Private Health Policy Toolkit Final

JUNE 2013
PRIVATE HEALTH POLICY TOOLKIT
Tools for Engaging
the Private Health Sector
JUNE 2013
Tools for Engaging
JUNE 2013
Tools for Engaging

PRIVATE HEALTH POLICY
TOOLKIT
Tools for Engaging the
Private Health Sector

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©2013 The World Bank Group
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June 2013
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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.

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Table of Contents
Module 1: Fundamentals........................................................................................................................................................................1
Step 1: The Basics ............................................................................................................................................................................1
Step 1.1 The Health System.........................................................................................................................................................1
Step 1.2 Health System Functions ...............................................................................................................................................2
Step 1.3 The Policy Cycle ............................................................................................................................................................2
Step 2: The Private health sector ......................................................................................................................................................4
Step 2.1 Why the Private Sector Matters......................................................................................................................................4
Step 2.2 Used by Consumers Yet Ignored by Governments.........................................................................................................5
Step 2.3 Forms of Engagement with the Private Health Sector ....................................................................................................6
Module 2: Assessment ...........................................................................................................................................................................7
Step 1.1 Private Health Sector Assessment Overview .................................................................................................................7
Step 1.2 Relationship Between Assessment, Capacity Development and Engagement...............................................................8
Step 1.3 Learning From Previous Assessments...........................................................................................................................9
Step 1.4 Other Private Health Sector Assessment Audiences....................................................................................................10
Step 2: Assessment Models ............................................................................................................................................................10
Step 2.1 Focus of Private Health Sector Assessments...............................................................................................................10
Step 2.2 Log Frame for Private Health Sector Assessment........................................................................................................10
Step 2.3 Types of Private Health Sector Assessments...............................................................................................................11
Step 2.4 Descriptive Models.......................................................................................................................................................11
Step 2.5 Analytical Assessment Models .....................................................................................................................................12
Step 2.6 Predictive Assessment Models.....................................................................................................................................12
Step 2.7 A Summary Approach to the Assessment Process ......................................................................................................13
Step 2.8 Evidence Based Pyramid .............................................................................................................................................13
Step 3: Data Collection....................................................................................................................................................................14
Step 3.1 Secondary Data Collection...........................................................................................................................................14
Step 3.2 Main Types of Primary Data Collection Instruments.....................................................................................................15
Step 3.3 Ethics and Informed Consent .......................................................................................................................................15
Step 3.4 Observation..................................................................................................................................................................15
Step 3.5 Key Informant Interviews..............................................................................................................................................16
Step 3.6 Surveys ........................................................................................................................................................................17
Step 3.7 Focus Groups...............................................................................................................................................................17
Step 4: Assessment Considerations................................................................................................................................................18
Step 4.1 Determine Assessment Scope .....................................................................................................................................18
Step 4.2 Assessment First Step .................................................................................................................................................18
Step 4.3 Market Analysis............................................................................................................................................................18
Step 4.4 Key Assessment Themes.............................................................................................................................................19

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Step 4.5 Define Terms of Reference ..........................................................................................................................................19
Step 5: Conducting a Private Health Sector Assessment ................................................................................................................20
Step 5.1 Document Review and Key Informant Identification .....................................................................................................20
Step 5.2 Key Informant Interviews..............................................................................................................................................20
Step 5.3 Field Visits....................................................................................................................................................................21
Step 5.4 Data Analysis and Report Preparation .........................................................................................................................21
Step 5.5 Stakeholder Feedback .................................................................................................................................................21
Step 5.6 Develop Action Plan.....................................................................................................................................................21
Module 3: Engagement Tools...............................................................................................................................................................22
Step 1: Background.........................................................................................................................................................................22
Step 1.1 Key Definitions .............................................................................................................................................................23
Step 1.2 Evolution of a Public Private Dialogue..........................................................................................................................23
Step 1.3 Public Private Dialogue Benefits and Risks..................................................................................................................24
Step 2: Diagnosing the Status and Potential for Public Private Dialogue.........................................................................................24
Step 2.1 Diagnosis Project Sequence ........................................................................................................................................24
Step 2.2 The Public Private Dialogue Diamond..........................................................................................................................25
Step 2.3 Overview of Stakeholder Analysis ................................................................................................................................25
Step 2.4 Analyze Stakeholder Level of Influence and Support ...................................................................................................26
Step 2.5 Stakeholder Analysis Matrix .........................................................................................................................................26
Step 3: Designing a Public Private Dialogue Process......................................................................................................................27
Step 3.1 Mandate and Institutional Alignment.............................................................................................................................27
Step 3.3 Champions...................................................................................................................................................................28
Step 3.4 Role of the Facilitator ...................................................................................................................................................28
Step 3.5 Outputs ........................................................................................................................................................................29
Step 3.6 Additional Considerations.............................................................................................................................................29
Step 4: Implementation....................................................................................................................................................................30
Step 4.1 The Public Private Dialogue Action Plan ......................................................................................................................30
Step 4.2 Identifying Public Private Dialogue Opportunities .........................................................................................................30
Step 4.3 PPD Communications and Outreach............................................................................................................................30
Step 5: Monitoring and Evaluation of Public Private Dialogue .........................................................................................................31
Step 5.1 Monitoring and Evaluation Overview ............................................................................................................................31
Step 5.2 Challenges of Public Private Dialogue Monitoring & Evaluation ...................................................................................31
Step 5.3 Developing a Plan to Monitor Progress of Public Private Dialogue...............................................................................32
Step 5.4 Public Private Dialogue Monitoring and Evaluation Tools.............................................................................................32
Step 5.5 Indicators .....................................................................................................................................................................33
Module 4: Capacity Development.........................................................................................................................................................34
Step 1: Overview .............................................................................................................................................................................34
Step 1.1 Sample Course Agenda ...............................................................................................................................................34
Step 1.2 Framework ...................................................................................................................................................................35
Step 2: Private Health Sector Assessments ....................................................................................................................................35
Step 2.1 Benefits of Private Health Sector Assessments............................................................................................................36
Step 2.2 Conducting a Private Health Sector Assessment .........................................................................................................37
Step 2.3 Data Issues and Limitations .........................................................................................................................................37
Step 3: Strategies for Engaging the Private Health Sector ..............................................................................................................38

