child Health Namibia HIV / AIDS Nigeria Family Planning / Reproductive Health Paraguay Family Planning Senegal Family Planning / Reproductive Health Tanzania General, human resources for health Uganda HIV / ART and TB / HIV Integration Resources :  Health Systems Assessment Approach: A How-to Manual [PDF 1.23 MB]  Making Pregnancy Safer – Assessment Tool for the Quality of Hospital Care for Mothers and Newborn Babies [PDF 668 KB]  Rapid Assessment of Medicines Quality Assurance and Medicines Quality Control [PDF 250 KB]  Private-Sector Assessment Tool: A Handbook for Assessing the Potential for Youth Reproductive Health and HIV/AIDS Program Interventions in the Private Sector [PDF 3.75 KB] Step 1.2 Conducting an Assessment Figure 8. Steps in a Private Health Sector Assessment While each private health sector assessment is unique, depending on stakeholder interest and country characteristics, the assessment path generally follows the steps in figure 8, adapted from the Kenya Private Health Sector Assessment. These steps include document review, field visits, report preparation, and development of an action plan. Resources:  Health Systems Assessment Approach: A How-to Manual [PDF 1.23 MB]  Making Pregnancy Safer – Assessment Tool for the Quality of Hospital Care for Mothers and Newborn Babies [PDF 668 KB]  Rapid Assessment of Medicines Quality Assurance and Medicines Quality Control [PDF 250 KB]  Private-Sector Assessment Tool: A Handbook for Assessing the Potential for Youth Reproductive Health and HIV/AIDS Program Interventions in the Private Sector [PDF 3.75 KB]  What is a Health System? Health System Components / Control Knobs [site web] 7 Etape 1.3 Develop Action Plan Table 3. Action Plan by Stakeholder Group At the final engagement meeting for the private health sector assessment, the team and strategic stakeholders come together for a high-level meeting of the public and private officials and leaders to develop an Action Plan that outlines: -Major health sector challenges and how they relate to the private health sector, -Policy reforms, system changes and potential activities to address the challenges, and strategies to build support and mobilize resources to produce the desired changes. The Action Plan should encourage stakeholders to change their behavior or inspire them to take action through the dialogue process. Table 3 shows illustrative activities by stakeholder group for the action plan. Source: SHOPS, 2011 Step 2: Policy (Re)Design The next step in the policy cycle is to revise existing policies or design new policies. This involves developing the public private dialogue structure, identifying public private dialogue opportunities, and gaining stakeholder consensus. Step 2.1 Creating Public Private Dialogue Figure 9. Steps in Policy Design Process For governments to design and implement effective policies to engage the private health sector, they must first create a public private dialogue by engaging key stakeholders (figure 9). A public private dialogue (PPD) is a process enabling the government and private sector actors (not-for-profit and for-profit) to exchange views and share their perspectives on health sector issues of common concern and interest. The generic PPD process has been well documented in the Public Private Dialogue Handbook. Once a PPD is established, governments can work with private sector stakeholders to design and/or redesign policies that lead to increased engagement of the private health sector. 8 Step 2.2 Stakeholder Matrix Figure 10. Sample Stakeholder Mapping Matrix The stakeholder analysis matrix from the PPD Handbook provides a useful framework for plotting stakeholders and how best to approach them-- to persuade, influence, or empower their participation in a public private dialogue (figure 11). Stakeholders who strongly support reforms enabling PPDs in health and are highly influential are placed in the "Mobilize" box (top right). Those supporting reforms but who are less influential are placed in the "Leverage" box (top left). Those who are highly influential but strongly oppose the proposed reforms and/or PPDs are located in the "Co-Opt" box (lower right), while those who oppose and are less influential are placed in the "Persuade" box (lower left). Using this matrix can help identify how to reach out to different stakeholders:  Bring on board early stakeholders who favor the idea of PPD and have a high degree of influence.  Target for capacity building stakeholders who favor dialogue but are less influential.  Make a special effort to co-opt the most influential opponents by informing them about the purposes of dialogue and consulting them about design of dialogue mechanisms. Step 2.3 Strategies for Working with the Private Health Sector Figure 11. Strategies for Working with the Private Health Sector According to Private Participation in Health Services, governments can seek to work with the private health sector in four ways (figure 11): -Harness or influence the private sector that already exists -Grow the private sector in a strategic way -Turn over (convert) public services to private operation -Curb unsafe practices Growing and harnessing the private sector are both low risk, incremental strategies which require reallocating resources toward new efforts such as contracting, information dissemination, or tax incentives. Conversion is a riskier strategy since existing service delivery arrangements are interrupted when operations are transferred to private hands. Once the government's objectives are clear, new policies toward the private health sector can be developed. Resources :  Private Participation in Health Services [PDF 15.09 MB]  Private Sector Engagement in Sexual and Reproductive Health and Maternal and Neonatal Health [PDF 502 KB]  Step 3: Implementation Three important activities that promote government collaboration with the private health sector are:  Establishment of a public private partnership unit within the Ministry of Health to oversee all interaction with the private health sector  Creation of a private sector alliance that brings together all private sector stakeholders in health 9  Establishment of a committee for legal and regulatory review to determine which policies are inhibiting the participation of the private health sector in the health system. In this section we view case studies of governments implementing policy reform using these three mechanisms.. Step 3.1 Kenya Case Study An important part of engaging the private health sector is bringing together key stakeholders and gaining consensus on the need to establish a public private partnership in health. Often the foundation for such a partnership is laid during a private health sector assessment. The Private Health Sector Assessment in Kenya, conducted in 2010, concluded with an engagement workshop with representatives from the Ministries of Health and Medical Services, Public Health and Sanitation, Finance, and Planning, as well as representatives of private sector professional and regulatory bodies, health training institutions, faith-based organizations, for-profit health providers, and development partners. The assessment had several features built in to ensure forward movement on policy reform, including:  The Naivasha Declaration on Public Private Partnership, which committed stakeholders to collaborate to improve engagement of the private health sector  Summary of Board/Council Activities to Update Their Respective Health Act  A Draft Private Health Sector Workplan Step 3.2 Guatemala Case Study The United States Agency for International Development (USAID) began working with the private health sector in Guatemala via a private sector assessment in 2007 focused on HIV/AIDS. The assessment found that the private sector plays an important role in HIV/AIDS counseling, testing and treatment, but there were several gaps:  The private sector was not included in dialogue to create HIV/AIDS standards  There was no HIV/AIDS case reporting by the private sector to public sector  The private health sector was not included in donor-sponsored training As an outcome of the assessment process, the Government of Guatemala and stakeholders:  Formed a committee to oversee public-private health activities, the National Public-Private Sector Commission Against HIV (COSSEP-VIH in Spanish)  Drafted a new section on the role of the private health