NSS 1 Introduction

Working with the Non-State Sector to Achieve Public Health Goals

Consultation on Priorities and Actions 20-21 February 2006, Chateau de Penthes, Pregny-Genève

Alex Ross and Dominic Montagu Our environment

• Ambitious time-limited goals: MDGs, Universal Access, Bilateral programs – Translate into expansion of services – Population based – Coverage (to quality services) – Access -- overcoming barriers: equity, affordability, patient satisfaction, stigma and discrimination, etc • Competitive marketplace – New funding, but limited and for certain things – Politics: winners and losers • Funding drivers – Donor practices • NSS preferences: SWAps, Direct budget support – Global health initiiatives: requirements and opportunities – Performance based funding Our environment

• Multiple providers have been around for a long time – Nothing new, but new combinations – Government subsidies – Increasing recognition of multiple providers – Poor public sector capacity • Some health conditions more popular – The era of diseases of poverty: HIV/AIDS, TB, Malaria – Child health, safe motherhood, reproductive health – The ascension of health systems strengthening?? • Human resources The Non-State Sector as defined for this meeting

“All providers outside of government management”

• Companies – Provision as core business – Provision to employees / community • NGOs and FBOs • Clinics / individual providers • Pharmacies • Informal providers / drug sellers Some Claims about the NSS

Claim: Responses (that don’t work):

• Private sector is ‘out • Large scale regulation of control’ • Not properly trained • Massive training • Money minded only • Given them money • Don’t serve the poor • Ignore or chastise NSS • Private sector success providers is public sector’s loss • Public sector defensive How we got here

• Issues coming more frequently internationally • Montreux Challenge meeting on health systems identified NSS as one of a number of critical topics • Health financing • Management • Non-state sector • Health workforce platform • Health Metrics Network • Essential Medicines • WEF “building healthcare systems in sub-Saharan Africa • Forum on engaging the private sector for child health • National policy development (eg: Nigeria, Ghana, Uganda) PrivateIncidence sector and Careserves of IDD amongall wealth <5 in Africa strata

100% 30%

90%

25% 80%

70% 20%

60%

50% 15%

Where treated 40% Incidence of illness

10% 30%

20% 5%

10%

0% 0% poorest 2nd 3rd 4th richest Wealth Quintile

Source: Prata, Montagu, Jeffries 2005: analysis of DHS data Benin, Burkina, Cameroon, C. Afr. Rep, Chad, Comorrow, Cote d’Ivoire, Ghana, Kenya, Madagascar, Malawi, Mali, Mozambique, Namibia, Niger, Nigeria, Senegal, Tanzania, Togo, Uganda, Zambia, Zimbabwe PrivateIncidence sector and Careserves of IDD amongall wealth <5 in Africa strata

100% 30%

90%

25% 80%

70% 20%

60%

50% 15%

Where treated 40% Incidence of illness

10% 30% Private Facility 20% 5%

10% Public Facility 0% 0% poorest 2nd 3rd 4th richest Wealth Quintile

Uganda Government financing to NGOs

Social Organization and NGO/Non-Profits in China

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

Source: [Chinese] Ministry of Civil Affairs, Cited by [United States] Congressional-Executive Commision on China Private for-profits are increasing (in Asia)

Private ClinicPrivate Clinic Growth Growth in Indonesiain Indonesia '91-99 91-99

5500

5000

4500 Clinics 4000

3500

3000 1991 1992 1993 1994 1995 1996 1997 1998 1999

Change in treatment by hospital ownership in India 85-95 Global attention is increasing

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

15 Incidence 10

1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 Year Innovative strategies are being explored

Delegation Reorganize to Local User Fee Subsidies Performance Social Community Country Contracting Health Health Exemptions to Poor Incentives marketing Engagement Workers Agency

Cambodia 1 1 4 1 1 2 1 3 4 Ethiopia 4 2 3 2 3 4 Ghana 3 3 3 4 2 2 2 2 Indonesia 4 4 2 3 3 Kenya 4 4 3 3 3 Mali 3 3 3 Mozambique 2 1 3 3 Myanmar 3 2 3 3 3 PNG 4 3 Tanzania 1 4 2 3 3 4 Uganda 3 4 4 1 3 3 Vietnam 3 4 4 4 2 3 4 KEY Not applicable - no plan 1 Pilot only at outset 2 Pilot plus plan for full-scale at outset 3 Phased implementation without pilot 4 National scale at outset

Source: Janovsky and Peters Innovations 2005 Change in pvt financing going in both directions Change in private expenditure on health vs. total % of expenditure on health that is private, 1998 - 2002

-10

-20 % change in expenditure that is pvt: 1998-2002 -30

-40

Fiji Niue Chad Chile India Iraqd Egypt Nepal Nauru Spain Belize Israel Malawi Sudan France Eritrea Kuwait Jordan Liberia Gabon Angola Albania Samoa Bhutan Cyprus Guinea Austria Tunisia Finland Mexico Ireland Estonia Monaco LesothoBurundi Zambia Guyana Senegal Rwanda Morocco Portugal Sweden Jamaica Armenia Namibia Ethiopia Andorra Bulgaria Thailand Romania Mongolia MaldivesLebanon Australia Slovakia Comoros Uruguay Bahamas Denmark Germany Dominica Sri Lanka Cambodia Honduras Argentina Swaziland Nicaragua Costa Rica Indonesiac Saint Lucia Seychelles Philippines Switzerland El Salvador Kazakhstan Afghanistan Madagascar South Africa SierraMozambique Leone Cook Islands Côte d'Ivoire Luxembourg

