1. Abt Associates Inc. In collaboration with: Broad Branch Associates | Development Alternatives Inc. (DAI) | Futures Institute | Johns Hopkins Bloomberg School of Public Health (JHSPH) | Results for Development Institute (R4D) | RTI International | Training Resources Group, Inc. (TRG) October 29, 2015 Sharon Nakhimovksy & Kylie Graff, Abt Associates, Inc. Dr. Stanley Lalta, UWI-HEU How can we engage the private sector in our pursuit of UHC? Lessons from USAID’s Caribbean programs

2. Session Objectives  Review data on the private health sector’s size & significance  Two sources: private provider census & Health Accounts estimations  Consider ideas for maximizing private sector engagement in UHC and sustainable financing  Learn about USAID’s work supporting sustainable health financing

3. Partners and Projects  USAID Southern and Eastern Caribbean- funded projects to support health system strengthening in the Caribbean (2010 – present)  Health Systems 20/20 & Health Finance and Governance Project  Strengthening Health Outcomes Through the Private Sector (SHOPS)  Implementers  University of the West Indies, HEU, Centre for Health Economics (UWI-HEU)  Abt Associates, Inc.

4. The private sector is comprised of both not-for-profit and for-profit actors Formal Commercial Providers Solo practitioners, private health clinics Diagnostics Laboratories and diagnostic products Pharmaceuticals Retail pharmacies, Distributors, Local manufacturing Private Hospitals Industry May provide health services to employees & communities NGO/FBO Providers of health care Industry May finance services for employees & dependents Private Health Insurance Financiers of health care NGO/FBO

5. PRIVATE HEALTH PROVIDER CENSUSES (SHOPS)

6. Purpose of the Private Health Provider Census Conducted in: Antigua and Barbuda, Dominica, Saint Kitts and Nevis, Saint Vincent and the Grenadines

7. Private Sector Facilities across 4 Countries Percentages based on identified facilities – may not include whole population Facility typesAntiguaDominica Saint Kitts and Nevis Saint Vincent and the Grenadines Total Dental Practice1177328 Diagnostic Center - 1 - - 1 Hospital - 1 - 12 Laboratory621312 Not-for-profit clinic02 - 13 Not-for-profit community based organization 622111 Not-for-profit faith-based organization11 - - 2 Other1026422 Pharmacy12651134 Private group practice/clinic8 - 7722 Private nurse practice/clinic - 21 - 3 Private physician practice (solo)/clinic1816211570 blank110 - - 11 total73525046221

8. Most common specialists include: 1. OB/GYN 2. Surgeon 3. Pediatrician 4. Internal medicine 5. Radiologist 6. Dermatologist Service Availability and Utilization – Specialty Services

9. Service Availability and Utilization NGOs contribute to HIV testing 52% of physicians detect and/or treat cancer; labs identify cancer markers 31% of clinical facilities (solo, group, dental) offer surgery with general and/or local anesthetic 41% of private facilities provide diabetes care Services in the private sectorNumber of facilities antenatal care39 cancer detection91 cancer treatment26 condom distribution or social marketing of condoms26 diabetes care92 drug/alcohol abuse prevention or treatment services49 HIV testing23 hypertension care94 labor and delivery services35 Nutrition/ Dietary services56 oral hygiene and dental care59 pediatric care78 reproductive health63 Social services71 STI diagnosis85 STI treatment56 surgery local anesthesia49 surgery, general anesthesia21

10. HEALTH ACCOUNTS (HS2020, HFG, AND UWI-HEU)

11. Purpose of Health Accounts Raising revenue for health Managing/ pooling resources Purchasing services Total Health Expenditure (THE) – total spent to improve health by public and private actors in one year How much is spent on health care? From where do funds for health come? Who and how are these funds managed? To where do these funds go

12. IndicatorBarbadosSt. Vincent & GrenadinesSt. Kitts & NevisDominica THE per capita at exchange rate 1291 367857403 THE as % GDP9%5%6% MANAGEMENT OF HEALTH FUNDS, as % THE Private funds managed as % THE – insurance 6%4%6%1% Private funds managed as % THE – NGOs<1%8%1%2% Govt-managed spending54%75%37%69% Household out-of-pocket spending39%13%56%37% Other (incl. Social Security)<1% PROVISION OF HEALTH CARE, as % THE Private practices, clinics, hospitals, pharmacies45%8%24%26% By overseas care facilities1%20%8%1% Gov't hospitals, health centers41%53%58%62% Administration4%8%3%7% Providers of preventive care0%1%6%4% Other care not disaggregated by ownership9%11%1%0% Health Financing Flows Through Private Actors

13. Household OOP Spending by Provider BarbadosSt. Vincent and the Grenadines

14. Household OOP Spending by Provider Saint Kitts and NevisDominica

15. Summary of key findings  Significant #s of private providers across the region  Many of them are in dual practice  More than half of specialists are OB/GYN or surgeons  Provide cancer testing/treatment, chronic disease care, and HIV prevention services  Private insurance is small or insignificant in the countries studied; there is limited financial protection for those seeking care at private and overseas providers  Social security and non-insurance corporations play marginal roles in health financing

16. Discussion  Are these findings expected?  What aligns with your previous understanding of the role of private providers?  What differs?

17. Discussion What could we do next to better engage for improved efficiency and sustainable financing?

18. USAID’s HFG in the Caribbean (2015-2016)  Institutional capacity building for the routine collection and use of fiscal data for ministries of health  Investment Cases for the HIV Response  What resources are needed to achieve the 90-90-90 goal? How does this compare to the current resources?  What will happen to the new infections rate if spending remains at status quo? If HIV prevention programs are cut?  Target countries with higher HIV prevalence: Trinidad and Tobago, Bahamas, Barbados, and Suriname

19. Resources for private sector engagement  Private Health Sector Assessment Guide: www.assessment- action.netwww.assessment- action.net  ProCapacity Index (NGO Sustainability) Guide  Contracting FAQ: http://shopsproject.org/contractingfaq  Health System Assessment Manual  UWI-HEU & Abt Associates can otherwise provide:  Health Accounts estimations  Financial modelling  Private sector engagement strategies, including: public-private partnerships, private sector stewardship, contracting out, NGO sustainability and commercialization, public-private dialogue facilitation, policy dialogue and development

20. For more information  Health Finance and Governance Project: www.hfgproject.org/where- we-work/latin-america-and-the-caribbean/caribbean/ /www.hfgproject.org/where- we-work/latin-america-and-the-caribbean/caribbean/ /  Strengthening Health Outcomes Through the Private Sector (SHOPS): http://shopsproject.org/about/where/caribbeanhttp://shopsproject.org/about/where/caribbean  Saint Vincent and the Grenadines Private Provider Mapping: http://svghealthfacility.gov.vc/ http://svghealthfacility.gov.vc/  Key contacts  Stanley Lalta – Senior Health Finance Advisor – University of the West Indies, HEU, Centre for Health Economics: stanleylalta@gmail.comstanleylalta@gmail.com  Rene Brathwaite – USAID-Barbados: rbrathwaite@usaid.govrbrathwaite@usaid.gov  Lisa Tarantino – HFG Caribbean Director: lisa_tarantino@abtassoc.comlisa_tarantino@abtassoc.com  Kylie Graff – SHOPS Caribbean Technical Officer: kylie_graff@abtassoc.comkylie_graff@abtassoc.com