61895 Healthy Partnerships How Governments Can Engage the Private Sector to Improve Health in Africa Healthy Partnerships How Governments Can Engage the Private Sector to Improve Health in Africa ©2011 The International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org All rights reserved This volume is a product of the staff of the International Bank for Reconstruction and Development / The World Bank. The findings, interpretations, and conclusions expressed in this volume do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. 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Contents Acknowledgments vii Foreword ix Acronyms and abbreviations xi Executive Summary xiii Introduction 1 Section 1—What engagement is and why it matters 9 Observation 1: Health systems in Africa are in urgent need of improvement 11 Observation 2: The private health sector in Africa is too large to be ignored, though it is only partly and often poorly integrated into the health system 14 Observation 3: A minimum level of engagement is an important part of the solution 20 Section 2—What our research tells us about engagement 31 Results from the data collection 33 A different type of engagement: How governments partner with faith-based organizations across the region 55 Engagement in low-resource environment 58 Level of organization of the private health sector matters 59 Section 3—Conclusions and action plan for stakeholders 63 Reforms as a political process at the country level 64 Engagement through health systems strengthening approach 65 Key conclusions by domain 65 Recommended actions by group of stakeholders 68 Action plan for future research 71 Toolkit for further guidance 72 Appendixes 73 Appendix 1—Country snapshots 74 Appendix 2—Data tables 123 Appendix 3—Conceptual background on engagement framework 131 Appendix 4—Methodology for data collection 138 Appendix 5—Scoping the private health care market 142 Notes 144 References 146 Index 151 Healthy Partnerships | iii Boxes Box 01 The Role of Business Environment Measures in Reform 6 Box 1.1 The Context of the “Healthy Partnerships” Report 10 Box 1.2 Government Financial or Technical Support for Public Health Activities in the Private Health Sector 23 Box 1.3 What Happens When We Ignore the Private Health Sector? 24 Box 1.4 How Much Engagement is the Right Amount? 26 Box 1.5 (Social) Franchising as a Way to Expand Quality Improvements 27 Box 2.1 Placing the Focus on the Self-Financing Providers 32 Box 2.2 Good Practice Example on Policy and Dialogue: Ghana 34 Box 2.3 Good Practice Example: Burkina Faso 38 Box 2.4 Good Collaboration for the 2010 FIFA World Cup in South Africa 39 Box 2.5 Beating Dengue Fever in Cape Verde 41 Box 2.6 Good Practice Example: South Africa 43 Box 2.7 The (In)Complete Registry in Mauritius 45 Box 2.8 Time It Takes to Open a Clinic 46 Box 2.9 Voluntary Certifications by Third-Party Organizations 48 Box 2.10 Incentives for Some but not All in the Democratic Republic of Congo 52 Box 2.11 Private Sector Participation in Public Schemes—The Evidence from Tanzania 52 Box 2.12 High-Level Subsidy for Malaria Drugs 54 Box 2.13 The Christian Health Association of Lesotho 57 Box 2.14 The Example of South Sudan 59 Box 2.15 Trade Associations as a Conduit for Engaging with the Private Sector 61 Box A4.1 Respondent List 138 Figures Figure x.1 Summary of Results for Policy and Dialogue and Information Exchange xv Figure x.2 Summary of Results for Regulation xvi Figure x.3 Summary of Results for Financing and Public Provision of Services xvii Figure 01 Map of Africa Displaying the Geographic Scope of this Analysis 4 Figure 1.1 Breakdown of Total Health Expenditure by Source in Sub-Saharan Africa 11 Figure 1.2 Health Outcome Trends for Sub-Saharan Africa 1990–2008 12 Figure 1.3 Under-5 Mortality Rate, Regional Comparison 1990–2009 12 Figure 1.4 Health Services Access Deficit in Sub-Saharan Africa 13 Figure 1.5 Within Country Disparities in Quality of Care 13 Figure 1.6 Source of Healthcare by Wealth Quintile for Households in Sub-Saharan Africa 14 Figure 1.7 Source of Healthcare by Wealth Quintile and Type of Service Provider for Households in Sub-Saharan Africa 17 Figure 1.8 Distribution of Facility Ownership 18 Figure 1.9 Contributions of the Private Health Sector 19 Figure 1.10 Benefit Incidence of Public Health Spending 20 Figure 1.11 Comparison of Selected Business Environment Measures across Regions 21 Figure 1.12 Availability of Supporting Services in Sub-Saharan Africa 22 Figure B1.2 Percentage of Private Providers Receiving Financial or Technical Assistance for Delivering Public Health Services, Ghana and Kenya 23 Figure 2.1 Good Practice and Results in Policy and Dialogue 33 Figure 2.2 Map of Policy and Dialogue in Sub-Saharan African Countries 34 Figure 2.3 Engagement Policy and Practice 35 iv | Healthy Partnerships Figure 2.4 Dialogue in Practice 36 Figure 2.5 Good Practice and Results in Information Exchange 37 Figure 2.6 Map of Information Exchange in Sub-Saharan African Countries 38 Figure 2.7 Information Flows across the Region 39 Figure 2.8 Health Information Requirements and Provision in Sub-Saharan Africa 40 Figure 2.9 Good Practice and Results in Regulation 42 Figure 2.10 Map of Regulation in Sub-Saharan African Countries 44 Figure 2.11 Quality of Registry of Private Clinics 44 Figure 2.12 Inspections—Paper Compared to Practice 47 Figure 2.13 Good Practice and Results in Financing 48 Figure 2.14 Good Practice and Results in Public Production 53 Figure 2.15 Private Health Sector Organization 60 Figure B2.15a Trade Association Membership in Ghana and Kenya 61 Figure B2.15b Role of Trade Associations in Engaging with the Government 61 Figure 3.1 Detailed Domain Scores: Rwanda Example 64 Figure 3.2 Alignment between Framework Domains and Health Systems Building Blocks 65 Figure 3.3 Summarized Action Plan for Governments 69 Figure 3.4 Summarized Action Plan for the Private Health Sector 69 Figure 3.5 Summarized Action Plan for Donors 70 Figure 3.6 Summarized Action Plan for Third-Party Organizations 70 Figure 3.7 Summarized Action Plan for Future Research 71 Figure A3.1 Simplified Logic Model for Private Health Sector Contributions to Health Outcomes 131 Figure A3.2 Logic Model for Private Health Sector Contributions to Health Outcomes 132 Figure A5.1 Africa: Spending on Health, by Source 143 Tables Table 2.1 A Brief Glance at the Results 31 Table 2.2 Overall Assessment Framework 33 Table 2.3 Private Providers that Submit Data to the Ministry of Health on a Regular Basis, Ghana and Kenya 40 Table 2.4 HMIS Data Reporting Requirements, Burundi and Tanzania 40 Table 2.5 Private Providers Invited to Public Sector CME Training over the Last Three Years, Ghana and Kenya 46 Table 2.6 Resource Problems for Inspections 47 Table 2.7 Selected PPPs across the Region 49 Table 2.8 Most Common Incentives to Private Providers 50 Table 2.9 Level of Health Insurance Coverage where Reimbursement for Privately Provided Services is Theoretically Possible 51 Table 2.10 Intramural Private Practice in Public Facilities 55 Table 2.11 Selected Public-to-Private Referrals Across the Region 55 Table B2.13 CHAL Facility Requirements Compared to those of Self-Financing Providers 57 Table 2.12 How Private Sector Organizations Have Positively Influenced Public-Private Collaboration 60 Table A1.1 Further Details on the Indicators Used in the Snapshots Derived from Third-Party Sources 121 Table A2.1 Selected Sub-Saharan African Indicators 124 Table A2.2 Selected Indicators from Demographic and Health Survey Data 128 Table A2.3 Definitions for Country Policy and Institutional Assessment and Demographic and Health Survey Indicators Presented in Table A2.2 130 Table A3.1 Domain Matrix for Indicator Development 134 Table A4.1 The Principle Behind the Coding of Each Element 139 Healthy Partnerships | v vi | Healthy Partnerships Acknowledgments k l d t Acknowledgments T his Report, which is part of the World Bank Group’s “Health in Africa” initiative, was made possible through funding from the Bill & Melinda Gates Foundation and the International Finance Corporation (IFC). The findings and conclusions con- tained within are those of the authors and do not necessarily reflect positions or policies of the Gates Foundation or the IFC. Lead author and project team leader was Connor Spreng. Senior guidance through- out the project was provided by Alexander Preker, as well as Scott Featherston, Khama Rogo, April Harding, Marie-Odile Waty, Cecile Fruman, and Pierre Guislain. External project partners were the RAND Corporation, together with the Results for Develop- ment Institute and the Economist Intelligence Unit (EIU). Cowriters were Ryan Mar- shall, Ifelayo Ojo, and Leo Abruzzese; as well as Dominic Montagu, Tatiana Popa, David Bishai, April Harding, and Alexander Preker. The conceptual framework underlying this Report, the additional data collection (provider survey), and the analytical work accom- panying the Report in academic publications, including excerpts included in the Report, were developed jointly with the RAND Corporation, principally Neeraj Sood, Joanne Yoong, and Nicholas Burger. The provider survey was developed in consultation with the Institute for Health Metrics and Evaluation at the University of Washington, the Schaeffer Center for Health Policy and Economics at the University of Southern Cali- fornia, and individual outside experts. The emerging analytical framework and the story line for the Report were discussed at a number of consultative meetings. A special thanks goes to Ke Xu and Eyob Asbu who represented the World Health Organization (headquarters and Africa region, respectively) during the Report’s development. The team collecting the engagement data consisted of Jean-Baptiste Blanc, Maria Bouskela, Sandrine Kouamé-Amani, Ryan Marshall, Ifelayo Ojo, and Paula Tavares. Peer reviewers of the data collection methodol- ogy were Jishnu Das and Carolin Geginat. We are indebted to the more than 750 respon- dents in the 45 countries, and to the World Bank and IFC country teams, who strongly supported the data collection on the ground. We are also grateful to the validators of the coded data; they are listed on the report’s website (www.wbginvestmentclimate.org/ health) Peer reviewers of the Report were Benjamin Loevinsohn, Philip Musgrove, and Vincent Palmade. Project management support was provided by Therese Fergo. The Report was edited by Leo Abruzzese (EIU) and Diane Stamm. Design and typesetting were done by Naylor Design, Inc. Healthy Partnerships | vii Foreword d Foreword H ealth care systems across Africa urgently need improvement. Despite concerted efforts, many countries in Sub-Saharan Africa are not on track to achieve the Millennium Development Goals. If the region is to realize its considerable prom- ise and potential in the coming years, more Africans need to have access to affordable, good quality health services. Yet public resources for health are scarce. In fact, the private health sector