sector in the National HIV/AIDS law  Established training requirements with approved continuing medical education (CME) requirements  Created a referral directory of public and private providers Using these mechanisms the Government of Guatemala has been able to implement necessary reforms to integrate the private health sector into HIV treatment for better health outcomes. Resources:  Assessment to Action Approach [PPT 1.6 MB]  Partnerships in Practice [PPT 640 KB]  Has the Private Sector Been Left Out of the Policy Process in HIV/AIDS? Earning a Seat at the Table in Guatemala [PPT 2.5 MB] 10 Step 3.3 Republic of Congo Case Study In the Republic of Congo, the participatory engagement process began in 2011, and the following milestones have been achieved: -Private Health Sector Assessment of Republic of Congo (English and French) launched in 2012. -Development of a Public Private Dialogue Working Group with representatives from the public and private sectors. View the decree in French. -Development of a Joint Committee on the Supervision of the Legal and Regulatory Review. A "Note de Service" signed by the Minister of Health in 2011 formally established the Joint Committee, composed of representatives of the Ministry of Health and the private sector. View the decree in French. Step 4: Monitoring and Evaluation A sound monitoring and evaluation plan helps the government to track the success of new policies and PPD activities, build credibility and motivate other stakeholders to sustain momentum. In this section we examine how to monitor and evaluate a public private dialogue (PPD), as well as how to monitor government efforts to engage the private health sector. Step 4.1 Monitoring and Evaluation Overview Monitoring and Evaluation (M & E) is a systematic way to learn from past experiences to improve planning and allocating resources, ensure accountability, and demonstrate results. More specifically, monitoring is an ongoing activity that focuses on progress in terms of completing activities and use of funds. Monitoring tracks the use of inputs (activities) and outputs. Evaluation takes place at specific moments, and permits an assessment of a program's progress over a longer period of time. Evaluation tracks changes and focuses more on the outcome and impact level. Evaluation answers the question "what has happened as a result of the intervention?" Resources:  UNAIDS Monitoring and Evaluation Operations Manual [PDF 532 KB]  National AIDS Councils: Monitoring and Evaluation Operations Manual [PDF 950 KB] Step 4.2 Challenges of Public Private Dialogue Monitoring & Evaluation Like any other activity in which time and money are invested, public private dialogues (PPDs) need to be monitored and evaluated. A PPD poses particular challenges for M&E because it is largely process-oriented. Intangible benefits and 'outcomes' of PPD such as improvements in trust and cooperation are not easily quantifiable, but are significant. In the PPD process, ownership ultimately rests with national stakeholders, independent of international donors. Stakeholders may develop their own set of objectives and quantified targets, which may significantly differ from the M&E framework established at program onset. Nonetheless it is crucial to monitor and evaluate your PPD. M&E keeps PPD projects on track, creates the basis for reassessing priorities and creates an evidence base for current and future projects through the systematic collection and analysis of information on the implementation of a project. Resources:  Toolkit on Monitoring Health Systems Strengthening: Service Delivery [PDF 391 KB] 11 Step 4.3 Developing a Plan to Monitor Progress of Public Private Dialogue Setting up and conducting an evaluation for PPD is a three-step process: Step One: Design the M&E project brief with background information about the PPD, and the context under which the M&E exercise takes place. This includes a definition of the basic questions that need to be addressed by the M&E framework, the main indicators and how they can be verified and a description of the approach, methods and tools for the M&E framework. Step Two: Conduct the data-collection. Select instruments to ensure the M&E framework is coherent and reliable by verifying reliability of objective (hard) data and sufficiently cross-checking subjective (soft) data. Step Three: Write the process evaluation and impact assessment showing the organizational effectiveness and process development of the PPD, economic impacts of the PPD, and reform process impacts. Table 4 shows the issues to consider when monitoring progress on public private dialogue (PPD). Learn more about how to monitor and evaluate a PPD. Table 4. Checklist to Monitor Progress Annually Source: SHOPS, 2011 Step 4.4 Public Private Dialogue Monitoring and Evaluation Tools While remaining flexible and user friendly, the public private dialogue (PPD) monitoring and evaluation framework provides stakeholders with the ability to monitor internal processes and encourage transparency and accountability. Free online tools which stakeholders can use to develop a monitoring and evaluation plan include:  The Evaluation Wheel, an Excel-based tool that helps a PPD secretariat or independent evaluator create an evaluation wheel (with a score from 1 to 10) along the 12 key processes that matter to a PPD.  The Reform Process Table, on the same Excel-based tool, measures the impact of the PPD along the reform process in a given country, based on a score from 0 to 3. 12 The PPD Reform Tracking tool, a database tool, based on the software FileMaker Pro 10, that helps a PPD secretariat manage, track and report on the issues raised by working groups. Click on the links to access these tools. Resources:  Policy Framework for the Government-wide Monitoring and Evaluation System [PDF 202 KB]  Measuring the Impact of Health Systems Strengthening [PDF 1.23 MB]  Evaluation Wheel [site web]  Reform Process Table [site web]  PPD Reform Tracking Tool [site web] Step 4.5 Indicators for Measuring Engagement  Table 5. SMART Indicators for Gathering Performance Information Specific: Reflect what the project intends to change and are able to assess performance. M Measurable: Must be precisely defined; provide objective data, independent of who is collecting data; be comparable across projects allowing changes to be compared. A Attainable: Achievable by the project and sensitive to change. Feasible in terms of time and money to collect data using chosen indicators. R Relevant: Relevant to the project in question. T Time Bound: Describes when a certain change is expected. Source: Hertzberg 2010 Indicators measure project performance - the things that engagement projects do, what they produce, the changes they bring about and what happens as a result of these changes. Your indicators should make sense and work in practice. Training manuals and M&E workshops will often use the mnemonic SMART when constructing indicators (table 5). Measuring engagement can follow the five engagement domains presented in this toolkit and in the Healthy Partnerships Report: Policy and dialogue, information exchange, regulation, financing, and public provision of services. Click here to view a list of sample engagement indicators by domain. Step 4.6 Monitoring & Evaluation of Engagement Mechanisms Figure 12. Results Chain for Safe Motherhood Voucher in Uganda Source: Population Level Impact of Vouchers on Access in Uganda 13 Besides measuring the success of a public private dialogue and engagement as a whole, monitoring and evaluation of specific engagement tools such as contracts, vouchers, and other tools which will be explained in Module 3. Figure 13 shows the results chain for a safe motherhood program in Uganda. Resources:  Population Level Impact of Vouchers on Access in Uganda [PDF 995 KB] 14 Module 3: Engagement Tools In this Module, we learn about engagement tools associated with the following engagement domains: policy and dialogue, information exchange, regulation, financing, and public provision of services. Figure 13. The Engagement Continuum Government engagement can be thought of as a trade-off between the level of government intervention and the value received. A complete lack of government engagement results in inadequate policies regulating the private health sector, while too much government engagement leads to over-regulation and government monopolies (figure 13). Step 1: Policy and Dialogue Figure 14. Best Practice in Policy and Dialogue While not a specific policy instrument, policy and dialogue concerns the government's underlying policy framework for and dialogue with the private health sector. It is a key element of good engagement. Given the frequent mistrust and suspicion between the government and private providers in many countries, establishing an underlying policy framework for the private health sector helps frame the relationship as one of collaboration rather than competition. A functioning dialogue mechanism with private providers shows that the government views them as a partner to improve the overall health system performance. While having a private health sector policy is an element of good engagement, implementation is crucial. Figure Source: Healthy Partnerships 2010 14 shows best practice in policy and dialogue. 