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Step 3.1 Harnessing the Private Sector......................................................................................................................................38
Step 3.2 Growing the Private Sector...........................................................................................................................................38
Step 3.3 Conversion...................................................................................................................................................................39
Step 3.4 Restricting the Private Health Sector............................................................................................................................39
Step 4: Policy Instruments...............................................................................................................................................................39
Step 4.1 Overview of Policy Instruments ....................................................................................................................................39
Step 4.2 What About Quality, Equity, and Efficiency?.................................................................................................................40
Step 5: Information Flow..................................................................................................................................................................41
Step 5.1 Information Flow to Providers.......................................................................................................................................41
Step 5.2 Information Flow to Consumers....................................................................................................................................41
Step 6: Regulating the Private Heath Sector ...................................................................................................................................42
Step 6.1 What is Regulation? .....................................................................................................................................................42
Step 6.2 Benefits and Costs of Regulation .................................................................................................................................43
Step 6.3 Who Regulates Health Care?.......................................................................................................................................43
Step 6.4 Self Regulation by Professional Health Bodies.............................................................................................................43
Step 7: Contracting and Vouchers...................................................................................................................................................45
Step 7.1 Contracting Overview...................................................................................................................................................45
Step 7.3 Contracting Considerations ..........................................................................................................................................46
Step 7.4 Voucher Overview........................................................................................................................................................46
Step 7.5 Voucher Steps..............................................................................................................................................................47
Step 8: Social Franchising and Social Marketing.............................................................................................................................47
Step 8.1 Social Marketing Overview...........................................................................................................................................47
Glossary...............................................................................................................................................................................................51
Resource Links by Topic ......................................................................................................................................................................53
Figures
Figure 1. The Health Sector Within the Health System...........................................................................................................................1
Figure 2. The Policy Cycle ....................................................................................................................................................................2
Figure 3. The Engagement Continuum...................................................................................................................................................3
Figure 4. The Health Market...................................................................................................................................................................4
Figure 5. Source of Health Care by Region ............................................................................................................................................4
Figure 6. Source of Health Care by Income in Sub Saharan Africa ........................................................................................................5
Figure 7. The Health in Africa Initiative...................................................................................................................................................6
Figure 8. Health System Assessment.....................................................................................................................................................7
Figure 9. Three Pillars of Private Sector Stewardship.............................................................................................................................8
Figure 10. Levels of Private Health Sector Assessments .....................................................................................................................10
Figure 11. Types of Assessment Models..............................................................................................................................................11
Figure 12. Control Knobs for Health Sector Reform .............................................................................................................................12
Figure 13. Tri-Dimensional Assessment Approach...............................................................................................................................13
Figure 14: The Pyramid of Evidence in Study Design...........................................................................................................................13
Figure 15. Assessment Steps...............................................................................................................................................................20
Figure 16. The Policy Cycle..................................................................................................................................................................22
Figure 17. Diagnosis Project Sequence................................................................................................................................................25
Figure 18. Kenya PPD Diamond Analysis ............................................................................................................................................25
Figure 19. Sample Stakeholder Mapping Matrix...................................................................................................................................26
Figure 20. Example of Written Public Private Dialogue Agreement from Kenya ...................................................................................27
Figure 21. Sample Public Private Dialogue Structure ...........................................................................................................................27
Figure 22. Strategies for Engaging the Private Health Sector...............................................................................................................30
Figure 23. Strategies for Working with the Private Health.....................................................................................................................38
Figure 24. Regulatory Players in Health ...............................................................................................................................................43
Figure 25. Components of Successful Accreditation Program ............................................................................................................44
Figure 26. The Seven Steps of Contracting..........................................................................................................................................45

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Figure 27. Steps in a Voucher Program................................................................................................................................................47
Figure 28. Geographic Evolution of Franchises....................................................................................................................................49
Tables
Table 1. Standard Health System Functions of Government ..................................................................................................................2
Table 2. Stewardship and Engagement..................................................................................................................................................3
Table 3. Objectives and Expected Outcomes of a Private Health Sector Assessment ...........................................................................8
Table 4. Private Health Sector Assessment by Country and Focus Area ...............................................................................................9
Table 5. Private Health Sector Audiences ............................................................................................................................................10
Table 6. Inputs-Processes-Outputs-Impact Model................................................................................................................................11
Table 7. Secondary Data Sources........................................................................................................................................................14
Table 8. Primary Data Collection Methods ...........................................................................................................................................15
Table 9. Direct and Unobtrusive Observations .....................................................................................................................................16
Table 10. Assessment Topics...............................................................................................................................................................16
Table 11. Household and Provider Focus Group Themes ....................................................................................................................17
Table 12. Assessment Components.....................................................................................................................................................18
Table 13. Examples of Demand, Supply, and Pricing Analysis for Assessments..................................................................................19
Table 14. Assessment Themes ............................................................................................................................................................19
Table 15. Phases in Public Private Dialogue Process ..........................................................................................................................23
Table 16. Range of Stakeholders in Public Private Dialogue................................................................................................................25
Table 17. Worksheet to Analyze Stakeholder Level of Support and Influence......................................................................................26
Table 18. Typology of Champions from PPD Handbook.......................................................................................................................28
Table 19. Types of PPD Outputs ..........................................................................................................................................................29
Table 20. Focus of Monitoring and Evaluation......................................................................................................................................31
Table 21. PPD Checklist to Monitor Progress Annually ........................................................................................................................32
Table 22. SMART Indicators.................................................................................................................................................................33
Table 23. Sample Course Agenda on Strengthening the Private Health Sector (Click to Enlarge) .......................................................34
Table24: Harding-Montague-Preker Framework...................................................................................................................................35
Table 25. Private Health Sector Assessment Definition and Role.........................................................................................................36
Table 26. Private Health Sector Assessments......................................................................................................................................36
Table 27. Assessment Tips ..................................................................................................................................................................37
Table 28. Overview of Policy Instruments.............................................................................................................................................40
Table 29. Evidence on Effectiveness of Policy Instruments..................................................................................................................40
Table 30. The Benefits and Costs of Regulation...................................................................................................................................43
Table 31. Advantages and Disadvantages of Self Regulation ..............................................................................................................44
Table 32. Potential Advantages and Disadvantages of Contracting .....................................................................................................45