now provides half of all health services in the region to rich and poor alike. Private health care providers are often the only option for people living in rural regions and poor urban slums. In most of Sub-Saharan Africa, oversight of these health care providers is minimal, if it exists at all. National governments across the region and international partners are increasingly recognizing that one of the key elements to better health service delivery is improving the way in which governments and the private health sector work together. More effec- tive engagement between the public and private health care sectors in terms of better policies, regulations, information sharing, and financing mechanisms, including for the poor, would improve the performance of African health systems. It would save lives. I am therefore glad to present to our clients, partners, and other stakeholders this report on “Healthy Partnerships.” It is the first systematic and standardized assessment of government engagement with the private health sector. Along with an assessment, it also offers guidelines for improving the way public and private health sectors work together. I am confident this work will inspire practical discussions and tangible reforms, which will increase the private sector contribution to public health and cre- ate investment opportunities aligned with national health goals. IFC and the World Bank look forward to supporting these reforms and investments through our ‘Health in Africa’ initiative and through our work more generally. I wish to thank the Bill & Melinda Gates Foundation for their support, and to acknowledge the contributions of the RAND Corporation and the Economist Intel- ligence Unit. I congratulate the project team and our colleagues working in the region for their contributions and partnership in this effort. Their collaboration with external partners and clients throughout the development of this report has brought together public and private perspectives, contributing to a deeper understanding of how we can make quality health care more accessible for all Africans. Lars H. Thunell Executive Vice President and CEO of IFC Healthy Partnerships | ix Acronyms d Abbreviations y i t Acronyms and Abbreviations ACT artemisinin-based combination therapy AIDS aquired immune deficiency syndrome AMFm Affordable Medicine Facility for malaria ARI acute respiratory infection ARV anti-retroviral drug CHAL Christian Health Association of Lesotho CME continuing medical education CPIA Country Policy and Institutional Assessment CT scan computerized tomography scan DHS Demographic and Health Survey DPT diptheria, pertussis, and tetanus FBO faith-based organization FDI foreign direct investment GDP gross domestic product GHS Ghana Health Services HIV human immunodeficiency virus HMIS health management information systems HMO health maintenance organization IFC International Financial Corporation IMCI Integrated Management of Childhood Illness INSALUD coordinating organization for more than 100 NGOs IOM Institute of Medicine ISO International Standards Organization JCI Joint Commission International MCH maternal and child health MDGs Millennium Development Goals MOH Ministry of Health MOU memorandum of understanding NGO nongovernmental organization NHIF National Health Insurance Fund OECD Organisation for Economic Co-Operation and Development OHADA Organisation pour l’Harmonisation en Afrique du Droit des Affaires P4P pay-for-performance PHS private health sector PNC prenatal care PPH postpartum hemorrhaging PPM-Dots Public Private Mix-for Directly Observed Treatment PPP public-private partnership SSA Sub-Saharan Africa TB tuberculosis TBA traditional birth attendant TMP traditional medical practitioner VAT value added tax WDI World Development Indicators WHO World Health Organization Healthy Partnerships | xi Executive i y Executive Summary H ealth systems across Africa are in urgent constraints to better private sector contributions need of improvement. The public sector can be addressed, which in turn should improve should not be expected to shoulder the bur- the performance of health systems overall. den of directly providing the needed services Collaboration between the government and alone, nor can it, given the current realities of the private health sector is nothing new in Africa. African health systems. Therefore to achieve nec- Private providers, especially faith-based organiza- essary improvements, governments will need to tions (FBOs), have been serving African commu- rely more heavily on the private health sector.i nities for decades, often predating political Indeed, private providers already play a signifi- independence. But engagement between govern- cant role in the health sector in Africa and are ments and self-financing or for-profit ii providers expected to continue to play a key role, and pri- occurs far less often, even though the clear major- vate providers serve all income levels across Sub- ity of private providers are self-financing. Saharan Africa’s health systems. The World For this Report, a new framework was devel- Health Organization (WHO) and others have oped to assess the level of engagement between the identified improvements in the way governments public health authorities and private sector provid- interact with and make use of their private health ers. A team of researchers collected data through sectors as one of the key ingredients to health sys- interviews, supplemented by desk research, in tems improvements.1 Across the African region, 45 Sub-Saharan African countries. More than 750 many ministries of health are actively seeking to in-person interviews were conducted with key increase the contributions of the private health stakeholders in each country: senior government sector. However, relatively little is known about officials; private sector representatives, including the details of engagement; that is, the roles and practicing doctors and nurses; and independent responsibilities of the players, and what works experts. The results highlight those places where and what does not. A better understanding of the public-private collaboration is working well and ways that governments and the private health those where it is not. The framework and its indica- sector work together and can work together more tors also suggest strategies to enhance contributions effectively is needed. by the private health sector. This Report assesses and compares the ways in As stewards of the health care system, govern- which African governments are engaging with ments should be seeking ways to leverage available their private health sectors. Engagement is defined, resources, thereby improving quality and access. for the purposes of this Report, to mean the delib- Our research starts with three observations: erate, systematic collaboration of the government and • Africa’s health systems need to be improved. the private health sector according to national health • The private health sector is too large to ignore. priorities, beyond individual interventions and pro- • Engagement can improve the use and effec- grams. With effective engagement, one of the main tiveness of existing resources. i. The term “private health sector,” as used in this Report, includes all nonstate providers. ii. For-profit and self-financing are used interchangeably, as discussed in the Report’s introduction. Healthy Partnerships | xiii The poor performance of many of Africa’s national disproportionately benefit from public spending. health care systems is sobering. Less than 50 per- The disparity is especially pronounced in Sub- cent of all births in the region take place in a Saharan Africa, where the poorest 20 percent ben- health care facility, and only about half the chil- efit from only 13 percent of public money for dren with serious infections are treated in clinics health care compared to almost 29 percent of pub- or hospitals.2 These averages mask significant dis- lic money benefiting the richest 20 percent.7 parities in access: women in the top wealth quin- When the public and private health sectors tile are nearly six times more likely to deliver their work together, outcomes tend to improve. The lit- baby in a health care facility than women in the erature on maternal and child care shows that lowest quintile.3 Where pregnant women have closer coordination between the public and pri- access to prenatal care, it is often of poor quality. vate sectors has improved access to family plan- The private sector is part of the answer, if only ning and increased the participation of skilled because of its size. More than half of all health attendants during childbirth, both of which have care spending in Sub-Saharan Africa comes from saved lives.8 Contracting or purchasing services private parties,4 and private providers are respon- from the private sector, provided it is done well, sible for delivering at least half the services.5 This can also be effective. Here, too, the results from is true for the poor and the rich, and for urban and maternal and neonatal programs have been par- rural populations alike.6 Many patients choose ticularly impressive. private over public providers because they prefer the care, and others do so because care is not avail- Findings able from public providers. Although the quality of private services can range from very poor to Although public-private collaboration is not a very good, it is comparable to what is provided by new concept, the framework used in this Report public providers, often because many doctors and to measure it is. Based on a public economics nurses work in both sectors. The private health framework, we identified five domains that col- sector not only provides additional access to care, lectively constitute engagement: but also is a source of much-needed capital, com- • Policy and dialogue petition among providers, management skills for • Information exchange operating complex systems like hospitals, and • Regulation innovation and flexibility in health care delivery. • Financing Harnessing these potential contributions fully is • Public provision of services. the critical challenge. The goal of this Report is not to argue for a There is more engagement with the nonprofit sec- greater or smaller role of the private sector in tor than with self-financing providers across all health care, but for a closer collaboration between domains in all countries. Governments typically the public and private sectors and a stronger con- trust FBOs, the dominant form of nonprofit pro- tribution of the private sector toward national viders, because of their social aims and their com- health priorities. The policies and practices sug- mitment to the public good. The engagement is gested here can improve public-private engage- also high because FBOs are relatively well orga- ment. The private sector must be an integral part nized and often predate the establishment of the of any solution to providing more equitable health public health