15 Step 2: Information Exchange Figure 15. Best Practice in Information Exchange Information exchange involves information flows between the public and private sectors. Figure 16 shows elements of best practice in information exchange. A crucial ingredient of engagement is the government having accurate information on the private health sector. This is especially pertinent if the private health sector is providing a large amount of care in a country, as in many African countries. Key elements of information exchange are: -Collection of basic information on all the health service facilities, regardless of whether they are public or private, for appropriate planning and action. -Informing private practitioners and facilities of changing regulations, infectious disease outbreaks, Source: Healthy Partnerships 2010 new treatment protocols, and other information relevant to their operations or delivery of care. Step 2.1 Training and Information Flow to Providers Government-led training has traditionally been provided exclusively to public sector providers, although private providers could also benefit from new medical technologies and protocols. New thinking has emerged championing training of private providers since such a significant percentage of consumers frequent private providers in most countries. Outreach to providers motivates some private practitioners to expand delivery of promotive or preventive care. Such training may take the form of regular programs such as continuing medical education, or may focus on training in a specific technical skill such as a Norplant insertion training in Uganda, shown above. Detailing, which consists of face-to-face interaction and guidance through personal encounters with practitioners, has proven effective in changing physician behavior in treating common childhood illnesses in Kenya and elsewhere. Training is most effective when combined with other modalities, such as information dissemination to consumers, regulation, and incentives. Ressources :  Getting Clinicians to Do Their Best: Ability, Altruism and Incentives [PDF 331 KB]  Can Interventions Improve Health Services from Informal Private Providers in Low and Middle Income Countries? A Comprehensive Review of the Literature [ PDF Abstract]  Kenya: Reaching the Poor Through the Private Sector: A Network Model for Expanding Access to Reproductive Health Services [PDF 625 KB]  Technical Exchange on Engaging the Private Sector to Strengthen Health Systems and Achieve HIV/AIDS Goals [PDF 1.8 MB] 16 Step 2.2 Private Sector Provision of Data to the Public Sector Since the private health sector provides a sizable percentage of care in most countries, collecting key health data is necessary to give policymakers a complete picture of health trends. While most countries require private firms to provide health management information system (HMIS) data, only a small percentage actually do so. For example, in the Democratic Republic of Congo, the private sector supplies 46 percent of health care but the compliance rate for HMIS data is less than 10 percent. (Healthy Partnerships, 2010) Reasons why private sector data is not reaching the government include:  Confusion on the part of the private sector about reporting requirements  Onerous reporting requirements that make compliance difficult  Lack of HMIS data exchange system in place  Financial disincentives such as taxes linked to service utilization rates for private providers. Resolving these issues is the first order of business to improve information flows between the public and private sectors. Ressources :  Building Health Management Information Systems in Egypt [PDF 3.2 MB] Step 2.3 Private Sector Inclusion in Disease Surveillance Program Figure 16. Information Flows in Disease Surveillance Systems Increasingly, governments recognize the importance of private sector participation in national disease surveillance programs, particularly during outbreaks such as avian flu or dengue fever. However, even when they are included, private facilities are typically less involved than public facilities. What is needed is systematic collaboration between the public and private sectors for national disease surveillance, in which the private sector reports routinely to the country's disease surveillance unit (figure 17). Adapted from Framework for implementation of revised IHR 2005 in India Step 2.4 Information Flow to Consumers Patients can be a key (though often overlooked) determinant of treatment choices. Making information available to households and consumers can empower them to demand appropriate care, which in turn improves overall quality of care. For example, counseling consumers on HIV/AIDS treatment options, as shown above. Information dissemination to consumers has been successfully used to expand demand for vaccination, malaria treatment, HIV/AIDS treatment, birth spacing, nutrition supplements, and treatment for specific childhood illnesses. Key ways to reach consumers include: "edutainment" through TV / radio / drama / street theater / songs / music videos with a health theme, community-based action, religious forums, youth clubs, women's groups, and focus groups. 17 It is a critical component of accreditation and social marketing strategies as well as training strategies to influence behavior of private providers. Resources:  Does Publicizing Hospital Performance Stimulate Quality Improvement Efforts? [PDF 133 KB]  The Public Release of Performance Data: What Do We Expect to Gain? A Review of the Evidence [PDF 240 KB]  Consumers and Quality-Driven Health Care: A Call to Action [PDF 107 KB]  Technical Exchange on Engaging the Private Sector to Strengthen Health Systems and Achieve HIV/AIDS Goals [PDF 1.8 MB] Step 3: Regulation Figure 17. Best Practice in Regulation The regulation aspect of engagement focuses on the government's ability to design and implement a regulatory framework for the private health sector. A regulatory framework is considered good if the rules are understandable, if they address the problem they are meant to correct, if they do not contradict other rules, if they establish a clear framework for what happens if they are not followed, and if the severity of punishment for breaking the rules matches the severity of the problem (figure 17). Three core aspect of the government's regulatory function are: -The proper registration and recording of new entrants into the health market. -The existence of a quality regulatory framework for opening a private facility, similar rules for public and private clinics, inspection of a private clinic, and inclusion of informal providers. -Effective enforcement of existing regulation, which requires regular inspections of private facilities. Any potential regulations must be aligned with the country's ability to enforce them. Source: Healthy Partnerships, 2010 Ressources :  Regulation and Quality Improvement: A Review of the Evidence [PDF 95 KB]  Regulation of Health Services. Chapter 4 in Private Participation in Health Services [PDF 26 MB]  A Review of the Regulatory Framework for Private Healthcare Services in Kenya [PDF 188 KB] 18 Step 3.1 Regulation Costs and Benefits Table 6. Costs and Benefits of Regulation Regulation is a powerful policy tool for improving the private sector's contribution to national health goals. Often considered primarily a means of improving quality of care, regulation is also used to reduce disparities in quality or access (geographic