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Preface
There is growing recognition that the private health sector is a
significant source of health care in most African countries.
According to the report Healthy Partnerships: How
Governments Can Engage the Private Sector to Improve
Health in Africa (2010), the private sector share of total health
expenditure in Sub-Saharan Africa is on average 51 percent.
Use of the private health sector in Africa is particularly strong
among groups that policymakers most want to reach,
including the poor, women and children, and people with
tuberculosis, malaria and HIV.
Since the late 1990s, the World Bank has spearheaded
initiatives to include the private sector as a partner in health
sector reform through a focus on contracting out, social
insurance, and public private partnerships. International aid
organizations have also encouraged dialogue and partnership
between the public and private health sectors including the
U.S. Agency for International Development, the U.K’s
Department of International Development and the German
Agency for International Cooperation (GIZ). Major global
health initiatives such as the Global Alliance for Vaccines
Initiative and the Global Fund to Fight AIDS, Tuberculosis and
Malaria include private sector actors to improve efficiency and
incorporate private sector models into program delivery.
In 2007, the World Bank Group published a seminal report
entitled ‘The Business of Health in Africa,’ which highlighted
the role of the private sector in health in Sub-Saharan Africa.
The report showed that the private sector (both for-profit and
not-for-profit) can be an important part of the solution to
Africa’s health care problems when part of a publically-led,
equitable health care system. Following this report, the World
Bank Group launched the Health in Africa Initiative (HiA) to
help African governments harness the potential in the private
sector to better address Africa’s health challenges through the
generous support of the Governments of France, Japan, the
Netherlands, the Bill and Melinda Gates Foundation and the
Rockefeller Foundation.
The HiA has three main components of supporting African
governments with advisory services in engaging the private
health sector better, providing equity and debt financing to
private providers, and improving the knowledge base. HIA’s
activities in several African countries indicate that
governments in Africa are under pressure to reach
international health targets such as the Millennium
Development Goals. Due to financial and human resource
constraints, most African governments are unable to bear the
burden of meeting their health care needs alone. Efforts to
leverage the assets and mobilize the resources of both the
public and private sectors can help to scale up the delivery of
essential interventions.
The HiA team discovered that a lack of information about the
private sector’s role has hindered national policymakers from
including the private sector to the extent needed to benefit
health systems. Engagement with the private sector may also
be compounded by suspicion on both sides and a history of
lack of communication. These constraints can translate into
restrictive policies and poor oversight of the private health
sector.
To address this information and communications gap, HiA
developed the Private Health Policy Toolkit, which gathers
resources and tools about engaging the private health sector
that were previously unavailable in one location. The toolkit,
available in both online and PDF versions, advances the
collective knowledge of engagement resources on the private
health sector from the development partner and academic
communities with checklists, case studies, templates, reports,
slide presentations and videos. The toolkit contents were
developed by Hortenzia Beciu, April Harding, Bettina Brunner,
and Alexander Preker through collaboration with Results for
Development, Strengthening Health Outcomes through the
Private Sector (SHOPS), Banyan Global, Health Systems
20/20, and University of California San Francisco. WBG staff
also administered two surveys of key stakeholders to inform
the design and content of the toolkit.
The toolkit provides viewers with tools for analyzing the
opportunities for engaging the private sector in a health
system as well as for designing strategies and approaches to
do so. The toolkit breaks down the topic into modules, then
detail specific activities that can result in greater private health
sector engagement leading to sustainable change that is pro-
poor. Toolkit contents are based on the three pillars of
enhancing private sector stewardship, which are assessment
(Module 2), engagement (Module 3) and capacity
development (Module 4). This toolkit's focus on public-private
engagement is based on the understanding that
improvements in the operating environment will positively
influence contributions of the private sector and improve the
health system overall. The private sector engagement
process is mutually reinforcing. For example, conducting an
assessment may require building capacity in order to develop
engagement activities and so forth. Each engagement path is
unique, reflecting country conditions and stakeholder
expectations.
Module 1, Fundamentals, sets the stage and discusses the
health system, the policy cycle, public sector stewardship
towards the private health sector, the importance of the
private health sector, and outlines policy mechanisms
governments can use to better engage the private health
sector. Module 1 explains that engagement is the deliberate,
systematic collaboration of the government and the private
health sector according to national health priorities, beyond
individual interventions and programs. Module 1 also
explains that the private health sector is important because it
constitutes a significant portion of available healthcare in low-
and middle-income countries and thus cannot be ignored.
Private sector health services are used even in the poorest

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countries among the lowest income groups due to perceived
ease of geographic access, shorter waiting periods, flexible
hours, and greater availability of staff and drugs. Yet the
private health sector is often ignored by governments and
development partners due to distrust on both sides and lack
of productive dialogue.
Module 2, Assessment, defines the private health sector and
where it fits within the health system. While the private health
sector has various definitions, for this toolkit it includes non-
profit and for-profit private hospitals, clinics, laboratories,
pharmacies, and the people working in these establishments
such as doctors, nurses, midwives, pharmacists, and informal
providers of health services. It also encompasses producers
and distributors of pharmaceuticals as well as health
education institutions. Module 2 also discusses assessment
models, including descriptive, analytical, and predictive
assessments, with explanations of when to use each type of
assessment. This module also offers a new approach to
assessment using tri-dimensional coordinates corresponding
to the subsector, comprehensiveness and depth of the
assessment. Primary and secondary data sources are then
defined and their utility in assessments detailed. Module 2
then outlines how to conduct a private health sector
assessment and provides examples of terms of reference and
action plans.
Module 3, Engagement, explains how to engage the private
health sector by designing, implementing, and evaluating a
public private dialogue based on the policy cycle. The
module, adapted from the PPD Handbook, shows how to
diagnose the status and potential for public private dialogue,
conduct a stakeholder analysis, and design a public private
dialogue process. Along the way, toolkit viewers learn how to
develop a public private dialogue action plan. Once the
government's objectives are clear, new policies toward the
private health sector can be developed.
Module 3 describes the challenges of monitoring and
evaluation and the steps in developing a plan to monitor
progress of public private dialogue with sample indicators and
online tools.
Module 4 provides policymakers and capacity builders with
tools to better understand how to work with the private health
sector. The materials presented in this module come from
World Bank Institute training courses on private health sector
policy and public private collaboration conducted over the last
eight years. The focus of the course is private sector
engagement as a means to achieve clearly identified health
policy objectives and includes tools for primary care and
hospitals. Module 4 provides a sample course agenda and
then outlines private health sector assessment s and
strategies for engaging the private health sector, such as
harnessing, growing, converting or restricting it. Module 4
then covers the major policy instruments, including
accreditation, contracting, information flow to providers,
information flow to consumers, regulation, self-regulation of
private providers, social franchising, social marketing, and
vouchers. For each policy tool, definitions, best practice, case
studies and links to subject-specific resources are provided.

