1. When Single Sector Solutions are not Enough: Addressing Health Systems Gaps with Public-Private Partnerships Barbara O’Hanlon, Senior Policy Adviser, SHOPS Susan Mitchell, Project Director, SHOPS October 8, 2010

2. Presentation overview Growing interest in working with the private sector Different levels of private sector engagement Benefits of partnering with the private sector Strategies for addressing health systems gaps through public-private partnerships Examples of successful private sector programs

3. Growing interest in PPPs

4. Context Growing recognition among donors and developing countries of the need to work with all actors in the health sector Many in global health community are promoting public private partnerships Lots of confusion exists on When is appropriate to engage the private sector to address public health objectives What are PPPs

5. Benefits of engaging the private sector

6. Why work with the private sector? Partnering with the private sector can strengthen the health system by ….. Building sector-wide capacity to deliver high quality services and products Increase number and distribution of health personnel Improve the generation, dissemination and use of health information Enhance government’s ability to ensure availability of quality, affordable medicines Mobilize resources and expertise Strengthen government oversight through dialogue and greater interactions

7. Different levels of private sector engagement P 1 Public private dialogue Coordination between the sectors to exchange information and to dialogue on issues related to health P 2 Public private interaction Cooperation between the public and private sectors to produce policy reforms creating favorable environment in PPPs in health P 3 Public private partnerships Formal partnerships improving access to health services and products

8. Working definition of PPPs (P 3 ) A PPP in health is any formal collaboration between the public sector at any level (international donor agencies, bilateral government donors, national and local governments,) and the non-public health sector (commercial, non-profit and tradition) to jointly regulate, finance or implement the delivery of health information and communication; services; products and equipment; and research.

9. Types of PPPs (P 3 ) Market Model – commercially viable activity Charity Model – CSR/Philanthropic activities Mixed Model – Combination of market and charity activities PPPs (P 3 )

10. When to partner with the private sector

11. When to use P 3 P 3 should be used selectively Requires considerable time and money to negotiate Requires new stewardship skills on gov’t side Often requires outside “honest broker” to connect Rationale for govt to decide to enter into a P 3 Are there persistent gaps in the health system not being addressed by single sector approaches? If no, then do not need P 3 If yes, explore P 3 to bridge health system gaps to choose P 3 models known to address common gaps

12. Algorithm to decide when to use P 3 Are there persistent gaps in the health system not being addressed by single sector approaches? IF NO No need for PPP’s. Continue to use single sector approaches. IF YES Will PPPs address equity, access and efficiency? IF YES Broker PPPs with appropriate partners and formalize agreements for implementation IF NO Consider different approach and/or invest in single sector approach.

13. Health system gaps

14. Health system gaps and possible solutions

15. Strategies to strengthen health systems with the private sector

16. Health system gaps Governance gap Legal and regulatory reform to permit private providers to perform key public health tasks in a private settings (Ethiopia, Kenya, Zambia) PPP dialogue mechanisms in Kenya, Ghana, Mali and Uganda Creation of PPP Units in Ghana, Kenya, Nigeria, Mali Uganda and South Africa Human resource gap MOUs and contracting with private medical training institutions (Kenya) Contracting private management firms and/or private health providers to manage private hospitals (Kenya, Lesotho, Zambia)

17. Health system gaps Affordability gap A pilot insurance project covering informal workers with basic healthcare in private sector (Okambilimbili Project, PharmAccess, Namibia) THT, a HMO/PPO, delivering affordable family wellness services under the NHIS (PSP-One, Nigeria) Innovations in insurance – micro insurance, micro-finance – to cover informal workers (Uganda, Kenya) Demand gap Vouchers for ITNs (AED, multiple countries) Vouchers for maternal health and RH services (KfW, Uganda and Kenya)

18. Health system gaps Access gap Indian generic mfg. (FAMICARE) distributing generic OC thru NGO distributor (SFH) (LOCAN-PSP-One-Nigeria) Network of legal (private) drug outlets in rural areas to supply essential OTCs (MSH-SEAM, DLDBs in Tanzania) Private provider network -PrimeCure- delivering affordable services and medicines (South Africa) Private provider network -NewStart- delivering VCT services (PSI- multiple countries) PPPs with local health authorities and extractive industries to expand services to remote communities (Namibia, South Africa) Concessionary / leasing of MOH hospital infrastructure to private providers (Lesotho)

19. P 1 and P 2 – Kenya Example P 1 Dialogue – multi-sectoral body formed and lead with equal representation between sectors P 2 Interactions – active engagement on key policy reforms underway  Update of Health Policy framework  Review of 17 health acts  Development of PPP Framework

20. A PPP to introduce Zinc in Nepal Sustainable supply of pediatric Zinc tablets created Increase access to pediatric Zinc for caregivers of under-5 children Improve caregiver knowledge and treatment so that caregivers provide ORS/ORT together with Zinc for uncomplicated diarrhea regardless of source Improve private provider knowledge and treatment practices Sustained provision and use of pediatric Zinc in addition to ORS/ORT as the first line treatment for uncomplicated diarrhea for children under 5

21. Why a PPP? Use by source of supply DHS 2006

22. Sustainable commercial supply Three Nepalese pharmaceutical manufacturers assisted in bringing to market quality pediatric Zinc products Affordable pricing ($0.19 – 0.52) National commercial distribution Challenge: Government preference for local supply

23. Improving access Launch in a phased manner Phase 1: Fund public sector introduction in priority private sector geographic focus (capital region) Phase 2: Program extension to all 27 Community-Based Integrated Management of Childhood Illness (CB-IMCI) districts from February through September 2008 Challenge : Coordinating with the phased government approach (at program inception public sector had introduced Zinc in 5 of 75 districts and planned a three year phase-in)

24. Improving provider knowledge Developed private providers’ training materials to be consistent with Government protocols Trained: 5810 private doctors/chemists Trained manufacturer's detailers for message reinforcement Job aids and informational materials delivered to over 8000 trainees Challenge : Ensuring private practitioners and pharmacists had access to the same training as public sector staff

25. Improving caregiver knowledge Built consensus on messaging and logos through an official body: Zinc task force Created a national umbrella campaign logo used on wall charts, posters, and billboards Produced and aired radio generic spots and one television advertisement that promoted Zinc use in general Challenge: Creating a common communications message

26. Nepal conclusion Lesson: Building a “true” public-private partnership takes time, flexibility and willingness to compromise but yields sustainable results

27. Take home messages Health system strengthening efforts focusing solely on the public sector over look available important private sector resources It is critical for governments to determine if a sole sector or partnership approach is needed given the considerable time and effort to engage the private sector Private sector can make important contributions to address a wide range of health system gaps Different levels of private sector engagement – the first two are necessary conditions to reach PPPs (P 3 ) Public-private dialogue (P 1 ) Public-private interaction (P 2 ) Public-private partnerships (P 3 )

28. Thank you!