Making health-related markets work better for poor people: Improving provider performance Gerald Bloom Institute of Development Studies, UK Abuja January 2009

Background to this meeting 2004 Workshop on Future Health Systems and 2008 special issue of Social Science and Medicine 2005 launch of Future Health Systems Consortium, scoping studies in China, Bangladesh, India, Uganda and Nigeria and interventions designed 2008 Preparation of report for the Rockefeller Foundation 2008 Meeting in Dhaka with innovators and researchers and launch of programme on making markets work better for the poor Partnerships for Future Health Systems in Nigeria

2004 Workshop on Future Health Systems and 2008 special issue of Social Science and Medicine

2005 launch of Future Health Systems Consortium, scoping studies in China, Bangladesh, India, Uganda and Nigeria and interventions designed

2008 Preparation of report for the Rockefeller Foundation

2008 Meeting in Dhaka with innovators and researchers and launch of programme on making markets work better for the poor

Partnerships for Future Health Systems in Nigeria

Rapid spread of markets for health-related goods and services Out-of-pocket payments account for a large proportion of health expenditure in many countries Emergence of pluralistic health systems with a variety of providers of health-related goods and services in terms of skills and relationship to legal framework Blurring of boundaries between public and private sectors and increased role of market relations within the public sector Increased channels for health related information through education, mass media, information technologies and promotion of drugs

Out-of-pocket payments account for a large proportion of health expenditure in many countries

Emergence of pluralistic health systems with a variety of providers of health-related goods and services in terms of skills and relationship to legal framework

Blurring of boundaries between public and private sectors and increased role of market relations within the public sector

Increased channels for health related information through education, mass media, information technologies and promotion of drugs

Performance of poorly organised health markets Overemphasis on curative services Dangerous practices (sub-standard drugs, iatrogenic illness) Ineffective treatment, unnecessary costs and late referral Segmented system and lack of access by poor

Overemphasis on curative services

Dangerous practices (sub-standard drugs, iatrogenic illness)

Ineffective treatment, unnecessary costs and late referral

Segmented system and lack of access by poor

Understanding market systems (M4P) Relationship between providers and purchasers of goods and services Performance influenced by formal and informal rules and a variety of agencies Local and global markets are linked Interventions need to bridge micro and macro and take into account power and the existence of segmented markets

Relationship between providers and purchasers of goods and services

Performance influenced by formal and informal rules and a variety of agencies

Local and global markets are linked

Interventions need to bridge micro and macro and take into account power and the existence of segmented markets

Health-related markets Information asymmetry and trust-based institutional arrangements Path dependency, increasing returns and the importance of history Emergence of pluralistic health systems and the challenge of creating organised markets A turning point in global health markets

Information asymmetry and trust-based institutional arrangements

Path dependency, increasing returns and the importance of history

Emergence of pluralistic health systems and the challenge of creating organised markets

A turning point in global health markets

The health knowledge economy and the creation of market order Spread of markets faster than creation of appropriate institutional arrangements From low efficiency equilibrium to well-organised markets Organisations: ownership, motives, incentives and reputation Institutions: partners, co-production and the balance between social and individual interests

Spread of markets faster than creation of appropriate institutional arrangements

From low efficiency equilibrium to well-organised markets

Organisations: ownership, motives, incentives and reputation

Institutions: partners, co-production and the balance between social and individual interests

Organisations for better provider performance Informal providers and the creation of market order Building and maintaining reputations (branding, franchises and accreditation) Public providers in health markets

Informal providers and the creation of market order

Building and maintaining reputations (branding, franchises and accreditation)

Public providers in health markets

Co-production of organised markets for health-related goods and services Local and national government Traditional accountability structures Faith-based and philanthropic organisations Trade and professional associations Citizen and community groups International organisations (market, philanthropic and government actors)

Local and national government

Traditional accountability structures

Faith-based and philanthropic organisations

Trade and professional associations

Citizen and community groups

International organisations (market, philanthropic and government actors)

New technologies and institutional development: the case of ICTs Tools for building and maintaining reputations (management systems, performance monitoring) Multiple channels for spread of knowledge and information Proliferation of content providers Regulating the new knowledge economy

Tools for building and maintaining reputations (management systems, performance monitoring)

Multiple channels for spread of knowledge and information

Proliferation of content providers

Regulating the new knowledge economy

Support for innovations: where innovations arise Spread from advanced market economies (investment and training) Adaptation to different contexts New markets, sources of innovation and regulatory challenges (eg drugs) Pro-poor innovation in unorganised markets and bottom-up approaches

Spread from advanced market economies (investment and training)

Adaptation to different contexts

New markets, sources of innovation and regulatory challenges (eg drugs)

Pro-poor innovation in unorganised markets and bottom-up approaches

Support for innovation: entrepreneurship and learning Identify, test and take local innovations to scale Facilitate spread of knowledge, experience and organisations Role of social entrepreneurs ( blurred boundary between social and commercial entrepreneurship) Securing new sources of finance and establishing new service delivery organisations Creating new markets, new organisations and new institutional arrangements

Identify, test and take local innovations to scale

Facilitate spread of knowledge, experience and organisations

Role of social entrepreneurs ( blurred boundary between social and commercial entrepreneurship)

Securing new sources of finance and establishing new service delivery organisations

Creating new markets, new organisations and new institutional arrangements

Building an evidence base: learning approaches to innovation and scaling up New organisations and new understandings of their role Co-production of institutions, rules and ethical norms Risk, unintended consequences, interests and the importance of path dependency Little systematic evidence on alternative strategies for improving provider performance Monitoring studies for design and redesign to adapt to context Evaluation, learning and development of indicators for regulation

New organisations and new understandings of their role

Co-production of institutions, rules and ethical norms

Risk, unintended consequences, interests and the importance of path dependency

Little systematic evidence on alternative strategies for improving provider performance

Monitoring studies for design and redesign to adapt to context

Evaluation, learning and development of indicators for regulation

A time of opportunities and challenges Major political changes and a move beyond ideological understandings of the roles of states and markets New sources of finance for non-government actors (public and donor funds, IFC, social entrepreneurs) Involvement of new private and state actors from China, India and other countries Economic crisis (implications for aid flows, increased competition, growing importance of regulatory issues) New understandings of the need for regulatory partnerships Responding to a window of opportunity

Major political changes and a move beyond ideological understandings of the roles of states and markets

New sources of finance for non-government actors (public and donor funds, IFC, social entrepreneurs)

Involvement of new private and state actors from China, India and other countries

Economic crisis (implications for aid flows, increased competition, growing importance of regulatory issues)

New understandings of the need for regulatory partnerships

Responding to a window of opportunity

WORKSHOP OBJECTIVES Build greater understanding of existing and proposed innovations Explore possibilities for building partnerships for innovation and learning

Build greater understanding of existing and proposed innovations

Explore possibilities for building partnerships for innovation and learning

PLANNED OUTPUTS Improved innovations A multi-disciplinary team to support learning approaches Proposals for collaboration on making health-related markets work better for the poor

Improved innovations

A multi-disciplinary team to support learning approaches

Proposals for collaboration on making health-related markets work better for the poor