or economic) to health care, improve technical efficiency and to reduce waste and corruption. Costs and benefits of regulation are shown in table 6. Regulation and standard setting can include (but is not limited to): -Treatment protocols -Licensing and accrediting providers, pharmacies, and laboratories -Price controls for health services, if necessary -Regulation of pharmaceutical products—essential drug lists and the role of private pharmacies -Regulation of private insurance -Protecting the poor—targeting children for fee waivers -Improving legal and regulatory barriers -Involving not-for-profits and private providers in establishing standards. Source: SHOPS, 2011 Ressources :  Working with the Private Sector for Children's Health [PDF 150 KB]  Regulation and Quality Improvement: A Review of the Evidence [PDF 95 KB]  Beyond Government Health Services: Issues in Oversight and Regulation in Developing Countries [PDF 307 KB]  Finding Middle Ground: Making Better Use of the African Private Health Sector Through More Effective Regulation [PDF 632.27 KB]  Navigating Uncharted Waters: A Guide to the Legal and Regulatory Environment for Family Planning Services in the Private Sector [PDF 1.22 MB] Step 3.2 Accreditation Figure 18. Components of a Successful Accreditation Program Accreditation is a review of compliance, conducted by external peers, using agreed written standards, administered by an independent body, aimed at encouraging organizational building. Accreditation is an important form of health regulation. It measures an organization against the ideal achievable standard of quality. An example of accreditation is requiring drug sellers and pharmacists to seek accreditation to improve the quality of service for health care customers. A successful accreditation program includes: • A well-defined mission and philosophy, • Published performance standards, • A transparent accreditation infrastructure, • Ongoing funding and field operations, and • Rules in place for accreditation decisions. 19 Figure 18 shows components of a successful accreditation program. (Toolkit for Accreditation Programs.) Ressources :  Toolkit for Accreditation Programs [PDF 1.08 MB]  Quality and Accreditation in Health Care Services, A Global Review [PDF 929.3 KB]  Accreditation and Other External Quality Assessment Systems for Healthcare: Review of Experience and Lessons Learned [PDF 225 KB]  Joint Commission International [Website]  Accredited Drug Dispensing Outlets in Tanzania: Strategies for Enhancing Access to Medicines Program Final Report [PDF 1.2 MB]  Council of Health Services Accreditation of South Africa (COHSASA)[Website]  International Organization for Standardization (ISO) [Website] Step 3.3 Self Regulation by Professional Bodies Besides governments, professional bodies, such as medical boards and associations are also very effective at regulating their members. Self-regulation can be viewed as a continuum, with purely private arrangements (with no governmental delegation) at one end and various forms of publicly mandated delegation at the other. Table 9 shows potential advantages and disadvantages of self- regulation by professional bodies. Table 7. Potential Advantages and Disadvantages of Self Regulation To ensure successful regulation by professional bodies, those professional bodies need strong internal leadership and external accountability. Technical capability, motivation, and incentives to staff are also critical, along with continued political support at the local, regional, and national level. Source: Baldwin and Cave, 1999 Step 3.4 Private Health Sector Registry An accurate private provider registry is a fundamental element of good engagement. Yet most governments are not aware of the scale of private provision of health services or may update their registries infrequently. Many countries have a large informal sector, where providers are not registered and largely out of sight of the government. Encouraging unregistered private providers to come forward, register, and engage with the government is an important part of stewarding the entire health sector. Thus health facility surveys must include both public and private providers. View the health registration form (in French) used in Rwanda for all public and private sector health facilities. 20 Step 3.5 Standardized Rules for Private Facilities Governments frequently have standardized regulations for opening a private health clinic and for monitoring or inspecting private facilities. However, the quality of regulations may be low, outdated, inconsistent and full of gaps. Often the private health sector is held to a higher inspection standard than the public sector. Given the importance of traditional medicine in many countries, it is critical to include this group in government regulations and encourage self-regulating bodies for traditional medicine practitioners.  Standards for opening private facilities  Sample checklist for inspecting private clinics  Policies for traditional medicine practices Ressources :  Regulations Governing Private Hospitals and Unattached Operating Theatre Units [PDF 145 KB]  Private Hospital Guidelines for the Construction, Establishment and Maintenance of Private Hospital and Day Procedure Facilities [PDF 980 KB]  National Policy on Traditional Medicine and Regulation of Herbal Medicines: Report of WHO Global Survey [PDF 1.25 MB]  Checklist for Joint Inspection by Regulatory Bodies in the Ministry of Health [PDF 205 KB] Step 3.6 Continuing Medical Education While continuing medical education (CME) requirements for licensed health professionals are much in vogue, many countries do not require medical licenses to get renewed at all. There is a clear need for reform of requirements for medical licenses in some countries. Even in countries where a CME requirement exists, actual levels of participation can be low. Resources:  World Health Organization's Regional Guidelines for Continuing Medical Education/Continuing Professional Development [PDF 718 KB]  Quality Assurance in Medical Regulation in an International Context [PDF 2.09 MB]  Regulating the Regulators [PDF 165 KB] Step 4: Financing Figure 19. Best Practice in Financing Engaging the private sector through financing refers to actual or potential revenue available to the private health sector and the government's influence of these funds through different mechanisms. Strategic government financing of private providers can create mutually beneficial arrangements that improve the efficiency of available public funds while taking advantage of capacities in the private health sector. Strategic purchasing allows governments to use limited resources on the most needed services, without regard for who is providing those services--public or private. Financing focuses on financial incentives for capital Source: Healthy Partnerships 2010 investments or operating costs (for example, tax exemptions), risk pooling, and making the private health Source: Healthy Partnerships, 2010 sector accessible to enrollees. Figure 19 shows elements 21 of best practice in government financing. Ressources :  Contracting Toolkit [Website]  Contracting for Reproductive Health Care: A Guide [PDF 829.72 KB]  Public Purchaser-Private Provider Contracting for Health Services [PDF 114.98 KB]  Buying Results? Contracting for Health Service Delivery in Developing Countries [PDF 75.26 KB] Step 4.1 Contracting Figure 20. The Seven Steps of Contracting In contracting, a financing entity procures a defined set of health services from a private provider. Contracting is a way for governments to harness private sector resources to help achieve national health objectives. Contracting has been successfully used for primary health care, public health outreach efforts, HIV/AIDS prevention services, and hospital management to: -Mobilize private capital investments; -Limit commitment to long-term recurrent costs; -Promote access, equity, or improved quality; -Influence the supply of health services such as the availability of medicines or the demand for health services; and -Help achieve broader social and economic objectives such as increasing employment opportunities in rural communities to halt migration. The success of contracting initiatives is contingent on the broader enabling environment as well as on government actions directly related to the program. Source: The Contracting Toolkit, 2008 Figure 20 shows the seven steps of contracting from the Contracting Toolkit. Resources:  Contracting Toolkit [Website]  Contracting for Reproductive Health Care: A Guide [PDF 829.72 KB]  Public Purchaser-Private Provider Contracting for Health Services [PDF 114.98 KB]  Buying Results? Contracting for Health Service Delivery in Developing Countries [PDF 75.26 KB] Step 4.2 Social Franchising In 2003, there were social franchises in 10 countries (blue), and in 2011, franchises were in 16 countries (blue and red) (figure 21). 