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Module 1: Fundamentals
Welcome to the private health policy toolkit, which offers health policy stakeholders and practitioners online access to a growing
collection of information about policies and practices that can help enhance the contribution of the private sector to important health
goals in developing countries.
Step 1: The Basics
In this toolkit, the activities involved with identifying and implementing policies to mobilize the private sector are divided into three
distinct categories:
 Assessment (Module 2),
 Engagement (Module 3), and
 Capacity Development (Module 4).
In each Module, you will find brief explanations of concepts along with resources to dive deeper into a subject area. The engagement
process is mutually reinforcing. For example, conducting an assessment may require build capacity in order to develop engagement
activities and so forth. Each engagement path is unique, reflecting country conditions and stakeholder expectations.
Step 1.1 The Health System
A health system is the network of people, information, resources, and policies all working together for better health outcomes.
Figure 1. The Health Sector Within the Health System
Figure 1 depicts how the health system
relates to the different organizational levels
of health and also shows the multitude of
factors involved in the health status of
individuals and the population. Many
factors outside the health system influence
people's health, such as poverty,
education, infrastructure, and the broader
social and political environment.
A health sector is smaller in scope than a
health system. It is the part of the
economy related to the demand for health
services from different individuals,
communities, organizations and
institutions (Bitrán et al, 2010). At the core
of the health sector are the clients for
which the health sector exists.
Resources:
 What is a Health System? [PDF 93 KB]

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Step 1.2 Health System Functions
There are many models proposed for the functions of the health system, explained in Building on Health Systems Frameworks for
Developing a Common Approach to Health Systems Strengthening. Using a classical public economics framework, this toolkit notes
the five functions of a health system as information, regulation, mandates (public private partnerships), financing, and production
(table 1).
Table 1. Standard Health System Functions of Government
Step 1.3 The Policy Cycle
Figure 2. The Policy Cycle
The policy cycle is a useful idealized framework which shows the sequence of events whereby
problems are identified, and policies are formulated, implemented, and evaluated (figure 2). It can
be used to help identify issues in their broader context, and to suggest linkages across different
stages of the cycle and different parts of organizations. Actual policy or service planning may involve
only some parts of this cycle, and may not follow the exact sequence shown here.
Information
 Information flows between the public and private health sectors
 Private sector inclusion in national health management information systems and
disease surveillance
Regulation
 Ability of the government to design and implement a regulatory framework
for the private health sector
 Registration of private health facilities
Mandates (PPP)  Formal or non-formal directive for dialogue between the public and private sectors
Financing  Sources of funding and purchasing arrangement to pay for goods and services
delivered by private providers.
Production  Goods and services directly produced by the public sector that impact the private
health sector.
Resources:
 Building on Health Systems Frameworks for Developing a Common Approach to Health Systems Strengthening.
 Review of World Bank's Experiences with Country-Level Health Systems Analysis [PDF 6.24 MB]
 Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa [website]
 Essential Public Health Functions Framework [PAHO website]
 Overview of Multiple Approaches to Health Systems Frameworks [PDF 138 KB]
 Everybody's Business: Strengthening Health Systems to Improve Health Outcomes: WHO's Framework for Action [PDF 843
KB]
Resources:
 Health Systems and the Cycle of Health System Reform [PPT]
 Evaluation and the Policy Cycle [PPT]

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Step 1.4 Stewardship and Engagement
To address quality issues and uneven growth in the health sector, policymakers and development organizations have started to focus
on financing arrangements, regulatory relationships, mechanisms for collecting and sharing information, and public private
collaboration. (OECD 2010) These efforts focus on strengthening underlying policies and processes as a means to enhance
governments' stewardship of and engagement with the private health sector, as defined in table 2.
Table 2. Stewardship and Engagement
Stewardship Engagement
The state's role in taking responsibility for the health
and well-being of the population, and guiding the health
system as a whole.
The policy actions and communication activities or public-private
dialogue activities involved with strengthening public sector
stewardship of private organizations.
Any initiative to enhance the contribution of the private sector to health goals involves:
 Implementing new policies to structure the relationship between public agencies and private organizations. These policies
establish new relationships and create incentives for private organizations to behave differently, which in turn increases the
private sector's contribution to health goals.
 Public-private dialogue (PPD) as a means to establish a common understanding between public officials and private
representatives with respect to health challenges, policy options and opportunities for collaboration.
Step 1.5 The Engagement Continuum
Figure 3. The Engagement Continuum
Government engagement can be thought of as a trade-off
between the level of government intervention and the value
received figure 3). A complete lack of government
engagement, which can result in inadequate policies
regulating the private health sector, is not cost effective.
At the other end of the spectrum, too much government
engagement leads to over-regulation and government
monopolies. This toolkit provides policymakers and
practitioners with policy tools to achieve "smarter government,
not more government."
Resources:
 Towards Better Stewardship: Concepts and Critical Issues [PDF 2.14 KB]
 Public Stewardship of Private Providers in Mixed Health Systems [PDF 2.56 MB]
 Improving Stewardship of Complex Mixed Health Systems: Learning from Health Care in the United States [PDF 888 KB]
 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]
 Report Of The Regional Workshop On Building Public-Private Linkages To Advance Priority Health Services in Africa [PDF
1.25 KB]
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system as a whole.
Resources:
1.25 KB]
3
system as a whole.
Resources:
1.25 KB]

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Step 2: The Private health sector
Figure 4. The Health Market
Governments have a responsibility as health stewards to guide the health
system to deliver quality healthcare to populations, reduce health
inequalities, improve access to health, and ensure adequate safeguards are
in place.
The health sector is comprised of several Industries which constitute the
health market. The health market is the set of all consumers, both actual and
potential, of a health care product or service. (figure 4). Health services
include private hospitals, clinics, laboratories, chemical shops,
and pharmacies, and the people working in these establishments such as
doctors, nurses, midwives, pharmacists, and informal providers. These
private providers can be one of three types:
-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, who rely mainly on donations and grants with patients making minimal or no
payment for goods and services.
Health consumers that play a role in the health sector include professional associations, employers, donors, and health clients
themselves.
Step 2.1 Why the Private Sector Matters
Figure 5. Source of Health Care by Region
The private health sector matters for many reasons. It constitutes a significant
portion of available healthcare in low- and middle-income countries and thus
cannot be ignored. The private health sector is the source of 80 percent of
healthcare 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 5).
Resources:
 Working with the Non-State Sector to Achieve Public Health Goals [PDF 2.7 KB]
 The Role of the Private Sector: Landscape Analysis of Global Players' Attitudes toward the Private Sector in Health Systems
and Policy Levers That Influence These Attitudes [PDF 464 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]
 Video: Perspectives on the Private Sector
4
in place.
investment;
themselves.
Resources:
1.25 MB]
4
in place.
investment;
themselves.
Resources:
1.25 MB]

