The document discusses the private health sector in developing countries. It notes that the private sector is a large and diverse group comprising formal providers like private clinics and hospitals as well as informal providers like traditional healers and drug shops. The private sector delivers a significant portion of healthcare, even for the poor. Ministries of health are increasingly recognizing the importance of partnering with the private sector to improve healthcare access and achieve health goals. Some benefits of public-private partnerships include leveraging private sector resources and expertise, expanding access to underserved groups, and improving efficiency. The document discusses various partnership models like contracting and discusses strategies for improving quality of care in the private sector through regulatory frameworks and certification programs.

1. Dr Rajeev Kashyap

2. Introduction
 In any country, the healthcare system is comprised
of both the public and private sector.
 The private sector is a large and diverse group that is
increasingly being recognized as a significant part of
developing country health systems.

3. Why Involve the Private Sector?
The major challenge for developing countries is how to
improve healthcare for all their people, especially the
poorest citizens.
 The most common approach focuses almost
exclusively on the public health sector:
 Building the capacity of public facilities
 Training and recruiting staff
 Expanding subsidized public services to the poor
 High quality, well-funded public services are essential.

4. High quality, well-funded public
services are essential
 A public sector-only approach fails to harness all the
resources available in the health sector.
 While not seeking to detract from the government's
role in providing healthcare, it is important to dispel
myths and misconceptions, and reasons why
ministries of health should work with the private
health sector to achieve health goals.

5. Private health sector in action
 Visiting the public hospital would cost a whole day in
lost pay to the factory's workforce.
 In Gujarat, India, a private obstetrician /gynaecologist
delivers new baby. She does not have to pay for care
because the state government has created a voucher
program that pays a set fee to private doctors who join
the program and serve poor patients. Is this an
example of the private health sector in action?

6. Who is the Commercial Sector in
Health? Most of the people never goes to the doctor. When he
or his family get malaria, they walk to the local drug
shop, get medicine, and treat their illness at home.
 If they get sicker, they call in a traditional healer. Is
this an example of the private health sector in action?

7. The Health Sector
The private sector in health is also called
the "non-state sector" and is typically
defined as comprising "all providers
who exist outside of the public sector,
whether their aim is philanthropic or
commercial, and whose aim is to treat
illness or prevent disease“.
(WHO, 2005)

8. Private Health Sector
The private health sector is a large and diverse group that
covers a wide range of health sector entities, including:
 Private practitioners, clinics, hospitals, and laboratories
and diagnostic facilities
 Non-profit non-governmental organizations (NGOs) and
faith-based organizations (FBOs)
 Shopkeepers and traditional healers
 Pharmacies and pharmaceutical wholesalers, distributors,
and manufacturers
 Private companies not engaged in health who provide
health care services to their employees and communities

9. Overview of the For-Profit Private Sector

10. Did You Know?
 In any country, the healthcare system comprises public
and private sectors. The public sector, which in many
developing countries is the largest healthcare provider,
includes the Ministry of Health and its network of
healthcare staff and infrastructure.
 Who are the principal private sector players in your
own country? Can you name examples of NGOs, FBOs,
and for-profit providers in your country?

11. Overview of the For-Profit Private
Sector
The for-profit private sector comprises a wide range of
actors, some of which are in the informal health sector.
The two primary health activities in which the private
entities engage are:
 Direct provision of private health services
 Provision of health products through private channels

12. Private Sector Providers
Private healthcare is delivered in both
the formal and informal health sectors.
Even the poor pay for health services in
the private sector
The private sector share of healthcare
markets varies from region to region
and within regions, based on political,
historical, and economic factors.