Marshall Islands Equatorial Guinea Brunei Darussalam

Syrian Arab Republic Antigua and BarbudaUnited Arab Emirates

Serbia and Montenegro Central African Republic United States of America

Democratic Republic of Congo

Saint Vincent and the Grenadines Venezuela, Bolivarian Republic of

Democratic People's Republic of Korea …and unrelated to system importance of pvt financing Change in private expenditure on health vs. total % of expenditure on health that is private, 1998 - 2002

40 100

90 30

80 20 70

10 60

0 50

40 -10

30 -20 20 % of health expenditure that is pvt: 2002 % change in expenditure that is pvt: 1998-2002 -30 10

-40 0

Marshall Islands Equatorial Guinea Brunei Darussalam

Syrian Arab Republic Antigua and BarbudaUnited Arab Emirates

Serbia and Montenegro Central African Republic United States of America

Democratic Republic of Congo

Saint Vincent and the Grenadines Venezuela, Bolivarian Republic of

Democratic People's Republic of Korea …and unrelated to system importance of pvt financing Change in private expenditure on health vs. total % of expenditure on health that is private, 1998 - 2002

40 100

Togo 90 30 Guinea Cambodia Iraqd Myanmar Sudan India 80 Azerbaijan Burundi Armenia Côte d'Ivoire Bangladesh 20 Cameroon Nigeria Georgia Nepal Uganda TajikistanYemen Viet Nam Uruguay Lebanon Democratic Republic of Congo Singapore 70 Morocco China Pakistan Indonesiac Dominican Republic Ecuador Egypt Trinidad and Tobago 10 Paraguay Afghanistan Haiti Albania Philippines Malawi Ghana South Africa 60 Chad Angola Central African Republic Cyprus GabonSuriname Benin Kenya Gambia ChileSenegal El Salvador United States of America Mexico Ethiopia Burkina Faso Syrian Arab Republic Brazil Uzbekistan Jordan Libyan Arab Jamahiriya Belize Venezuela, BolivarianTuvalu Republic of Guinea-Bissau Iran, Islamic Republic of Guatemala Bahamas Nicaragua Sri Lanka Bosnia and Herzegovina Tunisia Peru 0 Niger Mali Argentina 50 Lao People's Democratic Republic Kyrgyzstan Honduras Zimbabwe Republic of Korea GreeceDjibouti Zambia Malaysia Kazakhstan Bulgaria United Republic of Tanzania Madagascar Russian Federation Rwanda Jamaica Switzerland RepublicComoros of Moldova Swaziland Sierra Leone Bolivia 40 Botswana Serbia and Montenegro Saint Kitts and Nevis -10 Eritrea Fiji Latvia Timor-Leste Romania Saint Vincent and the Grenadines Netherlands Costa Rica TurkeyIsrael Marshall Islands Barbados Saint Lucia Australia Antigua and Barbuda Liberia Thailand Austria Canada Namibia Hungary Mozambique GrenadaMongolia Portugal Congo Turkmenistan Andorra 30 Malta Belgium Ukraine Spain PanamaDominica Equatorial Guinea Poland Bahrain Lithuania Tonga United Arab Emirates Mauritania Algeria Vanuatu Seychelles Belarus Cape Verde Slovenia Ireland Kuwait -20 Italy Samoa France Finland Guyana Estonia Mauritius Democratic People's Republic of Korea Saudi Arabia New Zealand Qatar Germany Brunei Darussalam % of health expenditure that is pvt: 2002 Monaco San Marino 20 Japane Oman Croatia

% change in expenditure that is pvt: 1998-2002 Colombia Denmark United Kingdom Iceland Norway Lesotho Sweden The former Yugoslav Republic of MacedoniaLuxembourg Cuba Sao Tome and Principe Maldives -30 Micronesia, Federated States of Papua New Guinea Nauru Slovakia Czech Republic Palau 10 Bhutan Cook Islands Solomon Islands

Niue -40 Kiribati 0

Marshall Islands Equatorial Guinea Brunei Darussalam

Syrian Arab Republic Antigua and BarbudaUnited Arab Emirates

Serbia and Montenegro Central African Republic United States of America

Democratic Republic of Congo

Saint Vincent and the Grenadines Venezuela, Bolivarian Republic of

Democratic People's Republic of Korea Interviews with many stakeholders

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

• Focus on Service Delivery – Education, financing, pharmaceutical production etc. put in ‘parking lot’

• Focus on important but neglected or new and relatively uncharted policy and operational challenges Eight issues

1. Scaling up 2. Stewardship & Policy 3. Regulation 4. New NGOs 5. Local Capacity 6. Data 7. Quality 8. Informal Sector Three Clusters

1. Scaling up • New entrants into 2. Stewardship & Policy service delivery 3. Regulation 4. New NGOs • Old challenges, but 5. Local Capacity new approaches 6. Data 7. Quality • Scaling up 8. Informal Sector