5
Figure 6. Source of Health Care by Income in Sub Saharan Africa
The private health sector is heavily used
by groups that policy-makers most want to
reach, including the poor, people with
specific diseases such as TB, malaria,
and HIV, and children and women. The
graph shows that the private sector's
share in delivering services in Sub-
Saharan Africa is fairly constant
across income quintiles in Africa, viewed
regionally (figure 6).
For country and regional presentations
and data on Demographic and Health
Surveys from 48 countries showing use of
the private health sector by wealth
quintile, click here.
Step 2.2 Used by Consumers Yet 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 omit the private health sector.
 Attitudinal barriers from both sides. Click here for real and perceived advantages and disadvantages of the public and
private health sectors.
 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.
Resources:
 Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa [View on issuu]
 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]
 Safe in Their Hands? Engaging Private Providers in the Quest for Public Health Goals [PDF 65 KB]

6
Step 2.3 Forms of Engagement with the Private Health Sector
Figure 7. The Health in Africa Initiative
When discussing collaboration between the public and private sector, it is
important to define key terms since many concepts are evolving and are used in
different ways by different stakeholders. This toolkit uses the following definitions
when discussing engagement with the private sector:
Public-Private Dialogue (PPD): 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 comes
in many forms. It can be structured or ad hoc, formal and informal, wide-ranging or
focused on specific issues. For more on this topic, see the Engagement Module
which focuses on public private dialogue as a means to engage the private health sector.
Public Private Partnership: This toolkit will follow the established use and health services research literature definition, and reserves
the term public private partnership or PPP for a specific transaction or initiative involving co-investment, such as a public-private joint
venture for a hospital.
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]
Resources:
 World Bank Public Private Dialogue Web site
 Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery in Africa [PDF .5 MB]

7
Module 2: Assessment
This module helps stakeholders including policymakers, technical staff, businesses and financial institutions to understand how to
better engage the public and private sectors through the results of an assessment process. Upon completing this module, the reader
will understand:
 Health systems frameworks for a health sector assessment
 The dimensions of a health sector assessment
 The dynamics of a private health sector assessment process
 Options for sources of secondary data
 The types of instruments which can be used for primary data collection
 Steps in the assessment process
Step 1: Private Health System Assessments: The Big Picture
Figure 8. Health System Assessment
Assessment as a general term means an evaluation or
appraisal. In the health sector, when you conduct an
assessment you examine a health issue against accepted
standards of a certain situation, performance or function. The
most comprehensive type of assessment examines the entire
health system within the country, regional and global context
(figure 8).
A comprehensive assessment of a private health system
investigates not only the core elements of the health
sector market and health policy, but also:
-The business and financial environment for the health sector,
-The country's general environment, and
-The political, economic, social and institutional environments.
Step 1.1 Private Health Sector Assessment Overview
Private health sector assessments help policymakers understand how the private health sector operates.
Resources:
 Building on Health Systems Frameworks for Developing a Common Approach to Health Systems Strengthening
 Health Systems Analysis for Better Health System Strengthening
 Health Systems and the Challenge of Communicable Diseases: Experiences from Europe and Latin America [PDF 3.3 MB]
 Business of Health: Analytical Frameworks [PPT 744 KB]
 Impact Evaluation Toolkit

8
Table 3. Objectives and Expected Outcomes of a Private Health Sector Assessment
A private health sector assessment, or PHSA, provides a
description of private sector activity at a specific point in
time. Information from a PHSA helps foster objective
dialogue between the government and private sector
stakeholders on how to increase the private sector's role
in health. The PHSA also recommends policy reforms,
identifies areas for coordination, and notes potential
collaboration opportunities.
The PHSA can examine the policy framework and
enabling environment affecting the supply, demand,
quality, price and market equilibrium for health care
products and services or focus on a specific activity or
product. Objectives and expected outcomes of
assessments are show in Table 3.
Step 1.2 Relationship Between Assessment, Capacity Development and Engagement
Figure 9. Three Pillars of Private Sector Stewardship
The policy process is informed through regular data collection,
assessments, and monitoring and evaluation activities to
identify and develop policies to address health challenges.
These activities may point to new regulations, training
activities, and other interventions needed to improve the
engagement of the private health sector in the health system.
Assessment activities are often carried out in tandem with
capacity building and engagement activities (figure 9). The
mutually-reinforcing nature of these activities is depicted
above. Engagement and Capacity Development are explored
in other modules of this Toolkit.
Developing and emerging market countries are at different
states of the assessment process. Some countries may focus
Resources:
 Cross-Border Health Care in the European Union. Mapping and Analyzing Practices and Policies [PDF 2.8 MB]

9
on understanding existing policies and regulation and improving them while others develop and implement new policies as part of the
assessment process.
Step 1.3 Learning From Previous Assessments
Table 4. Private Health Sector Assessment by Country and Focus Area
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
View assessments conducted by the
World Bank Group, the United States
Agency for International Development,
and other donors in table 4.
TableCountry 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
Uganda General
Tools:
 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]
Resources:
 Healthy Partnerships Report Presentation [PPT 1 MB]

10
Step 1.4 Other Private Health Sector Assessment Audiences
Table 5. Private Health Sector Audiences
In addition to policymakers,
investors, businesses, and
consumers (the general public
and patients) use assessments to
gauge private sector
development and identify
business investment
opportunities as well as the
quality of information and
services provided. Table 5
summarizes the needs of these
audiences.
Step 2: Assessment Models
In this section we learn about the main areas of the health sector and explore different assessment models, including a log frame,
models describing the type of assessment (descriptive, analytical, predictive), and a proposed summary approach to the assessment
process.
Step 2.1 Focus of Private Health Sector Assessments
Figure 10. Levels of Private Health Sector Assessments
A private health sector assessment can examine health dynamics at different levels of the health
system, including the global, national, sub-national/regional levels (figure 10). Each level
functions under different rules and regulations depending on factors such as involvement of the
international community and level of government decentralization. Descriptions and cross-
comparisons can be done among these levels of the health systems assuming that data is
defined, collected and analyze in ways that allows comparisons.
Private health sector assessments can also focus on different environments (business and
financial environment, social and institutional environment).
Step 2.2 Log Frame for Private Health Sector Assessment
Assessments can focus on even more specific health areas, including:
 Inputs such as revenues, supplies, or human resources,
 Processes like the governance of an organization or services in an intensive care unit or an internal quality assurance
process,