13. The formal sector
The formal sector includes a wide range of trained and licensed private
healthcare providers such as:
 Private doctors
 Nurses
 Midwives
 Paramedical staff, including clinical officers and
physician assistants
 Private pharmacists and drug sellers also play a critical
role in developing countries, as they are often the first-
line providers in the formal health sector that serve
remote population groups.
 The dynamic private health sector also includes a wide
range of support services such as private laboratories
and other diagnostic services

14. Informal Sector Private Providers
The informal health sector comprises:
Traditional healers
Traditional birth attendants
Market drug sellers
In India, care and treatment of sexually transmitted
infections, including HIV/AIDS, is provided not only
by physicians, but also by registered medical
practitioners and other qualified homeopathic and
traditional healers.

15. Private providersPrivate providers, whether formal or
informal, deliver their services in a
variety of locations:
Single room in the provider's home
State-of-the-art clinic
Privately owned hospital that offers a
broad array of health services
(International Finance Corporation Report,
2007)

16. Private Provision of Health
Products
The pharmaceutical industry boasted global sales of
US$643 billion in 2006. (IMS, 2007)
 The pharmaceutical industry (both internationally and
locally) plays a key role in the manufacture and
distribution of health products.
 In the private sector, product distribution is more
complicated and involves more marketing and detailing
than in the public sector.

17. Pharmaceutical Companies
 International pharmaceutical companies, also known as
research and development (R&D) companies or "Big
Pharma," manufacture many of the healthcare products
used in both the public and private sectors.
 These R&D companies often deal directly with private
healthcare providers, either through their own company
representatives located in-country or through a local
distributor, to satisfy existing demand and to create new
demand.
 There are also a growing and significant number of
pharmaceutical manufacturers in developing countries
that produce generic versions of "R&D" or "priority"
medicines (such as those used for the treatment of
HIV/AIDS and malaria).

18. International standards for generic
medicines
Because of the importance of ensuring
the quality, consistency, and
authenticity of generic and otherwise
new medications, the World Health
Organization (WHO) and other
multilateral organizations have joined
together to create standards for their
manufacturing and distribution.

19. Highlights
China, India, and Brazil are the powerhouses of
local pharmaceutical manufacturers, and supply
many parts of Africa and Asia with generic and
low-priced pharmaceutical products.

20. Retailers in Health Sector
Retailers are an important segment of the private health
sector because they are often the de facto health advisors in
many communities that are difficult to reach.
Retail outlets sell medicine and other health-related products
and include such places as:
 Pharmacies
 Over-the-counter drug shops
 Medicine and chemist shops
 Supermarkets and corner groceries
 Market stalls and kiosks

21. Unregulated Sector presents many
health challenges
 The poor quality of some drug products, whether
distributed in the formal or informal health sector, is
creating health problems such as increased drug
resistance in the treatment of malaria and HIV/AIDS.
 There is also an informal sector for health products,
particularly for drugs. This unregulated sector presents
many health challenges.

22. Private Services to Sell Healthcare
ProductsMany private sector companies support product
distribution and sales of healthcare products through
private channels including:
Advertising agencies
Market research firms
Public relation companies
Communication companies
Health communications campaigns can increase sales of
pharmaceutical products and encourage healthy
behaviours.

23. Why ministries of health work with
the private sector.
 In most countries, people already use the private sector
or pay for government health services. Individuals
paying out-of-pocket for both public and private
health services make up the majority of healthcare
expenditures.
 The percentages of public and private expenditures
vary widely, but consumers in all countries spend a
substantial amount of personal resources in the
private health sector.
(Rosen, 2000).

24. “Despite all the
evidence showing the
significant amount of
money being spent by
populations on
services from the
private sector, most
governments and aid
organizations still
focus quasi-exclusively
on public delivery of
health services”.
(Marek, 2005)

25. A study in Kenya found that
poor family planning clients
receive a variety of benefits by
choosing private sector facilities
over public sector facilities.
Benefits include a much greater
proximity of services and better
quality of interpersonal care.
When the cost of transportation
and wages lost was factored in,
the private sector facilities were
in fact cheaper than those in the
public sector.
(Agha and Keating, 2008)

26. With the right market incentives (
i.e., governments' policies and
actions) the private for-profit health
sector can become sustainable
enterprises that also serve the poor.
As part of the health system, the for-
profit sector can also help
governments achieve priority health
goals.