systems. In many countries, FBO care to all people, since the public sector cannot facilities are indistinguishable from public facilities solve the problem by itself. An example of a mis- and some serve as public reference hospitals. The conception about equitable health care is that it is close collaboration between the public health sec- sometimes believed that public spending on health tor and FBOs is not without its challenges, how- care mostly benefits the poor. However, it is fre- ever. Shortcomings in each of the five domains quently the relatively wealthy, not the poor, who frequently reduce the effectiveness of the engage- xiv | Healthy Partnerships ment with the FBOs. The often-blurred lines between the government and the private health between FBOs and public facilities make the stan- sector is low across the region. However, there dardized assessment and comparison of engage- are a growing number of countries in which a ment impractical. Therefore, the key findings and dialogue is being (re-)initiated as a necessary first conclusions for each domain, described below, step in improving engagement. In Ghana, for refer to the engagement between the government example, the level of engagement between the and the for-profit or self-financing providers—the government and the private health sector has clear majority of the private health sector. greatly improved since the existing private health sector policy was revived through a new forum Policy and dialogue for dialogue. The private sector, in turn, has The policy and dialogue domain concerns the pri- responded by forming an umbrella organization vate sector policy framework on paper and in of private providers, a critical step. Indeed, practice, as well as the level of dialogue between beyond Ghana, the organization of the private the public and private sectors. Policy and dialogue sector itself is critical in establishing a dialogue, between the government and the private health but is lacking in most countries. sector are the foundations of effective engage- See figure x.1 for a regional summary of the ment; they set out roles and responsibilities of the results for policy and dialogue and information different actors. A functioning dialogue with pri- exchange. For more details on the individual vate providers is a sign that the government is indicators, refer to Appendix 4 of the Report. aware of their presence, takes them into account, and views them as partners. Information exchange While more than 85 percent of the countries The information exchange domain concerns infor- we studied have an official policy of working mation flows between the public and private sec- with the private health sector, the majority of tors, and private sector inclusion in national health Sub-Saharan African countries do not actually management information systems and disease sur- implement the policy. The level of dialogue veillance. Accurate information about the scale FIGURE x.1 Summary of Results for Policy and Dialogue and Information Exchange Individual indicators Results for 45 countries Policy & dialogue Policy exists for engaging with PHS De facto implementation of engagement policy (1–4) Formalized mechanism for dialogue with PHS De facto dialogue (1–4) PHS included in information exchange (1-4) Information exchange PHS required to provide information to MoH beyond DS De facto information provision by PHS to MoH beyond DS PHS included in Disease Surveillance Program PHS receives DS updates from MoH in emergencies Source: “Healthy Partnerships” data, 2010. Yes / no Note: PHS = private health sector; MoH = ministry of health; DS = disease surveillance. High / medium / low / very low for 1–4 score For detailed definitions, see Appendix 4 in the Report. Healthy Partnerships | xv and scope of privately provided care is a key ingre- Regulation dient of engagement. Information systems remain The regulation domain focuses on the ability of incomplete if they do not include the private the government to design and implement a regu- health sector. This is especially pertinent if the pri- latory framework for the private health sector. vate health sector is providing a large proportion The registration of private health facilities, as a of health services. Having separate or designated basic precondition for effective planning in the information systems for the private health sector health system, falls under regulation. Among the on its own is neither necessary nor more effective. five domains, governments tend to overemphasize Information exchange is weak in most countries, regulation, without properly accounting for the with a majority of countries lacking basic elements lacking enforcement capacity. of a well-functioning system. Despite existing legal The registration of private providers is poor in requirements for the private sector to provide data most countries, which leaves a critical gap in the to the Ministry of Health, the data seldom reach understanding of “who does what” in the health the government. There are somewhat higher levels system. In addition, regulations are often inappro- of inclusion of the private health sector in disease priate or outdated and enforcement is weak across surveillance programs. Particularly during severe the region. Overly complex frameworks that are disease outbreaks, governments often reach out contradictory or that cannot be implemented as aggressively to private health providers and include intended create uncertainty and opportunities for them in official programs. arbitrary enforcement. Even private providers The few countries that do relatively well in this complain about the lack of consistent regulatory domain, such as Burkina Faso and Rwanda, keep oversight, which allows low-quality providers to the private sector well informed and include pri- continue to operate. It is critical for governments, vate providers in existing public health sector but also for the private health sector, to under- information channels, such as for health manage- stand that self-regulation can substitute for ment information systems data. enforcement by the government. A notable exception to the weak regulatory frameworks across the region can be found in FIGURE x.2 Summary of Results for Regulation Individual indicators Results for 45 countries Quality of private health sector providers registry (1–4) Reported judgment of quality of regulation Regulation is enforced as intended Standardized rules exist for opening PHS clinic Regulation Quality control process for clinics—de jure De facto quality control executed for PHS clinics Quality control is the same for PHS and public providers Cont’d med education requirement for license renewal Continued education open to PHS professionals Policy/engagement toward traditional medicine exists Source: “Healthy Partnerships” data, 2010. Yes / no Note: PHS = private health sector. High / medium / low / very low for 1–4 score For detailed definitions, see Appendix 4 in the Report. xvi | Healthy Partnerships South Africa, where the private health sector is financial incentives specific to private health sec- considered one of the best performing in the tor facilities serves as a proxy for whether the gov- world and operates in a highly regulated environ- ernment seeks to improve the investment climate ment, including strict enforcement. Aside from for the private health sector. Finally, and perhaps the fact that the capacity of both government and most important, the level of private provider cov- private health organizations is high, the private erage by health insurance is used as a proxy to sector is primarily funded through insurance. This assess whether a significant part of the population builds in a strong incentive for compliance with can access the private health sector without hav- rules and regulations. See figure x.2 for a regional ing to pay out-of-pocket. summary of the results. The Report finds that a third of Sub-Saharan Africa governments contract with self-financing Financing providers for services, and half of those govern- The financing domain covers the revenues that ments also offer financial incentives. Seven coun- are actually or potentially available to the private tries offer financial incentives but no contracts. health sector and the government’s influence of The level of health insurance coverage that would such funds through various mechanisms. The key allow reimbursement for treatment received in a to financing is to ensure that there is a mechanism private facility is low; in most African countries, it that allows poor people to have access to services, is available to less than 15 percent of the popula- and that public funds buy value for money from tion. But the levels of health insurance coverage either public or private services that compete on a are growing. There is a strong interest in expanding level playing field. This principle of strategic pur- such coverage and a clear momentum to do so. In chasing (buying services from the best providers several countries, for example, Ethiopia, Kenya, regardless of ownership) is especially important in Nigeria, and Uganda, the introduction of an countries where the private sector is large. expanded (public) insurance scheme is at an As a proxy for whether governments are com- advanced stage. See figure x.3 for a regional sum- mitted to improving the effectiveness of public mary of the results in financing and public provi- funds, the existence of any ongoing contracts to sion of services. pay private providers is used. The existence of any FIGURE x.3 Summary of Results for Financing and Public Provision of Services Individual indicators Results for 45 countries Government uses contracts with PHS Financing Incentives are provided for PHS operators Overall population covered by health insurance (0-4) PHS receives vaccines, medicines or similar for distribution PPS A functioning public-private referral process Source: “Healthy Partnerships” data, 2010. Yes / no Note: PHS = private health sector; PPS = public provision of services High / medium / low / very low for 0–4 score For detailed definitions, see Appendix 4 in the Report. Healthy Partnerships | xvii Public provision of services in the private health sector), on narrow issues The public provision of services domain focuses hold some promise for engagement at the sys- on how governments use the direct production of tems level. health care inputs and health services to collabo- rate with the private health sector. Through stra- Action plan tegic allocation of resources, governments can use public production to complement, crowd out, or While this Report focuses on the technical aspects build a supporting environment for private health of engagement, the importance of the political care markets. In addition, the public sector can process cannot be overstated. Sophisticated and ensure the availability of basic services and insti- technically appropriate solutions are useless if tutional support. Like the private