11
 Outputs such as the number of procedures performed by an organization or department or the bed occupancy rate of a
facility,
 Outcomes including, for example, the vaccination coverage of a catchment area, the number of children with measles in a
catchment area, the number of readmissions within 48 to 72 hours, and the service utilization rates per capita,
 Impacts such as client satisfaction with health services among the general population or the impact of health insurance
system in terms of individual or family financial protection against illness.
A cross-sectional analysis is also possible, such as with the accreditation process, which examines not only if processes are in place
in a health organization but over time can relate the current status of inputs and processes with the evolution of results such as output
indicators including quality, cost, and performance. Table 6 shows different areas of assessment within a functional model such as
inputs-processes-outputs -outcomes. It includes the impact component although impact is difficult to define and measure at the
organizational level. However, it is a desirable measure at the sub-sector or sector level.
Table 6. Inputs-Processes-Outputs-Impact Model
Areas Inputs Processes Outputs Outcomes Impact
 Health
systems
 Financing
capital
 Human
resources
 Drug supplies
 IT
 Medical
equipment
 Decision making
 Production services/
supplies
 Logistics
 Policies
 Regulation
 Services
 Service indicators
 Drug supplies
 Productivity
 Health
indicators
 Efficiency
 Equity
 Quality
 Productivity
 Access to
health
services
 Safety
 Financial
protection
 Health
status
 Patient
satisfaction
Step 2.3 Types of Private Health Sector Assessments
Many assessment models have been developed over the years, based on the availability of resources, knowledge base, and other
societal triggers. We have seen that private sector analysis can be performed at the organizational, sub-sector, sector, system,
regional and international level. For each of these levels you can perform a general assessment or dig deeper in a specific area. In
this toolkit we talk about three levels of analysis depth (figure 11):
Figure 11. Types of Assessment Models
Descriptive level assessments provide information on private
health sector operations and stakeholders, comparing them, for
example with other sectors, countries, or available standards.
They can be broad, general assessments or may address a
particular topic of interest.
Analytical frameworks go beyond description to analyze the
situation using different indicators, compare and contrast
existing or desirable objectives, and making inferences but
without proving a causal relationship.
Predictive assessments are narrow in scope but require rigorous research and funding to establish a causal relationship between, for
example, an intervention and its stated goals. Often descriptive assessments are coupled with analytical assessments or constitute
the first step toward an analytical or predictive assessment.
Ste
p
Tools:
 Building on Health Systems Frameworks for Developing a Common Approach to Health Systems Strengthening [PDF
275 KB]
 In Search of a Common Conceptual Framework for Health Systems Strengthening [PDF 431 KB]

12
2.4 Descriptive Models
Descriptive models provide a broad description of the health system, the financial and human resources dedicated to
improving health, key stakeholders and institutional arrangements. They describe many different relationships
among customers, products, and services but do not point out any causal relationships. Descriptive level
assessments can include simple bean counting of facts and figure to more complex comparative analysis of different
levels, countries, sector or health indicators. Descriptive models can look at different areas of investigation such as:
 Service delivery (primary, secondary or tertiary care),
 Disease (HIV/AIDS, TB, etc.), and
 Operations (procurement and distribution, etc.)
The Private Health Sector Assessment in Kenya is an example of a descriptive model.
Step 2.5 Analytical Assessment Models
An analytical approach to health sector reform requires the definition of objectives and the activities or interventions
related to the anticipated results. The inputs-processes-output-outcomes log frame can be a useful
framework to analyze the access, equity, productivity, and other health status indicators. Other models such as
supply and demand can be used to measure the accomplishments of health service delivery or health product
production in terms of responding to supply and demand market forces at the national, regional and global level.
The Private Health Sector Assessment in Ghana is a good example of an analytical assessment.
Step 2.6 Predictive Assessment Models
Figure 12. Control Knobs for Health Sector Reform
Predictive assessment models are used to analyze the direct relationship and
the degree of correlation between an intervention or an event and its impact on
individuals, communities and populations.
Health policy should be based on evidence that can predict the health
consequences of different policy options. By performing a predictive analysis in
areas which correspond to government policy goals for the health system, a
government can establish causal relationships between, for example, a
policy/interventions and the magnitude of the expected results..
One example of a predictive assessment model is the control knobs framework,
established by Roberts, Hsiao, Berman, and Reich in Getting Health Reform
Tools:
 A Descriptive Framework for Country-Level Analysis of Health Care Financing Arrangements [PDF 671 KB]
 Building on Health Systems Frameworks for Developing a Common Approach to Health Systems Strengthening [PDF 275 KB]
 Everybody's Business: Strengthening Health Systems to Improve Health Outcomes [PDF 84 KB]
 Healthy Partnerships: How Governments Can Engage with the Private Sector to Improve Health in Africa [Website]
Tools:
 Ghana Private Health Sector Assessment

13
Right: A Guide to Improving Performance and Equity (figure 12). It is currently used by the World Bank Institute as the basis for their
Flagship Program on Health Sector Reform and Sustainable Financing.
This assessment methodology consists of an analysis of the country's performance, defined by intermediary and final performance
goals, according to a set of "control knobs"-- financing, payment, organization, regulation, persuasion, politics, ethics, and values.
Step 2.7 A Summary Approach to the Assessment Process
Figure 13. Tri-Dimensional Assessment Approach
A useful way to represent the different assessment types is by using tri-dimensional coordinates where,
for example, the X axis represents the sub-sectors or the areas of assessment; the Y axis represents the
comprehensiveness of the assessment, and the Z axis represents the assessment depth. Each of these
three dimensions can be moved along the axes to indicate the area of investigation, level of detail
(inputs, processes or outputs), and depth (descriptive, analytical, predictive), depending on the time and
funds available (figure 13).
Step 2.8 Evidence Based Pyramid
Figure 14: The Pyramid of Evidence in Study Design
The Z axis from the tri-dimensional coordinate system on the previous page is known as the
pyramid of evidence in the study design area. The base of the pyramid is made up of
descriptive information from editorials, opinions, and reports. The second level of the pyramid,
the analytical level, is made of specialized analysis such as epidemiological studies. The third
level of analysis, the predictive assessment level is made of systematic reviews and meta-
analysis (figure 14).
Tools:
 What is a Health System? Health System Components / Control Knobs [Website]
 In Search of a Common Conceptual Framework for Health Systems Strengthening [PDF 431 KB]
Tools:
 Introduction to Health Impact Assessment [PDF 5.5 MB]
 Evidence-Based Medicine Pyramids [Website]
 Systematic Reviews and Meta-Analyses [PDF 105 KB]