27. The base of the
economic
pyramid (BOP)
are the 4 billion
people in the
world living on
less than US$2
per day.

28. The Private Sector Can Improve the
Quality of the Health Sector

29. Why individuals choose private
providers rather than public ones.Many consumers perceive that the quality of care they receive at
private sector facilities is high. Key factors driving the
perception of private sector facilities include:
 Cleanliness
 Convenience
 Wait time
 Friendliness
There is much debate about the quality of private sector
services. Many of the patient-perceived benefits do not
necessarily translate into higher standards of care or better
health outcomes.
 Although these concerns about private sector quality of care are
legitimate, publicly provided care also falls short of
acceptable standards.
 Clearly there is room to improve quality in both sectors.

30. The private sector can deliver, often at a lower
cost, priority services and products that are not
available through the ministry of health.
For example, by contracting out to the private
sector, the public sector can extend its reach to
underserved populations at a lower cost.
To deliver key services for distribution of health
products, social marketing and other private
sector partnerships can ensure wider and more
reliable availability to urgently needed health
products.(IFC, 2007).

31. Working with the Private Sector
can Strengthen Resources
 The private health sector employs a large proportion of
medical personnel all over the world.
 The public sector can greatly increase the number of
trained professionals working in the country by simply
including private providers in its training programs.
 Private providers have their own infrastructure and
clientele, where they can apply their new knowledge
and skills.
 The public sector can also create more flexible
regulations, thereby allowing more private providers to
set up practice

32. Strategies to strengthen quality in
the Health Sector
Improving the quality of private health services is
often a priority for governments and donors.
 Creating an effective regulatory framework
 Working through professional associations
 Voluntary certification and quality improvement
programs
 Supportive supervision

33. Dimensions of Quality in Healthcare

34. Quality healthcare has many different dimensions,
including provider technical competence, efficiency,
effectiveness, safety, access to services, physical
infrastructure, and strong communication skills.
A successful quality improvement process should result
in:
Increased provider compliance with evidence-based
protocols and guidelines
Reduced number of medical errors
Improved patient satisfaction
Efficient use of healthcare resources
Improved health status of the population.
(Fischer, 2009)

35. Governments and donors have
legitimate concerns about the
quality of services in the private
health sector, due to:
Diverse and fragmented nature
Weak regulations
Poor enforcement
Informal private providers
Counterfeit unregulated drugs

36. Government in its role as a health
steward can improve quality in the
private health sector and protect
consumers by updating laws and
procedures. This can create a "level
playing field" in which all
healthcare providers (public,
private, NGO) abide by the same
rules and standards of quality.

37. Major legal and Regulatory Areas
Quality that governments can address include:
 Qualifications for medical practice
 Scope of practice for different professions
 Facility licensing
 Provider relicensing
 Continuing education
 Criteria to establish private practices
Regulations are only as effective as the systems that are
available to monitor and enforce them. Strengthening
regulatory agencies and political commitment to
sufficiently fund these institutions are also important
components of quality improvement. (Ravenholt, 2006)

38. Factors that Affect Private
Provider Quality Policy and program interventions can encourage and
inhibit quality in the private sector.
 Governments interested in improving private sector quality
need to leverage factors that motivate, and mitigate those
that inhibit, private providers.
 Countries that have successfully improved quality in the
private health sector have consistently included a wide
range of key health sector actors outside the MOH.
 Involving these multiple stakeholders in policy
considerations provides the MOH a wide range of
perspectives on factors that motivate the private
sector.(Brugha and Zwi 1998)

40. Regulatory Tools
Accreditation,
Certification,
and
Licensure

41. Continuing professional
development
In addition to provider training and skill
development, innovative approaches to change
provider behaviour include:
 Job aids (e.g. worksheets, checklists, decision tables)
 On-the-job training
 Modularized training
 Distance learning
 Web-based approaches