sector in gen- they are not translated into concrete action by the eral, the private health sector also depends on stakeholders. Indeed, the application of the frame- infrastructure services such as water, electricity, work proposed here, and the implementation of and good roads. changes in policy and practice, is a political chal- In many countries, there is some evidence that lenge rather than a technical one. All stakehold- governments and the private sector can collabo- ers—governments, the private health sector, but rate relatively well on disease and immunization also donor and third-party organizations—are programs. In addition, there is some form of patient impacted by such reform. referral between the private and public sectors in Key actions needed include the following: most countries. These instances of collaboration, • For governments, a first step in the short term sometimes prompted by the requirements of is to avoid interventions that are unnecessarily donor programs (for example, requirements to burdensome for the private health sector. make donated medicine also available to patients xviii | Healthy Partnerships Beyond that basic step, an ongoing dialogue • Third-party organizations, such as insurance with the private sector is needed, as is a basic agencies and civil society organizations, can play understanding of its size and activities: who is an important role in facilitating and supporting in business, which services they are providing, engagement and providing support to the pri- and where they are located. A better under- vate health sector to upgrade its operations. standing of what type of private providers are With respect to the analytical work, the action serving the poor, for example, is critical for the plan going forward is to build on this important success of public health programs. In the longer first step in understanding engagement in a more term, review and reform of the key policy systematic way. What lies ahead is the further instruments are needed, particularly of regula- development of the framework for assessing tion. Often it will be a matter of simplifying engagement and its application in areas that were the rules and bringing them into alignment beyond the scope of this Report. Further work with what can be enforced. Especially for toward how public-private engagement can be instruments that are technically and politically improved will benefit African health systems and difficult, such as financing, it is advisable to their patients. start with relatively simple, but concrete, steps. Designated resources are available for stake- That way the necessary capacity and experi- holders interested in taking an active role in the ence can be developed over time. improvement of public-private engagement. A • For the private health sector, forming credible toolkit with detailed information on approaches associations or representative organizations is and practical steps to reforms can be found at an essential first step. Being well represented www.wbginvestmentclimate.org/health. will enable a productive dialogue with the gov- In conjunction with the other available resources ernment, including the identification of priori- and with the expertise at the country level, this ties and capacities. An especially important Report should be used as an advocacy tool in the area for collaboration in the longer term is reform process. The framework developed here quality of care. Provider networks, improve- and used to assess engagement across Sub-Saharan ments of internal quality control in clinical Africa provides a starting point for developing a practice, and business management training are country-specific reform agenda, and better engage- all effective ways for the private sector to ment can lead to reforms in the health sector more improve the quality of their services. broadly. Even though the challenges are enormous and • Donors are asked to support engagement at all improvements in African health systems are levels and to include the private health sector urgent, the willingness—and even demand—to in intervention programs, where appropriate. look at health systems in a new way is reason to Donor funding and project designs should not hope. When public and private sectors work in be based on preconceived notions of the size, partnership, improved access to affordable, high- ability, and motivations of the private health quality care is achievable in Africa. sector. Healthy Partnerships | xix xx | Healthy Partnerships Introduction A frica’s health systems are in crisis. Sub- A set of measures to assess and compare engage- Saharan Africa accounts for 12 percent of ment is presented in Section 2. The emphasis is on the world’s population yet bears 26 percent a basic level of engagement—whether private of the global disease burden.9 Health outcomes in health provision is included in the government’s the region are poor and significantly worse than policies, planning, and implementation. Especially elsewhere. Patients too often are denied access to in countries where the private health sector is high-quality goods and services, and achieving large, engaging the private health sector along the Millennium Development Goals (MDGs) 4, 5, basic domains that we have defined is essential for and 6, which are related to health, is unlikely. the proper functioning of the health care system. Most of the region lacks the infrastructure and Such engagement should be undertaken strategi- facilities necessary to provide adequate levels of cally rather than piecemeal, and within the context health services and products. It also faces a severe of the country’s priorities and political decisions. shortage of trained medical personnel; just 3 per- In this Report, the term public-private partner- cent of the world’s health workers are deployed ship (PPP) is used only as a reference to particular in Sub-Saharan Africa. transactions. A public-private joint venture for an Asking governments alone to provide more individual hospital, for example, would be called a and better services is not enough. Since the pri- PPP. The other use of the term PPP, to denote vate sector is large, improving services only ongoing public-private cooperation more generally, through improvements of public sector services will is not applied here. PPPs are discussed as one par- be—at best—only partially successful. Although ticular form of engagement on individual projects. the size of the private sector varies by country, it is surprisingly large and constitutes an important, Definition of the private sector diverse component of the region’s health care sys- The private health sector is defined here to include tems. Roughly half of all spending across the all nonstate providers. This includes pharmacies, region is captured by private providers.10 Helping hospitals, retailers, and doctors who operate on private providers offer a wider range of quality both a for-profit and a nonprofit basis. Many coun- services is imperative. Part of the solution lies in tries also rely heavily on traditional healers. There better collaboration between the public and pri- are several organizational forms: vate health sectors. • For-profit operators typically pay market rates The objective of this Report is to suggest poli- to obtain financing and charge a market rate for cies and practices that improve engagement their products and services. The “for-profit” between the public and private health sectors, label can be misleading, however, because based on the needs and priorities of each country. many do not make an officially declared profit For the purposes of this Report, engagement and some incur significant losses. To account means the deliberate, systematic collaboration of the for this, we use the term “self-financing” inter- government and the private health sector according changeably or in conjunction with “for profit.” to national health priorities, beyond individual inter- ventions and programs. Healthy Partnerships | 1 • Nonprofits are typically associated with a private health sectors, the quality of provided broader nongovernmental organization, whether care and the ability to deliver care in underserved domestic or international, from which they areas is highly variable.iii The growth of the pri- sometimes receive financial or managerial sup- vate health sector for its own sake is not the goal port. Some of the declared nonprofits are actu- of this Report. National governments should, ally quite profitable, charging market rates for however, make best use of available resources to all of their services. Faith-based organizations address the tremendous health care challenges. are the dominant nonprofit health providers The insistence that privately provided care in many African countries, and are sometimes should be replaced at any cost by publicly pro- so intertwined with the public health sector vided care does not provide a practical way for- that they are indistinguishable.11 As Section 1 ward for African health systems. explains, however, faith-based organizations— With regard to financing of health care ser- though they are the most important nonpro- vices, we refer to the conclusions of the “World fits—are not as prevalent in the health care Health Report 2010,” which calls attention to system overall as is commonly thought. The the high proportion of out-of-pocket payments self-financing or for-profit facilities collectively for health systems in poor countries, particularly provide a far larger share of health care services in Africa.12 The report strongly advocates reduc- in most countries. ing the share of out-of-pocket payments while increasing the reach of risk-pooling mechanisms, • Traditional practitioners and informal provid- whether public or private. The same conclusion ers constitute a large group in many countries. was reached in the International Finance Corpo- Bringing them under the direct influence of ration 2008 report, “The Business of Health in policies and engaging with them at the systems Africa,” which focused on the private health sec- level is a major challenge. Their role within the tor in Africa.13 Reducing out-of-pocket pay- health system must be well understood if ments is likely to be achieved at least partly by health interventions are to be successful. increased public financing and by a lower overall These different entities that constitute the private private sector share in health financing. Appen- health sector, and their engagement with the gov- dix 5 offers projections for how health financing ernment, are further discussed in the following and the public-private mix in health financing sections. may develop in the coming years. Two additional groups of actors are worth The focus of this Report is primarily on final mentioning, though they are not considered a service delivery and the facilities that provide part of the private health sector: (a) intermediaries such services (hospitals, clinics, pharmacies and, or third-party organizations, such as insurance to a limited extent, diagnostic laboratories). Less authorities, nonhealth private sector organizations, focus is placed on the private sector’s role in input or civil society organizations (such as consumer markets, such as for drugs and equipment, educa- advocacy groups); and (b) donors, who have an tion of medical professionals, and so forth. This important role in financing health programs and prioritization does not imply that the private sec- shaping health policy indirectly at a national level. tor does not matter for input markets, but is sim- ply based on the need to focus the analysis. The role of the private sector in Engaging the private sector outside of service delivering and financing health care services The role of the private health sector is not just a iii. The private health sector is said to be better at providing curative care than preventive care, even when preventive care might be critical issue, but a contentious one as well. This more cost-effective. This observed tendency, however, has much Report does not recommend an appropriate size to do with the way care is financed (that is, largely out-of-pocket for the private sector, particularly in terms of payments paid by individuals only when they get sick) and less with what types of services the private health sector can provide health care service delivery. For the public and effectively. 