14
Step 3: Data Collection
Information for health assessments comes from many different sources, and includes primary and secondary data. Secondary data
has already been collected and is available to the public. The sources of secondary data include international databases, journals,
census data, articles and country reports. In contrast, primary data is usually collected firsthand by a researcher through surveys,
focus groups, interviews and observations.
Step 3.1 Secondary Data Collection
Table 7. Secondary Data Sources
Secondary Data Sources Type of Data
Accreditation Agencies
Accreditation reports for different segments of the health market at the facility level (private sources)
assess organizational capacity, assets, strategy, facility, department output indicators, quality
indicators, client satisfaction, and risk assessment.
Consultancy Firms
Reports on private health sector for many countries, describing and/or assessing
organization, financial viability, and the general economic and country environment.
National Statistics
Country-specific websites such as ministry of health sites, statistical databases, and government
business registries have epidemiological data, output indicators at the facility level, budgeted
revenues, legislation and regulatory frameworks.
Organization for Economic
Cooperation and
Development
Health status, health resources (human, financial), utilization of services, medical technology,
pharmaceutical consumption, and socio-economic indicators.
Population Reference
Bureau
Census data by country, Demographic and Health Survey (DHS).
World Bank and United
Nations Agencies
Demographic and socio-economic indicators, Public Expenditure Reviews (PER), consumer quality
indicators, country status reports, and market scoping studies.
World Health Organization
Epidemiological data, outpatient and inpatients output data, consumption of goods and services,
health human resources database, and national health accounts.
Secondary data is data which has been collected by someone other than the user, such as international organizations, governments,
and consultancy firms (table 7). It is rapid and can be relatively inexpensive to collect if available through open source channels. It
plays an important role in the exploratory phase of the private health sector assessment, helping to define the key issues.
Potential drawbacks to keep in mind with secondary data:
 How terms such as private health sector are defined,
 Measurement error,
 Source bias, reliability, and timescale (FAO).
Also, many secondary data sources such as statistical health databases focus on the public health sector and do not provide
adequate detail on the private health sector.
Tools:
US National Center for Health Statistics [Website]
Tools:
 Secondary Data Links by Category

15
Step 3.2 Main Types of Primary Data Collection Instruments
Table 8. Primary Data Collection Methods
Primary data collection concerns tailored data collection by the user of that data. For health
assessments, it can take many forms, depending on whether you seek information from
experts or the public about the private health sector organization or environment. Observation,
surveys, key informant interviews, and focus groups are the main primary data collection
tools, although many other tools exist. Click on Table 8 to review primary data collection
methods.
Depending on the assessment's purpose, data availability, and funding, primary data
collection can be considered an option to complement existing secondary data. For example,
in Indonesia, morbidity data is periodically collected through secondary analysis,
but to gain further insight, the Indonesia Family Life Survey used trained health workers to
collect morbidity data such as height, weight, hemoglobin status, lung capacity and blood
pressure.
Step 3.3 Ethics and Informed Consent
Ethics and informed consent are important issues in primary data collection. Recommendations for those
undertaking private health sector assessments are:
 Respect the cultural traditions of study populations and communities.
 Develop culturally meaningful approaches to informed consent.
 Provide ongoing feedback to the study participants and the community.
Step 3.4 Observation
There are two types of research observations: direct (reactive) observations and unobtrusive observations (table 9). Observations can
be interpreted in three ways:
1. Descriptive observational variables require no inference-making on the part of the researcher. It involves observing
something then writing it down.
2. Inferential observational variables require the researcher to make inferences about what is observed.
3. Evaluative observational variables require the researcher to make an inference and a judgment from the behavior.
Tools:
 Evaluation Ethics, Politics, Standards, and Guiding Principles
 Ethical Challenges in Study Design and Informed Consent for Health Research in Resource-Poor Settings
 World Bank Code of Ethics
 Links to Ethics websites

16
Table 9. Direct and Unobtrusive Observations
Direct (Reactive) Observation Unobtrusive Observation
 When people know that you are watching them.
 Dangers: a) that they are reacting to you, and b) the
sample of individuals may not be representative of the
population.
 Direct observation can either be continuous or for a
specific time allocation.
 When individuals do not know they are being
observed.
 Dangers: Issues of informed consent and invasion of
privacy should be addressed.
 Numerous observations of a representative sample
need to take place in order to generalize the findings.
Step 3.5 Key Informant Interviews
A key informant is a person with unique skills or professional background on the health issue being evaluated. Key informants are
crucial to the assessment process. Examples of private sector key informants include:
 providers (doctors, midwives, traditional healers, etc.)
 provider associations
 pharmaceutical companies
 manufacturers, distributors, retailers
 health care management companies
 health insurance companies
 industry associations, etc.
Table 10 provides examples of topics for assessment key informant interviews.
Table 10. Assessment Topics
Topics for Assessment Key Informant Interviews
 Role of private providers and their ability to respond to market demand
 Whether government should encourage growth of the private sector and options the government could pursue
 Dual employment of medical personnel and private sector views on this topic
 Quality of graduates from different health education schools
 Regulation of the health sector and its impact on the private sector
 Access to finance for the private health sector: demand, challenges and opportunities.
Tools:
 How to Conduct a Key Informant Interview [PDF 13 KB]
 Getting the Lay of the Land On Health: A Guide for Using Interviews to Gather Information [PDF 67 KB]
 Management of Acute Malnutrition in Infants (MAMI) Project: Key informant interviews[519 KB]
Tools:
 Evaluative Criteria for Qualitative Research in Health Care: Controversies and Recommendations

17
Step 3.6 Surveys
ADePT: Software Platform for Automated Economic Analysis is a free tool from the World
Bank Group that uses data from surveys such as household budget surveys, Demographic
and Health Surveys and Labor Force Surveys to produce rich sets of tables and graphs for
analysis.
Sampling surveys are one of the most important basic research methods in social sciences
and applied work. They consist of relatively systematic standardized approaches to collecting
information on individuals, households, organizations or larger organized entities through
questioning previously identified samples, such as the ADePT software platform for
automated economic analysis.
While there are many types of survey instruments, the most relevant for private health sector assessments include:
 Interviews
 Telephone survey
 Mail survey
 Internet survey
Step 3.7 Focus Groups
Focus groups are group interviews with selected individuals designed to elicit in-depth insights and an understanding of motivations
and perceptions of participants. They are are useful to establish key health policy issues. Two key constituencies are providers and
households (table 11).
Table 11. Household and Provider Focus Group Themes
Household Focus Group Themes Provider Focus Group Themes
 Problems encountered with the existing health care
system
 Role of private medical practice in their province
 Government encouragement of the private health
care sector
 The need for regulation of the private health sector
 Part time work of public doctors in private sector
 Timeliness, price, and quality of service
 Availability of medical personnel and medicines and
medical supplies in private facilities
 Role of private medical practice
 Cost and quality issues
 Whether government should encourage more private health
facilities and if so how
 A range of issues including medical advertisements, part-
time private practice for public doctors and regulation of the
health sector.
Tools:
 Survey Tools for Assessing Performance in Service Delivery
 Health Facility Surveys: An Introduction
 Analyzing Health Equity Using Household Survey Data
 Ghana Private Health Sector Assessment: Hospital Questionnaire
 Ghana Private Health Sector Assessment: Clinic Questionnaire
 Ghana Private Health Sector Assessment: Laboratory Questionnaire
 Ghana Private Health Sector Assessment: Retail Pharmacist/Chemical Seller Interview Guide
 Patient Satisfaction Questionnaire