42. Studies in India show that training private
medical practitioners can address some of these
quality barriers by improving private providers‘
technical knowledge
and
perception

43. An Effective Strategy to Improve
Quality of Care
Clinical guidelines, based on WHO, International
Planned Parenthood Federation, and US Centers for
Disease Control and Prevention (CDC) standards
and revised by a committee of leading physicians from
different sectors
 Training of private physicians
 Ongoing development of an assessment tool (Quality
Improvement Package)
 Orientation for physicians on steps in the certification
process

44. Quality of CareProfessional health associations offer:
 Organizational umbrella and structure
 Credibility to influence professional standards and
scopes of practice
 Ability to provide input into pre-service education and
training policies
 Advocacy for their patients and profession.

45. To Improve QualityMost professional associations in developing countries need capacity
building and organizational strengthening to be effective in working
with the private sector to improve quality.
 Such support can include:
 Strategic planning
 Leadership development
 Training
 Peer support and supervision programs
 Information systems
 Institutional growth and sustainability
Many US- and European-based professional organizations are
establishing partnerships with "sister" organizations in developing
countries to transfer skills, help build systems, and share experiences.

46. Partnership Model
 Identify critical stakeholder members
 Explore different associations’ interests and potential
contributions
 Agree on the policy focus
 Determine how the partners will work together
 Identify actions to work on together as group

47. Supportive supervision
Supportive supervision has the following advantages
for the private health sector:
Promotes quality by improving communication
Focuses on problem-solving
Facilitates teamwork
Provides leadership and support to empower health providers
to monitor and improve their own performance
For supportive supervision to work well in the private
sector, there must be:
 Group or network of identified private providers
 Entity or organization to coordinate and provide the
supportive supervision
Challenges with this approach include:
Costs associated with providing supportive supervision
Scheduling difficulties for busy providers.

48. Public-private partnerships(PPPs) in
health involve government and
the private sector working
together
to achieve common goals,
share risks and rewards,
leverage each partner's
comparative advantage, and
use each partner's resources
effectively (O'Hanlon, 2008).

49. Some of the most common forms
of PPPs for health service delivery
include:
· Contracting out
· Subsidies
· Vouchers
· Health insurance
· Risk pooling

50. Public-private partnerships Improve health outcomes among target populations
such as poor and rural groups
 Remove barriers to healthcare (access, economic,
quality)
 Reduce government spending (eliminating large up-
front investments of scarce public funds)
 Improve efficiency (due to private partners'
operational efficiency)
 Leverage technical or management expertise
 Spur technology transfer (Nikolic and Maikisch, 2006)

51. ContractingTo increase access to health services and improve
performance of the health system, driven by the
following factors:
 Need to rapidly scale up coverage or range of services
 Frustrations regarding the availability, quality, and
efficiency of centralized publicly provided services
 Shortages of public healthcare personnel
 Client preference for private care.

52. Contracting to Increase Access to
Primary Health Services
There are two main types of contracting:
 Contracting-out, or a "service delivery contract." In a
service delivery contract, the contract specifies that
the contracted entity will both manage and supply the
production infrastructure such as personnel,
equipment, and drugs.
 Contracting-in. The government contracts a private
sector entity to manage existing government services
in a specific area (a "management contract") or to
provide some other support service with existing staff,
logistics arrangements, and infrastructure.

53. Benefits of Contracting-out
Benefits of contracting-out include the following:
 Taps the private sector's greater flexibility to improve
services and strengthens the focus on measurable results
 Provides for competition among private providers,
which increases the efficiency and effectiveness of
health service delivery (Loevinsohn and Harding, 2004)
 Builds the capacity of NGOs that often deliver these health
services, in areas such as clinical services, nutrition and
immunization programs, and consumer education
campaigns

54. Steps to
Design an
Effective
Contract
for Health
Services

55. Thank You
Presentation Based on Reference
UNICEF/ WHO Guidelines