Asia Network Private Health Sector Policy April Harding World Bank/ IFC Bali Hyatt Hotel, Sanur, Bali June 2010

Distrust, lack of dialogue, lack of cooperation undermine effective implement of private sector engagement strategies Strategies for overcoming constraints include  mechanisms for on-going communication  formalizing participation of private sector representatives in the policy making and implementing process  support to implementing officials to shift to new approach.

 The Challenge  Six Steps of Implementation  Strategies to help ensure implementation success

The Challenge

 Inherently political  Conflicting views & objectives of stakeholders  Cultural & institutional context  Typically more attention paid to policy content or design than to implementation

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

Is getting policy accepted as important, desirable and feasible ◦ Depends directly on consultation and communication with the regulated entities (Consultative mechanism)

Any forum or mechanism where public and private actors meet to exchange information; discuss policy issues; agree on coordinated or partnership activities.

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

 Assessment  Gaining support of allies/ beneficiaries (must be able to make good arguments)  Reducing opposition (or impact of…)

 Having a strategic plan for dealing with stakeholders  Having a strategic communication plan

Explain your initiative and what it means for people…… Or someone else will.

 Who are key public actors? Likely positions?  Who are key private actors? Likely positions? (CM)  How strong are they?

 For allies/ beneficiaries ◦ How can you bring about collaboration/ coordination? ◦ How can you strengthen their influence?  For potential opponents ◦ What are their biggest concerns? ◦ Can you address some of their concerns?

 Who may be your allies? - How can you strengthen their influence? – What are their biggest concerns? – Can you address some of their concerns? Who may be opposed?

 Stakeholder Analysis  Political Mapping/Analysis (  Policy Workshops

 A stakeholder is any individual, community, group or organization with an interest in the outcome of a policy  Three types: ◦ Key: can significantly influence success of activity ◦ Primary: ultimately affected by an activity (either positively or negatively) ◦ Secondary: all other individuals/institutions with a stake, interest or intermediary role in activity

Stake- holder Position*Strength (1=low; 5=high) Strategies * 1=strongly support; 2=support; 3=neutral; 4=oppose; 5=strongly oppose

Stake- holder Position*Strength (1=low; 5=high) Strategies Private hospitals – H Support? 4Empower/ strengthen Private hospitals - L Oppose? 3Persuade; bargain; threaten PhysiciansNeutral? Oppose? 4Persuade/ negotiate Population Support? 1Inform; bring on board

Empower, strengthen Collaborate, harness resources Consult, persuade, bargain Consult, persuade, bargain (threaten or control) Support Oppose Low resourcesHigh resources

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

Financial resources Do implementation plans ensure predictable flow of funds to support implementation? Often private sector engagement is pursued without funding (as a result of financial constraints)

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

 Establishing procedures, objectives, systems and structures to carry out policy implementation.  Entails creating new organizations and relationships - formal or informal  Bodies with appropriate authority  Clear allocations of responsibility and accountability

 Adequate planning for review & revision of needed laws?  Implementing bodies: ◦ clearly understand their roles & responsibilities? ◦ have adequate authority? (Does authority need to be assigned or redistributed?)  Are plans based on realistic assumptions about private actors?

Role of private representative bodies  What are their capacities? Interests?  What are they willing to do?  How will gov’t ensure they are behaving appropriately?  How will gov’t step in if they fail?

A consultative mechanism can play an important role in implementation of private health sector engagement.

Many initiatives to work with the private sector fail due to lack of understanding, or due to lack of their engagement in policy design and implementation

 Formalizing consultation of most relevant private actors (or representative bodies) in consideration of policies directly related to their activities  EX: Australia private hospital legislation reviews – private hospital association participates at every stage.

Representatives of different government actors payers (HIC, State Gov’ts); public and private providers; technical experts. Temporary Working Groups are established to support intensive engagement toward addressing specific policy issues (health workforce; patient information; health technology assessment; consumer protection/ patient rights; medical education)

Physician reimbursement consultative mechanisms Formal bodies that meet to work out adjustments to physician fees – usually exist on a continuous basis Members are physician reps (medical assns); payer reps (gov’t/ independent/ private); technical experts.

France: Standing Commission on Physician Reimbursement Germany: Concerted Action Commission Canada: (Provinces): Schedule of Benefits Working Group (Ontario)

 Improved information for decision- making  Greater consensus about and ownership of new policies  Greater accountability of public decision- makers  More resources for agreed actions  Building of trust….leading to better relations in the longer-term

 Participation of ◦ truly representative actors/ bodies ◦ authoritative actors (highly knowledgeable; speaking for other actors)  Clear agendas for meetings  Resources to prepare for, facilitate meetings and follow-up on meetings  Transparency about how agenda is set

 Establish government commitment  Establish clear objectives  What can the private actors gain through participation??  Establish and share goals and agenda ◦ What will they discuss ◦ What outputs can be expected?  Figure out who to invite (consult with)  Logistics (where to meet, staffing)  Identify resources/ responsibility for follow-up

Can be structured, or at least initiated around an analytical piece of interest to the private actors (e.g. Quality Regulation Review; Private health sector assessment; Improving Child Health; Fighting TB or HIV/ AIDs)

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

Ensuring implementing actors and individuals are going forward Implementing officials – ◦ Who are the key ones? ◦ How can you motivate or “incentivize” or persuade them? ◦ How can they be monitored? ◦ Getting feedback from private actors (CM)

Legitimation Organizational Design Administration Politics Mobilizing Actions Ensuring Resources Monitoring Impact Constituency Building

Critical to check to see if actions  are being implemented  are having desired impact Review results together (CM)

. Malaria medicine regulation in Uganda (REDUCED access to front-line drug) - Licensing regulations can reduce access to needed services - Quality standard rules can increase informality

 How can policymakers engage the private sector in implementation without allowing some private actors to “capture” the process?  In your country, do public and private collaborate in implementation of any initiatives?  What problems have emerged?  How can such problems be overcome?