18
Step 4: Assessment Considerations
In designing your private sector health assessment, consider the type of information you seek. Do you desire a description of the
private health sector, an analysis of a specific health activity, or a predictive assessment that considers both qualitative and
quantitative aspects? These models will help you determine the strategic and technical questions to ask to help define the output. In
this section we learn about the strategic and technical assessment considerations involved in developing a private health sector
assessment plan.
Step 4.1 Determine Assessment Scope
Recalling our earlier Assessment Models discussion, it is important to consider the type of outputs you desire.
 Do you want a general description of the private health sector--a snapshot of current trends and activities? Consider a
descriptive assessment.
 Do you want to drill down and analyze a specific issue within the private health sector, such as a specific practice or issue?
Consider an analytical assessment.
 Do you want to understand the impact of an activity on the health system? Do you want to evaluate the efficiency of the
private health sector in the context of the health system? Then you may want to consider a predictive assessment, which
is less commonly performed and can be more difficult to administer.
Step 4.2 Assessment First Step
When planning a private health sector assessment, it is important to understand how the private sector relates to the health and
business environments. For this reason most private health sector assessments start with a review of the overall functioning of the
private health sector (table 12).
Table 12. Assessment Components
Components of Basic Private Health Sector Review
 Mapping of the size, coverage, configuration of the private sector and its share of total health expenditures to identify areas
of opportunity for potential private players and investors.
 Basic analysis of the physical capital and human capital within public and private health facilities.
 Basic analysis of the quality, equity, and efficiency delivered by the private health care sector.
 Market analysis (supply, demand, policy environment and market equilibrium analysis) to understand why consumers seek
care in the private sector, which is the subject of the next section.
Step 4.3 Market Analysis
When deciding on the type of private health sector assessment you wish to perform, consider demand/supply analysis and pricing.
Examples of each are found in table 13.
Tools:
 Woreda and City Administrations Benchmarking Survey III: Key Informant Interviews and Focus Group Discussion
Report, Survey of Service Delivery Satisfaction Status [PDF 2.3 MB]
 Patient Satisfaction Questionnaire

19
Table 13. Examples of Demand, Supply, and Pricing Analysis for Assessments
Supply Side Demand Side Pricing
 Diversity, distribution and contribution
of private sector health care providers
 Private provider networks as entry
points to working with private sector
and/or as franchisor functions, etc.
 Possibility of private sector contracting
with private providers
 Private sector supply chain for health
products
 Pharmaceutical products
 Quality control
 Demand for private sector provision of
health products and services
 Opportunities to create or increase
demand for private sector
 Recent efforts to create demand for
health products and their prospects for
growing the market for specific
services
 Can demand creation improve market
segmentation amongst the public, not-
for-profit, and private health sectors?
 Pricing in open market
 Pricing with incentives
(taxes or subsidies)
 Pricing through
distorting market power
(monopoly,
monopsony)
 Pricing in non-market
(due to lack of supply
or lack of demand)
Step 4.4 Key Assessment Themes
While not exhaustive, important themes for a private health sector assessments include public sector interface with the private sector,
the investment/business climate for the private health sector, and public/private twinning opportunities (table 14).
Table 14. Assessment Themes
Public-Private Sector Interface Business/Investment Environment Twinning Opportunities
 Effectiveness of current policies in
integrating private sector into the health
system
 Contribution of private sector to public
health objectives and how this
contribution could be improved
 Financing and regulatory instruments
which provide incentives for, facilitate
and/or impede the private sector
 Existing and/or upcoming PPPs, as well
as opportunities for future PPPs
 Frameworks for quality control and
accreditation
 Types of policy dialogue platforms and
information sharing mechanisms among
private sector providers and between
private and public sectors
 Regulations (e.g. licensing,
registration, ownership
restrictions, investor protection,
etc.)
 Access to key factor inputs,
including human resources for
health, physical (infrastructure)
and financial capital
 Role of the regional market;
including access to customers
and suppliers Sources of
revenue, including health
insurance scheme and health
mutuals
 Viability of different health sub-
sectors for private investment
and awareness of health as an
investment sector
 How the private sector can
enhance the manufacturing,
supply, and sale of drugs, by
establishing private
pharmacies and drug stores;
 How to invite private
entrepreneurs to build
private clinics and hospitals
to ease the burden on
government facilities;
 How the private sector could
partner with the government
to establish effective health
insurance schemes.
 How government could
collaborate effectively with
the private sector in capacity
building and continuing
professional education
programs.
Step 4.5 Define Terms of Reference
The assessment terms of reference (TOR) set the tone for the intervention and describe the context and expected
outputs. Each TOR is unique, but they share the following features:
 Background and country context
 Project objectives and outcome

20
 Scope of work
 Requirements for analytical framework Requirements for engagement component
 Outputs and deliverables
 Selection criteria
While each country context is unique, consider adapting the Terms of Reference found below for your needs.
Step 5: Conducting a Private Health Sector Assessment
Figure 15. Assessment Steps
While each private health sector assessment is unique, depending on
stakeholder interest and country characteristics, in general the assessment
path follows the steps below from document review and field visits to report
preparation and development of action plan, adapted from the Kenya Private
Health Sector Assessment (figure 15).
Step 5.1 Document Review and Key Informant Identification
The first phase of the assessment consists of desk research. The team identifies background documents and statistics about the
country generally and the health system specifically, via Internet research as well as recommendations from contacts at the health
ministries, donors in-country, and key informants contacted prior to the visit.
Through discussions with health ministries and health partners, identify key informants at the national level, identify priority areas of
interest, and select sites for visits. After an initial round of key informants is identified, team members from health ministries can assist
in setting up meetings.
Step 5.2 Key Informant Interviews
In step two of the private health sector assessment process, an in-country assessment team interviews numerous stakeholders at the
national level. Important interviewees include:
 professional health and business organizations,
 professionals from health and other ministries,
 health training institutions,
 faith-based and NGO representative organizations, and
 representatives of donor organizations
Tools:
Terms of Reference for Private Health Sector Assessments in:
 Ghana [PDF 491 KB]
 India [PDF 108 KB]
 Kenya [PDF 426 KB]
 Mali [PDF 494 KB]

Private Health Policy Toolkit Final

Private Health Policy Toolkit Final

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