2 | Healthy Partnerships delivery (such as support services like nonmedical While a part of this informal provision of care services for public hospitals) is discussed in Sec- will remain outside the reach of policies and reg- tion 3 as an example of how to start with small ulations, informal providers who are not regis- reforms. The critical role of the private health sec- tered but who offer services in a commercial tor in input markets and potential indicators of fashion are important players in many African public-private engagement in input markets can health care systems. The quality of care among be addressed in future research. this group of providers ranges widely. Creating efficient platforms for their formalization and Type of providers we focus on including more of these informal providers in This Report focuses on government engagement the organization and planning of the overall with the full range of actors within the private health sector should be a priority. The best strat- health care system, especially smaller providers of egies for engaging these groups will vary from private health services, because they comprise the country to country, but the potential benefits of most numerous and most accessible source of care forging closer links are large. to many people. The sophisticated and highly spe- cialized institutions, such as private tertiary hospi- Geographic scope of analysis tals for the urban affluent, are also an important The Report focuses on 45 Sub-Saharan African part of the landscape. We are a bit less interested countries, excluding Djibouti, Eritrea, and Soma- in these institutions, however, even though they lia.iv Page 4 contains a complete list and map (fig- are of interest to investors. These institutions do ure 01) of the countries. not really have a problem with engagement It should be noted that the framework for because they are big and prominent; they deal analysis and reform of engagement introduced in directly with the government and often do so this Report may be relevant for developing coun- fairly well. Partnerships with these institutions are tries outside of Africa, as well. discussed separately below. At the other end of the spectrum, health ser- iv. All countries in the study are grouped in the Africa region of the World Bank Group. Djibouti is part of the Middle East and North vices are often offered by small formal and infor- Africa region. Data collection could not be carried out in Eritrea and mal providers, including friends and family. Somalia. Healthy Partnerships | 3 Broadly, the geographic scope of the study is Sub-Saharan Africa. More specifically, the study covers the following 45 countries (shaded blue in figure 01): • Angola • Gabon • Niger • Benin • Gambia, The • Nigeria • Botswana • Ghana • Rwanda • Burkina Faso • Guinea • São Tomé and Príncipe • Burundi • Guinea-Bissau • Senegal • Cameroon • Kenya • Seychelles • Cape Verde • Lesotho • Sierra Leone • Central African Republic • Liberia • South Africa • Chad • Madagascar • Sudan • Comoros • Malawi • Swaziland • Congo, Democratic Republic of • Mali • Tanzania • Congo, Republic of • Mauritania • Togo • Côte d’Ivoire • Mauritius • Uganda • Equatorial Guinea • Mozambique • Zambia • Ethiopia • Namibia • Zimbabwe FIGURE 01 Map of Africa Displaying the Georgraphic Scope of this Analysis Tunisia Morocco Algeria Arab Former Libya Republic Spanish of Egypt Sahara Cape Mauritania Verde Mali Niger Eritrea Senegal Chad The Gambia Sudan Burkina Guinea-Bissau Faso Djibouti Guinea Benin Côte Nigeria Ethiopia Sierra Leone d’Ivoire Ghana Liberia Central African Rep. Togo Cameroon Equitorial Guinea Somalia Uganda São Tomé and Príncipe Gabon Kenya Rwanda Congo Dem. Rep. of Burundi Congo Tanzania Seychelles Comoros Angola Malawi Mayotte Zambia (Fr) Zimbabwe Mozambique Namibia Mauritius Madagascar Botswana Réunion (Fr) Swaziland South Africa Lesotho 4 | Healthy Partnerships Maternal and child health serves as a proxy, Between February and July 2010, a team of six where needed consultants conducted more than 750 face-to- This Report deals with health systems in general face interviews with key stakeholders during on- and so does not focus on a particular disease. site visits to the 45 countries mentioned above. Where it is useful to be more specific, however, Data were collected and coded for each of the five maternal and child health (MCH) is used as a domains from each of the 45 countries. This proxy. This is appropriate, because MCH is included written (de jure) information and empir- included in two of the three health MDGs and ical information—that is, what was happening in will therefore rightly capture the attention of pol- practice (de facto), as we describe in Section 2. icy makers and other stakeholders. On a more Standardized guidelines were used to collect technical level, MCH measures are good proxies the data, and a key-respondent list was developed for the performance of the overall health system, to ensure that approximately the same number especially in Africa. Indeed, the best current data and type of respondents were interviewed in each source for health-related information is the country. Interviewees included government offi- Demographic and Health Survey (DHS), which cials, policy makers, regulators, private providers, has good coverage of MCH issues. development organizations, and independent experts. The data collected during the interviews Assessing engagement across the region were combined, as appropriate, with data from As mentioned, the objective of this Report is to desk research. The team coded the interview data improve engagement between the public and pri- to allow comparison across countries. The results vate health sectors. We identified five “domains” were then validated by two in-country experts to that comprise engagement. They are as follows: ensure accuracy. • Policy and dialogue: This encompasses the Why measure at all underlying policy framework related to the pri- Introducing new comparative measures in the vate health sector and the degree to which the health sector is especially challenging, because the private health sector is included in discussions standard for demonstrating impact is high. For regarding policy and practices. individual interventions or programs, scientifically • Information exchange: This is the flow of opera- rigorous impact evaluations are necessary to dem- tional information between the private health onstrate impact. At the systems level, such tools sector and the Ministry of Health. cannot be employed easily, especially with poli- cies or practices pertaining to the private health • Regulation: This comprises the rules that gov- sector. Most of the effects one might hope to attri- ern the private health sector, including the bute directly to changes in policy will be over- registration of health providers and quality whelmed by other variables, including changes in control. nonhealth policies, the economy (for example, the • Financing: This comprises the sources of funding recent global recession), weather, agricultural out- and purchasing arrangements to pay for goods put, and nutrition. and services delivered by private providers. This should not be a reason to ignore the rela- tionship between the private and public health • Public provision of services: This includes the care sectors. The policies and practices of public- goods and services directly produced by the private engagement can and ought to be studied.14 public sector that impact the operating envi- As Section 2 will show, engagement matters in ronment of the private health sector. countless cases across the region; successes have The process used to collect data for this Report been documented where engagement works well, was as follows. and inefficiencies linger where it does not. We have also explored the more tenuous link between Healthy Partnerships | 5 BOX 01 The Role of Business Environment Measures in Reform I nternational organizations that need to assess and com- pare the operating environment for private business across countries use such sources as the World Bank’s Doing Business Overall, Rwanda introduced reforms in 7 of the 10 catego- ries, including reducing the time to start a business to three days (involving just two procedures), better than rankings, the World Economic Forum’s Global Competive- most developed countries. It also cut the time required to ness Index, and the Economist Intelligence Unit’s country- register property by 255 days, eased access to credit by risk profiles. These business environment snapshots, while allowing a wider range of assets to be used as collateral, imperfect, are a useful guide to the political, economic, and removed bottlenecks at the revenue authority. Rwanda legal, and regulatory challenges firms face when operating also maintained its place among the top-10 reformers in locally. In Sub-Saharan Africa, where the private health sec- the 2011 Doing Business report, coming in second of the tor is large and diverse, the quality of the business environ- top-10 reformers and improving its overall rank on the ment is particularly important, and is likely to be a critical ease of doing business scale to 58th of the 183 economies factor in the provision of private health services. ranked. Most Sub-Saharan African countries rank poorly in the However, health care is not like most other industries, global business environment indexes. In the 2011 Doing so most business environment measures are insufficient. Business indicators, the 46 Sub-Saharan Africa countries All global