22 Figure 21. Geographic Evolution of Franchises In social franchising, a franchisee receives a turnkey health system that includes training, purchasing advantages and brand marketing in exchange for member dues, adherence to franchise procedures, and monitoring requirements. Consumers benefit through improved quality and reliability of service. A social franchise has four primary goals: -Access: Increase the number of service delivery points (providers) and health care services offered -Cost-effectiveness: Provide a service at an equal or lower cost to other service delivery options, inclusive of all subsidy or system costs -Quality: Provide services that adhere to quality standards and improve the preexisting level of quality -Equity: Serve all population groups, emphasizing those most in need. Resources:  Clinical Social Franchising: An Annual Compendium of Programs, 2011 [PDF 5.35 MB]  Franchising in Health: Emerging Models, Experiences, and Challenges in Primary Care [PDF 53 KB] Step 4.3 Social Marketing Social marketing is the planning and implementation of programs designed to bring about social change using concepts from commercial marketing. Like commercial marketing, social marketing involves:  Consumer orientation  Market analysis/segmentation  Tailor made strategies  Long term planning Unlike commercial marketing, social marketing involves:  A more challenging target group  Changing deep-rooted beliefs and behaviors  Often limited resources, with benefits that are not always easy to personalize or quantify  Unclear bottom line Social marketing has been successfully applied to:  Oral Rehydration Therapy  Insecticide Treated Bed Nets  Contraceptives (condoms and pills)  Iodized Salt  Treatment for Sexually transmitted infections Resources:  Social Marketing Resources [Website]  Using Behavior Change Communications To Overcome Social Marketing Sales Plateaus: Case Studies of Nigeria and India [PDF 1.18 MB]  When Donor Support Ends: The Fate of Social Marketing Products and the Markets They Help Create [PDF 383.07 KB]  Social Marketing Models for Product-Based Reproductive Health Programs: A Comparative Analysis [PDF 755 KB] 23 Step 4.4 Vouchers The idea behind vouchers in health is that subsidizing demand among the poor for specific health services by a competitive market will be more beneficial than using those same resources to subsidize supply. Benefits of vouchers include: Allows targeting of beneficiaries Encourages use of under-consumed services Can be easy to administer Reduces provider-induced demand. Scenarios in which vouchers might make sense include:  For targeting subsidies more accurately  For stimulating demand for under-consumed services  For reducing provider-induced demand  For providing service packages of fixed or predictable cost  For increasing client satisfaction  For providing services to marginalized population groups. Competitive voucher schemes are an extremely flexible tool, but their success is tied to the validity of the underlying analysis of the problems they are intended to address. Learn more about the voucher process in A Guide to Competitive Vouchers in Health Resources:  A Guide to Competitive Vouchers in Health [PDF 610.81 KB]  Primer for Policymakers - Vouchers for Health: A Focus on Reproductive Health and Family Planning Services [PDF 383.13 KB]  The Reproductive Health Voucher Project [site web]  Use and Misuse of a discount Voucher scheme as a Subsidy for Insecticide-Treated Nets for Malaria Control in Southern Tanzania [PDF 145.49 KB] Step 4.5 Incentives for Providers Governments have a range of financial incentives available to private providers, including duty exemptions, value added tax (VAT) exemptions, and general corporate tax exemptions. Some countries offer all these incentives to private providers while others offer none. In Lesotho, private providers interviewed for the Healthy Partnerships Report (2010) indicated that the administrative burden for taking advantage of these incentives is so high that most private providers prefer not to deal with them. Several countries, particularly in Africa, offer free land and reduced property taxes to private facilities willing to locate outside of major cities. In this way rural populations are better served. Some countries, such as Madagascar, offer private providers tax reductions if they agree to treat a certain number of indigent patients, thus increasing access for populations who could not otherwise afford health services. 24 Resources:  Reforming Health Care: Financial Incentives for Health Care Providers and Consumers [PDF 410 KB]  Changing Health Care Provider Incentives to Promote Prevention: The Chilean Case [PDF 208 KB]  Performance Incentives for Global Health: Potential and Pitfalls [site web] Step 4.6 Insurance Table 8. Models of Risk Pooling The introduction and expansion of health insurance, when successful, can be a game changer in many countries, leading to improved access and equity. This is especially true when the program includes premium subsidies to allow the poor to be part of the program. Private sector participation in public insurance programs is dependent on being able to bill public insurers and receiving timely reimbursement. Table 8 shows models of risk pooling by key characteristic with country examples. (Adapted from The Business of Health in Africa, 2007) Resources:  Health Insurance Handbook [PDF 3.75 MB]  Development and Implementation of Prepayment Schemes in Rwanda [PDF 222 KB] Step 5: Public Provision of Services Table 9. Best Practice in Public Provision of Services By public provision of services, governments use direct production of health care inputs and health services to collaborate with the private health sector. Through strategic allocation of resources, governments can use public production to complement, crowd out, or build a supporting environment for private health care markets.Examples of public provision of services include private sector participation in government or government sanctioned vaccine programs and referral systems for transferring patients from the private to the public sector and vice-versa. Figure 23 shows elements of best practice in public provision of services. Source: Healthy Partnerships, 2011 25 Resources:  Mobilizing the Commercial Sector for Public Health Objectives [PDF 5.95 MB] Step 5.1 Distribution of Public Goods Many countries engage the private health sector through participation in government disease and immunization programs. Donors programs such as the Global Fund are a big driver of such collaboration. Public private collaboration on disease-specific programs such as HIV and tuberculosis can be a catalyst for further engagement. Case Study The Global Fund's Affordable Medicine Facility for malaria (AMFm) is an example of supranational financing to subsidize vital technologies. Recognizing that most people in poor countries are treated for malaria in the private sector, in 2005 the Institute of Medicine (IOM) recommended a global subsidy for coformulated artemisinin-based combination therapy (ACTs) for the entire global market to bring prices down to US$0.20 to US$0.50 per course of treatment. In May 2010, the first purchase orders for ACTs subsidized under AMFm began. Retail prices for ACTs have dropped dramatically in some markets. For example, in Ghana and Kenya, ACTs retail prices dropped from US$9.00 and US$6.00 to US$0.70 and US$0.60 respectively. (Adapted from Healthy Partnerships Report, 2010) Ressources :  Mobilizing the Commercial Sector for Public Health Objectives [PDF 5.95 MB]  Improving Access to Essential Medicines Through Public-Private Partnerships [PDF 1.2 MB] Step 5.2 Functioning Referral System Figure 22. Referral System Flows An efficient referral process between the public and private sectors can be an essential area of