The Role of Non State Providers in Child Health in East Asia and the Pacific Dr Abby Bloom Sydney Medical School & Menzies Health Policy Inst Nossal Global Health Institute, Univ Melbourne Dr Dominic Montagu Univ California San Francisco, Global Health

Out-of-pocket spending on health as a percentage of national Total Health Expenditure Source: WHO, 2006 National Health Accounts Data: Group 1 countries (plus China) Group 2 countries (plus Mongolia)

Out-of-pocket spending on health as a percentage of national Total Health Expenditure Source: WHO, 2006 National Health Accounts Data: Group 1 countries (plus China) Group 2 countries (plus Mongolia)

Source of Healthcare by Wealth Quintile Source: DHS Data (Cambodia 2005; Indonesia 2007; Philippines 2003; Vietnam 2002)

A Wide Range of Models for NSP Involvement in Child Health Contracting (PPPs) Purchasing Social marketing Social franchising Social entrepreneurship NGO and FBO direct provision of care Vouchers Insurance (including Social insurance) Accreditation Certification Output Based Aid Provider Training Patient Education Manufacturer-based supplements Manufacturer-based product subsidies

Source of healthcare: Cambodia 83% of healthcare from private providers 78% of healthcare from private providers Source: DHS Data Cambodia 2005

Cambodia - Current Situation Poor health, but steady improvements Private Out of Pocket (OOP) is main source of financing 80% of population treated in private facilities Good examples of government & private collaboration to increase access & quality for priority health services

Cambodia: Malaria Treatment 70% of fevers treated in the private sector Aim: to assure widespread coverage of ACTs. Government & PSI are partners in Affordable Medicines Facility-Malaria (AMFm) initiative. PSI co-packages ACT and rapid test kits Comprehensive training provided IEC and BCC create market demand 270,000 units sold in 2009 Will be available in both private and Govt shops and clinics

Source of healthcare: Indonesia 83% of healthcare from private providers 69% of healthcare from private providers Source: DHS Data Indonesia 2007

Indonesia – Current Situation Private sector provides ¾ of all health services ½ of all financing for health is private Dual practice by government clinical staff Decentralization has led to financing challenges within the national delivery system Self-treatment for simple ailments is common

Indonesian Midwives Association USAID-supported initiative to improve quality standards among private midwives BidanDelima program for training and certification 7,800 members: 10% of all Indonesian Midwives

Source of healthcare: Philippines 75% of healthcare from private providers 46% of healthcare from private providers Source: DHS Data Philippines 2003

Philippines – Current Situation Private health expenditure > than government expenditure Poor most often seek healthcare from informal sector: shops, friends, and relatives Pharmaceutical sales = 46.6% of THE Strong national leadership + well-managed national health insurance program = foundation for collaboration

Philippines:Drugstore Franchising Philippines has highest retail drug costs in EAP Government response: BotikangBayan franchise of private drug stores Operated by PITC, governmental trade company Central procurement from India, China, and local generic manufacturers 1,971 participating pharmacies across the country photo:

Key Message 1: The private sector is pervasive and has been filling the gap in EAP for some time Whats wrong with the current situation? The private sector is often unqualified, usually unregulated, overservices or provides ineffective care And… out-of pocket payment (OOPS) is regressive and penalizes poor.

Key Message 2: Government engagement, let alone "stewardship, is very limited. Stewardship Lite But there is opportunity now to review and strengthen.

Key Message 3: There are already very impressive examples of private sector initiatives contributing to the health of children: Cambodia Indonesia Philippines, Vietnam, Fiji, etc.

Key Message 4: There is a very broad menu of mechanisms from which Government can choose. Options are much greater than is generally considered – and Most are much easier, and less risky, than traditional PPPs, and Have much greater impact on the poor and on equity.

Key Message 5: Government must answer 3 questions: 1. What are we trying to achieve? Lower infant mortality? Build and equip new hospitals? Replace inefficient work practices? Improve equity???? 2. What options have been proven to achieve these objectives? Look at the long list of options available – and choose the ones that are likely to have the outcomes Government wants for poor children.

3. What is our countrys capacity to support these initiatives and mechanisms? To engage and manage the private sector for the "public good"? What is our capacity for stewardship? Are we ready now? If not, what can we do to be ready to manage technical, financial and economic risks? Ex: Review & revise legislation, regulations and funding (Mongolia, Vietnam, Indonesia) Ex: This Workshop: bringing together stakeholders, including Ministries of Finance and NSPs, not just MOH, to consider strategies.

Contact details: Dr Abby Bloom