business environment guides assume companies had an average rank of 137 out of 183 countries, the are providing goods and services in a market environment worst in the world. The relative standing for most African in which the private sector is dominant, the normal forces countries is similar in other indexes, as well. Although the of supply and demand are paramount, and a lighter regu- rankings do not measure conditions for health providers— latory touch is preferred. These assumptions are not always such as the number of procedures required to open a clinic true in health care. Medical care is widely regarded as a or a pharmacy—the focus on small, locally owned and human right, not a discretionary service. As such, govern- operated firms is relevant, because most private health ments will inevitably play an oversight role, setting national providers are in this category. policies and goals and then, ideally, integrating the private Some of the measures have been quite successful in sector into a wider plan. The partly public nature of health motivating policy reform. For example, Rwanda has care usually leads governments to take on the responsibil- steadily reformed its commercial laws and institutions and ity of ensuring access to and quality of the system, con- was the leading reformer in the Doing Business 2010 cerns that are typically the responsibility of private firms in report, moving from 143rd to 67th place in the ranking. nonhealth businesses. Source: World Bank, Doing Business 2010; World Bank, Doing Business 2011. engagement and health outcomes, but these International and regional agreement on results are not presented here due to their tenta- the issue—demand for this work tive and somewhat experimental nature. This Report is not unique in arguing for increased See box 01 for a discussion of how standard- attention to engagement. Internationally, a con- ized policy measures can be effective in spurring sensus is emerging that the private sector’s role reform, even as the health care sector differs from in delivering health care should be understood the business sector in terms of goods and services and better leveraged. Even among critics, the provided in a market environment. importance of proper engagement is increasingly acknowledged, and prominent international organizations increasingly are endorsing this view. The World Health Organization in 2010 emphasized the importance of “strengthening 6 | Healthy Partnerships the capacity of governments to constructively Section 2 presents the results of our compara- engage the private sector in providing essential tive analysis of engagement in 45 Sub-Saharan health-care services.”15 African countries. Using a public economics More important, it is African policy makers framework, we analyze engagement using the five and health sector practitioners who are increas- domains described earlier. Positive and negative ingly aware that improved engagement is needed. case studies illustrate the challenges and potential Policy makers are recognizing the need to employ for reform. the resources that are available in their countries Section 3 discusses next steps, both in terms of and to work with the choices that consumers future research and needed reforms. An action make, such as when they choose private over plan is presented for each of the relevant stake- public providers. Indeed, we have found strong holders: governments, the private sector, donors, support for our work among policy makers and and third-party organizations. Topics that should private sector representatives, and among inde- guide future policy discussions are introduced and pendent experts in each country. There is almost briefly discussed. universal consensus about the overall approach: Five appendixes present additional indicators the private sector, including the for-profit sector, for countries covered by this Report and details should be better included in the national health on the methodology used. Appendix 1 provides a system and can make a greater contribution to it snapshot of each of the 45 countries. Appendix 2 than is currently the case. contains data tables with the full set of indicators that are used in the Report. Appendix 3 presents Roadmap of the Report background on the concepts underlying the Section 1 explains the focus on engagement and framework of engagement. Appendix 4 presents why this is an opportune time to offer a frame- the methods used to obtain the engagement data. work for analysis and reform. Appendix 5 offers projections for how health financing and the public-private mix in health financing may develop in the coming years. Healthy Partnerships | 7 8 | Healthy Partnerships Section 1: What engagement is and why it matters In July 2010, 27-year-old Yaaba was admitted late at night to the All Saints Hospital in Western Africa, a private facility run by Dr. Kwabena. Referred from the nearby Sophie’s Maternity Home, also a private institution, Yaaba reached the hospital already in shock. She had been in labor for 36 hours and had suffered a uterine rupture before her arrival at All Saints. While Dr. Kwabena performed emergency surgery, other medical staff began blood transfusions and fluid replacement, but neither Yaaba’s life nor that of her child could be saved. Her obstructed labor was not in itself a death sentence. Prompt identification of the problem and quick referral to the hospital would almost certainly have saved her life and her child’s. To make matters worse, several other pregnant women had been referred from Sophie’s Maternity Home too late to make a difference, ending in needless tragedy. Two weeks after Yaaba died at All Saints, 22-year-old Efue arrived at the same hospital. She, too, was in obstructed labor and had been suffering for 10 hours. Fortunately, the problem was identified relatively quickly and she was referred early enough to All Saints—but from a different privately run maternity home. After Dr. Kwabena and two attending nurses performed a cesarean section, Efue delivered a baby girl who required only minor resuscitation. Efue and her daughter recovered quickly. After a week, Efue’s stitches were removed and she and her daughter were discharged.v S ome of the solutions for improving the per- sector overall would have had the chance to con- formance of health systems in Africa are not tribute better service. difficult, as the stories of Yaaba and Efue Private providers have an important role to show. From the perspective of both clinical prac- play across Africa. Much of the care provided by tice and health systems oversight, Yaaba’s death the private health sector is of high quality. Some was preventable. Had her obstructed labor been is not. As stewards of their health systems, gov- correctly identified by the midwife and the refer- ernments should be seeking ways to improve ral to All Saints Hospital happened sooner, both the contributions of the private sector across the she and her child would likely have been saved. region. Many are already doing so, but few Efue was more fortunate in choosing a provider details are known about the roles being per- who recognized the limits of her ability and formed, how they vary across the continent, and referred Efue in time. While this relatively simple what works and what does not.16 Even less is clinical solution can vastly improve health care known about what kind of collaboration for pregnant women in Africa, the continued between the public and private sector best fur- operation of a provider like Sophie’s Maternity thers the public interest in an African context. Home puts expectant mothers with any kind of This Report seeks to fill that gap by presenting complication at risk. Had a regulatory board or a and discussing our results in a way that will con- midwife’s council exercised even the most basic tribute to the conversation, regionally and in oversight, Sophie’s Maternity Home would have individual countries. (See box 1.1 for a discus- been forced to improve or close, and Yaaba and sion of the broader “Health in Africa” context in her child might have lived. The private health which this Report was written.) v. All names have been changed. Healthy Partnerships | 9 BOX 1.1 The Context of the “Healthy Partnerships” Report T his Report’s focus on how governments and the pri- vate health sector are working together is being pre- sented in the context of the “Health in Africa” initiative, a “The Business of Health in Africa” identified a number of significant constraints to the further development of a sus- tainable and socially responsible private health sector that is joint project of the World Bank and the International integrated into the broader strategies developed by regional Finance Corporation (IFC) (for more information, see governments. These include limited access to capital, short- www.wbginvestmentclimate.org/health). Assessing and ages of skilled workers, a lack of risk-pooling mechanisms improving public-private engagement is, however, only that can mobilize revenue for providers, and an inappropri- one element in increasing the contributions of the private ate operating environment. To improve the operating envi- health sector in the region. Therefore, some context on ronment, the report recommends (a) developing and the motivation for this Report is useful. enforcing quality standards through both government and In December 2007, with the assistance of the Bill & self-regulation, (b) encouraging governments and donors to Melinda Gates Foundation, the IFC published “The Busi- engage more closely with the private sector, and (c) modify- ness of Health in Africa: Partnering with the Private Sector ing local policies and regulations to better support and to Improve People’s Lives.” The report concluded that: mobilize the private sector. These findings inform the “Health in Africa” initiative (a) Private providers already play a significant role in the as it aims to increase access to health-related goods and health sector in Africa. A poor African woman today is services and improve well-being. Working directly with as likely to take her sick child to a private hospital or governments and the private health sectors in the region is clinic as to a public facility. a major part of this undertaking, as is the provision of financing mechanisms for private health care providers. (b) The private sector is sometimes the only option for As an integral part of these ongoing efforts, the Healthy health care in rural regions and poor urban slums. Pri- Partnerships Report reexamines some of the findings of the vate providers serve all income levels, have broad geo- “Business of Health in Africa” report and assesses the ways graphic reach, and are expected to continue to play a African governments are engaging with private providers. key role in Sub-Saharan Africa’s health systems. The detailed assessment and the recommendations of how (c) The private and public sectors must work together to partnerships can be improved are this Report’s principal con- develop more viable, sustainable, and equitable health tributions. With better knowledge about engagement, one care systems in Sub-Saharan Africa. The private sector of the main constraints to better private sector contribu- can help expand access to services for the poorest peo- tions can be addressed, which in turn will improve the per- ple and reduce the financial burden on governments. formance of the health system overall. Collaboration between the private and public In this Report, we focus primarily on the degree sector in health is nothing new in Africa. Indeed, to which engagement with the private health sec- the private sector as a provider of health care ser- tor is comprehensive. Thus, in accordance with vices predates political independence and the our definition of engagement, we consider the emergence of the public health sector in most most basic building blocks of engagement at the countries. There are many good examples of public- systems level: whether governments are taking private collaboration within health subsectors and the private health sector into account at a funda- disease programs. Partnerships on specific proj- mental level and therefore making the best possi- ects and in individual hospitals are not uncom- ble use of available resources in all the subsectors mon. We return to these below, because they of their countries’ health systems. constitute elements of what we understand to be engagement. 