collaboration. The most common type of referral is moving a patient from a small private facility to a larger public one to receive more advanced treatment. In countries with private providers able to offer highly advanced treatment, the referral flow may go from public to private facility. Referrals can be an alternative to sending public sector patients abroad for treatment. Figure 22 shows referral system flows. (Referral Systems: A Summary of Key Process to Guide Health Services Managers) 26 Ressources :  Referral Systems: A Summary of Key Processes to Guide Health Services Managers [PDF 199 KB]  Referral Systems Guidelines [Website]  Country Experiences [Website]  Referral Websites [Website] Step 5.3 Public Private Partnerships Figure 23. Key Types of Public Private Partnerships Source: Health PPPs-Different Solutions for Different Needs The term public private partnership (PPP) covers a variety of ventures involving a diversity of arrangements, varying with regard to participants, legal status, governance, management, contributions and operational roles. (WHO) There is common agreement in most PPP literature that PPPs involve cooperation between organizations, sharing risks for activities that result in new and better products or services that no single organization in either the public or the private could produce alone. Figure 23 above shows different PPPs options that governments can select according to their needs. Ressources :  Health PPP Website  Guidelines for Successful Public Private Partnerships [PDF 860 KB]  The Many Definitions of Public Private Partnerships in the Health Sector [PPT 93KB]  Health PPPs: Different Solutions for Different Needs [PPT 254kb]  Supporting the Development of PPPs in Health: The Health in Africa Initiative [PPT 28 KB]  Hospital PPPs, State of Mexico: IFC Transaction Experience [PPT 2 KB]  PPP Solutions for Healthcare in India [PPT 1.7 MB]  Subúrbio Hospital PPP: First Health PPP in Brazil [PPT 3.2 MB] 27 Module 4: Glossary This module contains the glossary of terms for engaging with the Formulation (drug): The act of developing or preparing a drug, private health sector.1 or the final product itself. For-profit: A for-profit health care company can earn a profit, Accreditation: The process by which an organization recognizes a provider, a program of study, or an institution as which is defined as revenues in excess of expenses. A for-profit health care organization has wide discretion on how to spend its meeting predetermined standards. profit. This distinguishes it from a not-for-profit corporation, which can only spend profits on the purpose for which it was Ancillary services: Supplemental services, including laboratory, radiology, physical therapy, and inhalation therapy formed. that are provided in conjunction with medical or hospital care. Franchise: A franchise is a commercial mechanism for Bilateral aid: Development assistance provided by one party or replicating a successful business strategy. Key components country directly to another. generally include a common business format, a branded identity, and quality assurance system. Capacity development: A locally driven process of transformative learning by leaders, coalitions and other agents Generic drug: A drug which is exactly the same as a brand- name drug; generic drugs can only be manufactured and of change that leads to actions to catalyze changes in institutional factors (enabling environment, stakeholder marketed after the brand-name drug’s patent has expired. ownership, policy instrument, and organizational related factors) to advance development goals. Health care: Care, services, and supplies related to the health of an individual. Health care includes preventive, diagnostic, Chronic care: Long-term care of individuals with long-standing, therapeutic, rehabilitative, maintenance, or palliative care, and persistent diseases or conditions. This includes care specific to counseling, among other services. Health care also includes the the problem as well as other measures that are undertaken to sale and dispensing of prescription drugs or devices. encourage self-care, promote health, and prevent loss of HIV/AIDS: Human immunodeficiency virus/acquired immune function. deficiency syndrome. Commercial sector: The commercial sector is a subset of the private health sector and is synonymous with for-profit entities. Informal health care provider: A subset of private sector The commercial sector is used to distinguish for-profit from not- providers. Typically includes traditional health practitioners and for-profit entities. unregistered vendors supplying traditional and modern drugs outside a registered health facility or pharmacy. Contracting: A process whereby the government or a government agency contracts with a private provider for delivery Inpatient care: Care given to a patient who is admitted to a hospital or other medical institution for at least one overnight of health services. Providers’ interest in maintaining revenue flows associated with contracts, give the contractor the ability to stay; distinct from care given when visiting such institutions as an outpatient. influence the behavior of the providers. Multilateral aid: Aid involving more than two nations or parties, Demand-side financing: In this type of financing, government or donor money goes directly to consumers in the form of a usually in the form of donations delivered through a multilateral subsidy; consumers use this subsidy to buy services and organization such as the United Nations, World Bank, or Asian products. Demand-side financing may be in the form of cash Development Bank. transfers or conditional cash transfers, or vouchers. Nonprofit: An organization whose primary objective is to Diagnostics: The art or practice of medical diagnosis. Also support an issue or matter of private interest or public concern for non-commercial purposes, without concern for monetary refers to instruments or techniques used in medical diagnosis. profit. FBO: Faith Based Organization. Nongovernmental organization (NGO): An NGO is an FDI: Foreign Direct Investment. organization or institution that is entirely or largely independent of the government. Although an NGO can technically be a for- profit organization, the term is generally used to describe an organization whose primary goal is social and supports a public good. 1Unless otherwise noted, definitions found here are from The Business of Health in Africa. NHA: National Health Accounts. 28 established professional standards and consume value OTC: Over-the-counter, which refers to health care products judgments. available without a prescription. Regulation: Health regulation is the range of factors exterior to Out-of-pocket payment: A fee paid by the consumer of health the practice or administration of medical care that influences services directly to the provider. behavior in delivering health care. Outpatient care: Treatment or diagnosis provided in hospitals or clinics that does not require an overnight stay. Secondary care: Services provided by medical specialists. Primary care: Basic or general health care provided outside of SME: Small and medium-sized enterprises. a hospital environment, usually by general practitioners. Social Enterprise: A self-sustaining enterprise with a minimum Private sector: Using the World Bank definition, the private (i.e., lower than commercial) expectation of financial return; the sector includes all actors outside government, such as for-profit, financial management of such an enterprise typically entails nonprofit, formal and non-formal entities. This broad definition reinvestment of profits in enterprise activities. includes service providers, pharmacies and pharmaceutical companies, producers and suppliers, shopkeepers, and Social franchise: A network of private health providers with traditional healers. outlets that are operator-owned. A social franchise has 4 primary goals: increased access to health care services, cost- Provider: This term usually refers to a health care institution effectiveness, improved quality, and equity. (usually a hospital) or doctor who “provides” care. A health plan, managed care company, or insurance carrier is not a health Social marketing: Social marketing is the use of commercial care provider. Those entities are called payers. marketing techniques to achieve a social objective. In