10 | Healthy Partnerships FIGURE 1.1 Three observations provide the starting point for this Report: Breakdown of Total Health Expenditure by Source in Sub-Saharan Africa • Health systems in Africa are in urgent need of 100 improvement.17 90 • The private health sector is too large to be 49.5 Public sector 27.6 Risk-pooled and other 80 ignored, though it is only partly and often share private expenditure poorly integrated into the health system.18 70 • Even a minimum level of public-private engage- 60 percent ment can improve the use of existing resources 50 and contribute to better-quality health care in 40 Africa.19 30 50.5 Private 72.4 Out-of-pocket sector expenditure 20 share OBSERVATION 1 10 Health systems in Africa are in 0 urgent need of improvement Source: World Bank, World Development Indicators, 2010. Africa’s policy makers face enormous challenges. Note: SSA averages include the 45 countries covered by this report. Even in areas where the solutions are well known, such as improving maternal health, many health systems are not performing well.20 The story of of children under 5 years of age in Sub-Saharan Yaaba is all too common. In too many countries, Africa have declined by 28 percent since 1990, the Millennium Development Goals (MDGs) are but every other region has improved even more, not being achieved and some trends are going in and the death rate is nearly twice as high as any the wrong direction.21 At the same time, out-of- place else (figure 1.3).27 pocket spending for health services is high, and Health systems across the region are not per- the burden of these direct payments, especially on forming nearly well enough to adequately address the poor, is potentially devastating (figure 1.1).22 the dismal state of health outcomes. Across the An African woman has a 1 in 16 chance of region, health systems lag far behind in measures dying in pregnancy or childbirth over the course of access and quality, and it is the poor who suffer of her life; in developed countries, the ratio is 1 in most from this lack of performance. On average in 4,000.23 Although progress has been made on a given country, only about half of all births take some fronts, health outcomes throughout much place in a health facility, and less than half of all of the continent are dismal and hardly improving. children with symptoms of acute respiratory Life expectancy at birth was just 53 years in Sub- infection (ARI) are taken to a health care facility28 Saharan Africa in 1990. By 2008, it had increased (see figure 1.4). to only 54 years, a legacy of the acquired immune While only 15 percent of women of reproduc- deficiency syndrome (AIDS) epidemic.24 In some tive age say they use modern family planning cases, Africa is backsliding: the number of new methods, a quarter of all women report an unmet tuberculosis cases (TB) in the region each year has need for contraception.29 Almost one-quarter of more than doubled in the last two decades (figure children aged 12–23 months have not been vac- 1.2).25 Sub-Saharan Africa accounted for almost cinated against measles; diptheria, pertussis, and 43 percent of all deaths globally in 2004 from tetanus (DPT)30 (see figure 1.4). communicable diseases, maternal ailments, and These regional averages mask significant dispari- poor nutrition, even though it represents only 12 ties, both among and within countries. In Benin, percent of the global population.26 Even where most women deliver in a facility; in Ethiopia, the progress has been made, it has been fitful. Deaths vast majority of births take place at home and only Healthy Partnerships | 11 FIGURE 1.2 Health Outcome Trends for Sub-Saharan Africa 1990–2008 Life expectancy and maternal mortality ratio Prevalence of HIV and incidence of Tuberculosis 55.0 800 8 0.40 54.5 (% of population ages 15–49) 700 7 0.35 Incidence of tuberculosis Maternal mortality ratio Life expectancy (years) 54.0 (% of population) 600 6 0.30 Prevalence of HIV 53.5 (per 100,000) 53.0 500 5 0.25 52.5 400 4 0.20 52.0 300 3 0.15 51.5 200 2 0.10 51.0 100 1 0.05 50.5 50.0 0 0 0.00 1990 1995 2000 2005 2008 1990 1995 2000 2005 2008 Life expectancy at birth, total (years) Prevalence of HIV, total (% of population ages 15–49) Maternal mortality ratio (modeled Incidence of Tuberculosis (as % of population) estimate, per 100,000 live births) Source: World Bank, World Development Indicators, 2010. Note: SSA averages include the 45 countries covered by this report. FIGURE 1.3 6 percent of women deliver in a formal health care Under-5 Mortality Rate, Regional Comparison 1990–2009 setting.31 For children suffering from ARI, access to 200 facilities also varies widely across the region. In Uganda, 76 percent of sick children see a provider Under-5 mortality rate (per 1,000) 180 160 Sub-Saharan Africa in a health facility compared with only 9 percent in 140 South Asia Chad.32 In Niger, 16 percent of women of repro- 120 Middle East & North ductive age report an unmet need for contracep- Africa 100 tion; in Rwanda, the figure is more than twice as East Asia & Pacific 80 large (37 percent).33 In countries as diverse as Cape Latin America & 60 Caribbean Verde, Eritrea, Mauritius, Rwanda, and the Sey- 40 Europe & Central Asia chelles, reported DPT immunization is almost uni- 20 North America versal (97 to 99 percent), while in Chad, 80 percent 0 European Union of children have not been immunized.34 1990 1995 2000 2005 2009 Even where services are available and used, the quality is far from guaranteed. Across countries, Source: World Bank, World Development Indicators, 2010. Note: Regional averages represent regional data as stated by the WDI. almost 80 percent of women reported receiving some form of prenatal care from a professional health services provider.35 In Namibia, Rwanda, Tanzania, and Uganda, 94 percent of expectant mothers said they received such prenatal care.36 However, when asked whether they received all five of the basic prenatal services at some point during their pregnancy (blood pressure checks, blood tests, urine tests, weight check, and discus- sion of complications), the picture is much bleaker. In Namibia, only 53 percent reported 12 | Healthy Partnerships FIGURE 1.4 Health Services Access Deficit in Sub-Saharan Africa Children under 3 with ARI symptoms receiving care in medical facility (%) Expectant mothers receiving prenatal care from a skilled medical professional (%) Deliveries with skilled medical professional (%) 0 10 20 30 40 50 60 70 80 90 100 Children receiving measles immunization (%) Children receiving DPT immunization (%) 0 10 20 30 40 50 60 70 80 90 100 Source: Demographic and Health Survey data; World Bank, World Development Indicators, 2010. Note: SSA averages represented for DHS data include the countries for which data are available (see Appendix 1). WDI averages include the 45 countries coverd by this report. ARI = acute respiratory infection; DPT = diptheria, pertussis, and tetanus. receiving all five services; in Tanzania, only 20 per- FIGURE 1.5 cent did; and in Rwanda and Uganda, less than 5 percent did (figure 1.5).37 Within-Country Disparities in Quality of Care Worse, large gaps persist among socioeconomic groups in almost all countries. While the quality 70 of prenatal care is fairly constant for women in 63.6 Namibia, Tanzanian women are four times more 60 likely to receive all five services if they are in the Women getting all 5 PNC 50.8 services (%): Total population top wealth quintile compared to the women in 50 48.0 Women getting all 5 PNC the lowest quintile.38 The disparities in quality of services (%): Poorest quintile 40 Richest quintile care are even bleaker for women in Rwanda and percent Uganda, as figure 1.5 shows. Similarly large gaps exist in terms of access to care. Women in the top 30 wealth quintile across the region are nearly six times more likely to deliver in a facility than 20 women in the lowest quintile, while women in 13.2 12.4 urban areas are three times more likely to do 10 so than women in rural areas.39 The lack of over- 0.3 3.0 1.4 all access exacerbates disparities, as we saw in 0 Rwanda Uganda Tanzania Namibia our earlier examples. In Ethiopia, inequality in access to facilities is stark: the richest women are Source: RAND analysis of Demographic and Health Survey data, latest survey year 35 times more likely to deliver in a facility than included. Note: PNC = prenatal care. the poorest women, and mothers in urban areas are 18 times more likely to do so than those in rural areas.40 Even at the lower end of the inequal- ity spectrum, Benin, differences persist: the rich- Healthy Partnerships | 13 est women are 1.6 times more likely to deliver in dren with symptoms of ARI do so from private, a facility than the poorest women, and women in self-financing providers.46 Across Africa, 52 per- urban areas are 1.2 times more likely to do so than cent of those in the bottom income quintile women in rural areas.41 received their care from private providers, equal to the proportion of Africans in the top quintile, as shown in figure 1.6. The figure shows that the OBSERVATION 2 private sector’s share in delivering services is The private health sector in Africa is fairly constant across the income quintiles, too large to be ignored, though it is viewed regionally. only partly and often poorly integrated into the health system Consumer choice matters The fact stated in the observation is not well Many patients have options when they need understood, even among policy makers. The pri- health services and make thoughtful decisions vate sector—whether funding health care or about where to access care. This is often a separate delivering it—is a large and important part of the concern from how far they have to travel or how landscape in Africa. Of the roughly US$55 billion much they need to pay.47 Research has shown spent on health care in Africa in 2007, 55 percent that consumers choose their health-care providers came from private parties, and most of that was based at least in part on perceived levels of qual- paid by individuals out-of-pocket.42 About half of ity.48 Studies conducted in rural northern Tanza- that expenditure was captured by private provid- nia found that people will skip providers closer to ers.43 Many of the transactions between patients and providers are happening FIGURE 1.6 regardless of government policy. Despite the availability of “free” essential services Source of Health Care by Wealth Quintile for at public health centers in some coun- Households in Sub-Saharan Africa tries, private facilities still provide a sig- 100 48 49 51 51 48 nificant portion of the services. In 90 Uganda, for example, more than 60 per- 80 cent of children with symptoms of ARI taken to a facility are treated by the pri- 70 44 vate health sector. 