the health arena, social marketing programs in the developing world Public health: The aspect of medical activity directed towards traditionally have focused on increasing the availability and use improving the health of the whole community. of health products, such as contraceptives or insecticide-treated nets. Public private dialogue initiatives: Structured partnerships that bring together the Government and the private sector for the Stewardship: The state's role in taking responsibility for the purpose of engaging in constructive dialogue aimed at health and well-being of the population, and guiding the health identifying, prioritizing and resolving key constraints to private system as a whole. sector development. USAID: The United States Agency for International Public/private partnership (PPP): For this Toolkit, the term Development. PPP is used only as a reference to specific health transactions, such as a public-private joint venture for an individual hospital. Utilization: The use of services and supplies. Utilization is Public sector: In the context of this Toolkit, the delivery of health- commonly discussed in terms of patterns or rates of use of a related goods and services by and for the government, whether single service or type of service, such as hospital admissions, national, regional or local/municipal. physician visits, and prescription drugs. Quality: According to the Institute of Medicine (IOM), the degree Voucher: A token that can be used in exchange for a restricted to which health services for individuals and populations increase range of goods or services, either partially (e.g. as a discount) or the likelihood of desired health outcomes and are consistent in total. with current professional knowledge. Quality can be defined as a measure of the degree to which delivered health services meet 29 Module 5: Resource Links by Topic This module has links to key policy reform tools by topic and by  The Reproductive Health Voucher Project [Website] order in the toolkit.  Use and Misuse of a discount Voucher scheme as a Subsidy for Insecticide-Treated Nets for Malaria Engagement Tools from Module 3: Control in Southern Tanzania [PDF 145.49 KB] Step 1: Financing Resources Step 2: Information Exchange Resources Contracting Training and Information Flow to Providers  Contracting Toolkit [Website]  Getting Clinicians to Do Their Best: Ability, Altruism  Contracting for Reproductive Health Care: A Guide and Incentives [PDF 331 KB] [PDF 829.72 KB]  Technical Exchange on Engaging the Private Sector to  Public Purchaser-Private Provider Contracting for Strengthen Health Systems and Achieve HIV/AIDS Health Services [PDF 114.98 KB] Goals [PDF 1.8 MB]  Buying Results? Contracting for Health Service  Can Interventions Improve Health Services from Delivery in Developing Countries [PDF 75.26 KB] Informal Private Providers in Low and Middle Income Countries? A Comprehensive Review of the Literature Health Insurance [Abstract]  Health Insurance Handbook [PDF 3.75 MB]  Kenya: Reaching the Poor Through the Private Sector:  Development and Implementation of Prepayment A Network Model for Expanding Access to Schemes in Rwanda [PDF 222 KB] Reproductive Health Services [PDF 625 KB] Incentives for Providers Private Sector Provision of Data to Public Sector  Reforming Health Care: Financial Incentives for Health  Building Health Management Information Systems in Care Providers and Consumers [PDF 410 KB] Egypt  Changing Health Care Provider Incentives to Promote Private Sector Inclusion in Country's Disease Surveillance Prevention: The Chilean Case [PDF 208 KB] Program  Performance Incentives for Global Health: Potential  Technical Guidelines for Integrated Disease and Pitfalls [Website] Surveillance and Response in the Africa Region Social Franchising  Enhanced Disease Surveillance Through Private Health Care Sector Cooperation in Karachi, Pakistan:  Clinical Social Franchising: An Annual Compendium of Experience from a Vaccine Trial [PDF 1.8 MB] Programs, 2011 [PDF 5.35 MB]  Report of the Technical Consultancy for Laboratory  Franchising in Health: Emerging Models, Experiences, Networks to Support Integrated Disease Surveillance and Challenges in Primary Care [PDF 53.43] and Response in the Africa Region [PDF 6.5 MB] Social Marketing Information Flow to Consumers  Using Behavior Change Communications To  Does Publicizing Hospital Performance Stimulate Overcome Social Marketing Sales Plateaus: Case Quality Improvement Efforts? [PDF 133 KB] Studies of Nigeria and India [PDF 1.18 MB]  The Public Release of Performance Data: What Do  When Donor Support Ends: The Fate of Social We Expect to Gain? A Review of the Evidence [PDF Marketing Products and the Markets They Help Create 240 KB] [PDF 383.07 KB]  Consumers and Quality-Driven Health Care: A Call to  Social Marketing Models for Product-Based Action [PDF 107 KB] Reproductive Health Programs: A Comparative Analysis [PDF 755 KB]  Technical Exchange on Engaging the Private Sector to Strengthen Health Systems and Achieve HIV/AIDS Vouchers Goals [PDF 1.8 MB]  A Guide to Competitive Vouchers in Health [PDF Step 3: Policy Cycle Resources 610.81 KB]  Primer for Policymakers - Vouchers for Health: A Policy Cycle Focus on Reproductive Health and Family Planning  Health Systems and the Cycle of Health System Services [PDF 383.13 KB] Reform [PPT 269 KB] 30  Evaluation and the Policy Cycle [PPT 365 KB]  What is a Health System? Health System Components / Control Knobs [Website] Assessment  Considerations When Designing a Public-  Review of World Bank's Experiences with Country- Private Dialogue Action Plan [PDF 1.27 KB] Level Health Systems Analysis [PDF 6.24 MB]  Performance Measurement for Health System Policy (Re) Design Improvements - (Part I Principles of Performance  The PPD Handbook [website] Measurement) [PDF 2 MB]  Private Participation in Health Services [PDF 15.09  European Observatory on Health Systems and MB] Policies [Website]  Private Sector Engagement in Sexual and  Health Systems Assessment Approach: A How-to Reproductive Health and Maternal and Neonatal Manual [PDF 1.23 MB] Health [PDF 502 KB]  Making Pregnancy Safer – Assessment Tool for the Quality of Hospital Care for Mothers and Newborn Implementation Babies [PDF 668 KB]  The Naivasha Declaration on Public Private  Rapid Assessment of Medicines Quality Assurance Partnerships in Health [PDF 112 KB] and Medicines Quality Control [PDF 250 KB]  Assessment to Action Approach [PPT 1.6 MB]  Private-Sector Assessment Tool: A Handbook for  Partnerships in Practice [PPT 640 KB] Assessing the Potential for Youth Reproductive Health  Has the Private Sector Been Left Out of the Policy and HIV/AIDS Program Interventions in the Private Process in HIV/AIDS? Earning a Seat at the Table in Sector [PDF 3.75 KB] Guatemala [PPT 2.5 MB]  Bangladesh Private Health Sector Assessment [PDF  Decree on Development of Public Private Working 720 MG] Group in Republic of Congo (French) [PDF 1.26 MB]  China Private Health Sector Assessment [PDF 508  Decree on Development of a Joint Committee on the KB] Supervision of the Legal and Regulatory Review  Ghana Private Health Sector Assessment [issuu] (French) [PDF 1.81 KB]  Indonesia Private Health Sector Assessment [PDF 500  Taking the Pulse of Policy: The Policy Implementation KB] Assessment Tool [PDF 681 KB]  Kenya Private Health Sector Assessment [issuu]  Malawi Private Health Sector Assessment [PDF Monitoring & Evaluation 512 KB]  UNAIDS Monitoring and Evaluation Operations Manual  Mali Private Health Sector Assessment (English, [PDF 950 KB] French) [issuu]  Toolkit on Monitoring Health Systems Strengthening:  Morocco Private Health Sector Assessment [PDF 183 Service Delivery [PDF 391 KB] KB]  South Africa: Policy Framework for the Government-  Namibia Private Health Sector Assessment [PDF 1.3 wide Monitoring and Evaluation [PDF 202 KB] MB]  Measuring the Impact of Health Systems  Nigeria Private Health Sector Assessment [PDF 426 Strengthening [PDF 1.23 MB] KB]  Evaluation Wheel [website]  Paraguay Private Health Sector Assessment PDF 1.41  Reform Process Table [website] KB]  PPD Reform Tracking Tool [website]  Senegal Private Health Sector Assessment [PDF  List of Sample Engagement Indicator [PDF 125 KB] 394.KB]  International Initiative on Impact Evaluation [website]  Tanzania Private Health Sector Assessment PDF 2.9  Uganda Safe Motherhood Voucher Impact Evaluation MB] [PPT 92KB]  Uganda Private Health Sector Assessment (HIV) [website] Step 4: Private Health Sector Resources  Ukraine Private Health Sector Assessment [PDF 368 KB] Private Health Sector Matters  Health Systems Assessment Approach: A How-to  Healthy Partnerships: How Governments Can Engage Manual [PDF 1.23 MB] the Private Sector to Improve Health in Africa [Report  Making Pregnancy Safer – Assessment Tool for the website] Quality of Hospital Care for Mothers and Newborn  Private Sector Participation and Health System Babies [PDF 668 KB] Performance in Sub-Saharan Africa [899 KB]  Rapid Assessment of Medicines Quality Assurance  Private Healthcare in Developing Countries [Website] and Medicines Quality Control [PDF 250 KB]  Working with the Non-State Sector to Achieve Public  Private-Sector Assessment Tool: A Handbook for Health Goals [PDF 2.7 KB] Assessing the Potential for Youth Reproductive Health  Health Governance: Concepts, Experience, and and HIV/AIDS Program Interventions in the Private Programming Options [PDF 6.77 KB] Sector [PDF 3.75 KB] 31  Report Of The Regional Workshop On Building Public-  Referral Systems: A Summary of Key Processes to Private Linkages To Advance Priority Health Services Guide Health Service Managers [125 KB] In Africa [PDF 1.25 MB]  The Role of the Private Sector in Health: A Landscape Public Private Partnerships Analysis of Global Players' Attitudes toward the Private  Health PPP website Sector in Health Systems and Policy Levers That  Guidelines for Successful Public Private Partnerships Influence These Attitudes [PDF 464 KB] [PDF 800 KB]  Trends and Opportunities in Public-Private  The Many Definitions of Public Private Partnerships in Partnerships to Improve Health Service Delivery in the Health Sector [PPT 93KB] Africa [PDF .5 MB]  Health PPPs: Different Solutions for Different Needs  Private Sector Engagement in Sexual and [PPT 254 KB] Reproductive Health and Maternal and Neonatal  Supporting the Development of PPPs Health [PDF 502 KB] in Health: The Health in Africa Initiative [PPT 28 KB] Stewardship and Engagement  Hospital PPPs, State of Mexico: IFC Transaction Experience [PPT 2 KB]  Engaging All Health Care Providers in TB Control: Guidance on Implementing Public-  PPP Solutions for Healthcare in India [PPT 1.7 MB] Private Mix Approaches [PDF 3.8 MB]  Subúrbio Hospital PPP: First Health PPP in Brazil  Private Sector Involvement in HIV Service Provision [PPT 3.2 MB] [website]  Public-Private Partnership Reference Guide, Version  Public Stewardship of Private Providers in Mixed 1.0 [PDF 5.7 KB] Health Systems [PDF 2.56 MB]  Trends and Opportunities in Public-private  Engagement with the Private Health Sector [PDF 333 Partnerships to Improve Health Service Delivery in KB] Africa [PDF .5 MB]  The Role of the Private Sector in Health: A Landscape  A Zebra or a Painted Horse? Are Hospital PPPs Analysis of Global Players' Attitudes toward the Private Infrastructure Partnerships with Stripes or a Separate Sector in Health Systems and Policy Levers That Species? [PDF 293 KB] Influence These Attitudes [PDF 464 KB]  Designing PPPs in Health [PDF 1.5 MB]  Report Of The Regional Workshop On Building Public-  Public-Private Partnerships And Public Hospital Private Linkages To Advance Priority Health Services Performance In São Paulo, Brazil [website] in Africa [PDF 1.25 MB]  World Health Organization Resources on Working with the Private Sector [website] Faith-Based Organizations  Her Majesty's Treasury: Public Private Partnerships  Faith-Based Organizations: How Can Governments [website] Work with FBOs to Strengthen the Health Force? [PDF  The Private Sector within a Public Health System: The 393 KB] German Example [PDF 1.4 MB]  Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa [View on Step 6: Financing Resources issuu]  Africa Christian Health Associations Platform [Website] Regulation  Regulation and Quality Improvement: A Review of the Partnership and Dialogue with the Private Health Sector Evidence [PDF 95 KB]  Public-Private Partnerships Reference Guide, Version  Regulation of Health Services. Chapter 4 in Private 1.0 Participation in Health Services [PDF 26 MB]  World Bank Public Private Dialogue [website]  A Review of the Regulatory Framework for Private  Supporting the Development of PPPs in Health-The Healthcare Services in Kenya [PDF 188 KB] Health in Africa Initiative [PDF 708 KB]  Regulation and Quality Improvement: A Review of the  Trends and Opportunities in Public-private Evidence [PDF 95 KB] Partnerships to Improve Health Service Delivery in  Beyond Government Health Services: Issues in Africa [PDF .5 MB] Oversight and Regulation in Developing Countries  IFC PPP in India [PPT 1.68 MB] [PDF 307 KB]  Finding Middle Ground: Making Better Use of the Step 5: Public Provision of Services Resources African Private Health Sector Through More Effective Regulation [PDF 632.27 KB] Distribution of Public Goods  Navigating Uncharted Waters: A Guide to the Legal  Mobilizing the Commercial Sector for Public Health and Regulatory Environment for Family Planning Objectives [PDF 5.95 MB] Services in the Private Sector [PDF 1.22 MB]  Improving Access to Essential Medicines Through Public-Private Partnerships [PDF 805 KB] Accreditation Functioning Referral System  Toolkit for Accreditation Programs [PDF 1.08 MB] 32  Quality and Accreditation in Health Care Services, A  Corporate Council on Africa Guides and Toolkits Global Review [PDF 929.3 KB] [website]  Accreditation and Other External Quality Assessment Systems for Healthcare: Review of Experience and Child Survival Lessons Learned [PDF 225 KB]  Kenya: Reaching the Poor Through the Private Sector:  Joint Commission International [Website] A Network Model for Expanding Access to  Accredited Drug Dispensing Outlets in Tanzania: Reproductive Health Services [PDF 625 KB] Strategies for Enhancing Access to Medicines Program Final Report [PDF 1.2 MB]  Council of Health Services Accreditation of South Africa (COHSASA)[Website]  International Organization for Standardization (ISO) [Website] Standardized Rules for Private Facilities  Regulations Governing Private Hospitals and Unattached Operating Theatre Units [PDF 145 KB]  Private Hospital Guidelines for the Construction, Establishment and Maintenance of Private Hospital and Day Procedure Facilities [PDF 980 KB]  National Policy on Traditional Medicine and Regulation of Herbal Medicines: Report of WHO Global Survey [PDF 1.25 MB]  Checklist for Joint Inspection by Regulatory Bodies in the Ministry of Health [PDF 205 KB] Continuing Medical Education  World Health Organization's Regional Guidelines for Continuing Medical Education/Continuing Professional Development [PDF 718 KB]  Quality Assurance in Medical Regulation in an International Context [PDF 2.09 MB]  Regulating the Regulators [PDF 165 KB] Sample Templates and Disease-Specific Guides Terms of Reference for Partnerships  Terms of Reference for Partnership Agreements, Bangladesh Urban Primary Health Care Project [PDF 580 KB] Terms of Reference for Private Health Sector Assessment  Ghana [PDF 491 KB]  India [PDF 108 KB]  Kenya [PDF 426 KB]  Mali [PDF 494 KB] Memorandum of Understanding (MOU)  Memorandum of Understanding (MOU) Overview [website]  Example of MOU for Private Accredited Facility in Rajasthan, India [PDF 162 KB] Disease Specific Programs with the Private Health Sector Tuberculosis  Engaging All Health Care Providers in TB Control [website]  Public-Private Mix for TB Care and Control [website] HIV/AIDS  HIV Prevention Knowledge Base [website] 33 Photo credits: Cover: World Bank Group p. 2: World Bank Group p. 10: Technical Exchange on Engaging the Private Sector to Strengthen Health Systems and Achieve HIV/AIDS Goals p. 10: Has the Private Sector Been Left Out of the Policy Process in HIV/AIDS? Earning a Seat at the Table in Guatemala p. 16: Technical Exchange on Engaging the Private Sector to Strengthen Health Systems and Achieve HIV/AIDS Goals p. 17: Technical Exchange on Engaging the Private Sector to Strengthen Health Systems and Achieve HIV/AIDS Goals p. 20: Samwel Ogillo, APHFTA, Private Health Sector, Trusted Partner in the Delivery of Quality Healthcare p. 20: Clinical Social Franchising: An Annual Compendium of Programs, 2011 p. 23: World Bank Development Outreach p. 24: BMZ, Vouchers: Making Motherhood Safer for Kenya’s Poorest women 34