60 percent 50 52 51 52 The private sector serves the poor 49 49 40 Private care is not just the province of the rich, who are better able to afford it. 30 While in some countries, such as 20 Namibia and South Africa, the private 10 health sector indeed caters primarily to 0 the wealthy who have private health Poorest Poorer Middle Richer Richest insurance, this situation does not hold Public sector Private sector regionally. Studies consistently show Source: Analysis of DHS surveys; latest survey year available included; that the private sector cares for people Montagu 2010. from a wide range of incomes, including Note: All data are drawn from the sum of all Population-Weighted Sub- poor and rural populations.45 In Chad, Saharan Africa Demographic and Health Surveys conducted after 2000. Source of treatment is a summary of respondents with children under 5 Niger, and Uganda, more than 40 per- years of age reporting treatment in the prior two weeks for diarrhea and cent of people in the lowest economic fever/cough. quintile who seek health care for chil- 14 | Healthy Partnerships them (or those that are possibly cheaper) and would rather not linger on the teaching hospi- travel longer distances for specific conditions.49 tal’s long and erratic waiting lists. The price dif- The severity of particular episodes of illness and a ferential between the private facility and the judgment of provider competence were the key government hospital is not large for surgeries, deciding factors. and the level of expertise of the surgeons is the Patients often choose private providers over same, although the teaching hospital is better public facilities because they prefer the type and equipped. quality of care being offered by private providers. Those who need antibiotics, hospital consum- It is important for governments to acknowledge ables, and other medications not available in the and, where possible, take advantage of, such teaching hospital’s pharmacy know to visit the health-seeking behavior rather than ignore it.50 private Momrota Pharmacy, which is conve- The private health sector, even on a single street, niently located next to the hospital. Ekundayo makes up a rich and diverse marketplace of ser- Pharmacy, another private provider about 300 vices that, on balance, contribute positively to the meters south of Momrota, also stocks everything health landscape. from over-the-counter medicines to intravenous fluids. Other drug sellers and patent medicine Taiwo Road example vendors can be found within walking distance on A drive along Taiwo Road in Ilorin, Kwara State, this busy street. A typical consumer walks in Nigeria, paints a picture of the typical cosmo- with a “prescription,” which could have been politan African town. Buildings of every size, written by a friend, colleague, or health worker. shape, and condition are arrayed in a jumble While some ask the pharmacists and drug sellers along the road; dingy and deluxe residential to recommend the best drug treatment plan to apartments exist side by side with banks, appli- treat their illness, a final decision may be based ance shops, and offices. Tucked between these on ability to pay. stores and shops are clinics, pharmacies, and, at Ilorin is also home to traditional bone setters, the upper end of the road, the federally funded who are well known for their expertise in “cur- University of Ilorin Teaching Hospital. People ing” fractures of all kinds. But they have been come to this almost three-mile-long strip to buy known to refer patients with genuinely serious practically everything—from clothes to electron- problems to orthopedic specialists at the teach- ics, groceries to medications. They also come to ing hospital. Some of these traditional practition- visit the bank, get a haircut or a manicure, and ers charge more than the teaching hospital for see a doctor. fracture management, but some consumers pre- The teaching hospital does not charge for fer them anyway. consultations, but all surgeries are billed accord- Baptist Hospital, a faith-based facility, is ing to a standard price list for the procedure. located in nearby Ogbomoso. It was established Medications and medical supplies can also be as Baptist Medical Center in 1917, but has since purchased from the pharmacy department at set grown to be a critical care institution with the fees. Hassanat Memorial Hospital, also on Taiwo rank of a teaching hospital. People have been Road, is a private establishment where many coming from neighboring villages and even states low-income mothers receive general medical to be treated at Ogbomoso because, like many care for their sick children. Use of generic medi- faith-based facilities in Nigeria, it is considered cations keeps prices low, and the average patient to be more accessible and affordable than other pays about 1,000 naira (about US$7) for malaria hospitals. treatment, the most common malady the hospi- The private health sector in many African tal sees. Further along Taiwo Road is Joe-Steve countries is similarly vibrant, demonstrating much Private Hospital, which is well known for elec- of the diversity on display in Ilorin, Nigeria. tive surgical services, especially for those who Healthy Partnerships | 15 Wide range of providers— vices offered by doctors in public facilities. They different needs and opportunities can triage patients and successfully treat most As the Taiwo Road example shows, health services common ailments, but they face a number of con- in Africa are delivered by a wide variety of private straints when they practice privately. providers. They range from formally trained spe- One common complaint among lower-level cialists in clinical care to roadside vendors hawk- health workers is the unequal opportunity to ing dubious medications to traditional healers in practice. They may be allowed to run public facil- corner shops. ities on their own, but must find a supervising As discussed above, the private sector share of doctor when they aspire to operate privately. health care provision across income quintiles is Some of the constraints are imposed for safety very stable. However, the share shifts toward more reasons—a few providers are overzealous and are formal and higher-quality providers in the higher- tempted to stray beyond their capabilities and income population. Figure 1.7 shows the sources training. But other constraints are simply due to of private health care by income. The formal pro- poor planning and untargeted policies. Regulators viders are labeled in blue and the informal provid- appear overwhelmed by the diversity of actors, ers in red. levels of training, and the difficulty in finding In some countries, drug sellers are recognized effective, standardized guides for their practice. as formal providers and are permitted to sell a Traditional medical practitioners (TMPs) are a limited range of medicines; in other countries, case in point. Policy makers (and international they cannot operate without a supervising phar- organizations working in health) have found it macist. Informal and traditional practitioners difficult to integrate them fully into the health most often work in rural areas, almost always systems. However, in some African countries, without government oversight. TMPs far outnumber orthodox practitioners; Official policies and practices impact different Swaziland is home to about 11,000 TMPs but providers in unique ways. The degree to which only 200 physicians for a population of about they are affected by, or are in need of, government 1.2 million.51 In other countries, the World intervention differs widely. A critical element of Health Organization (WHO) reports similarly good engagement is the government’s understand- glaring contrasts in availability of health service ing of the composition and capacity of the private providers. WHO cites studies done in Tanzania, sector. This includes knowing the approximate Uganda, and Zambia that reveal TMP-to-popula- range and relative importance of provider types in tion ratios of 1:200 to 1:400; allopathic practitio- each country. Some policies are based on an ner ratios were typically 1:20,000 or less.52 incomplete or inaccurate picture of the actors in Traditional medical practice is a highly lucrative the health system. This makes it essential to collect business in some countries, and consumers can basic information on private- and public-sector sometimes pay more than they would for allo- activities in a systematic, consistent manner. pathic clinical care. Zambia, for instance, has an As the Introduction indicated, this Report estimated 40,000 healers who garner about 60 focuses on the full range of the private health sec- percent of total household health spending.53 tor, including the numerous small, private provid- From these numbers, it is evident that traditional ers. These are doctors, nurses, and midwives with medicine is consistently popular among patients modest clinics, and lower-level health workers even though it comes with many challenges. Peo- who make primary care more readily available to ple have been known to suffer complications underserved populations in many countries. These because of time lost trying traditional cures, and workers go by different names in different coun- some herbal medicines are ingested in borderline tries and include clinical officers, assistant medical toxic proportions for long periods, leading to kid- officers, medical assistants, physician assistants, ney disease.54 Pregnant women have developed and health officers. Many of these providers also vesico-vaginal fistulas at the hands of overzeal- work in the public system or supplement the ser- ous traditional birth attendants (TBAs) who do 16 | Healthy Partnerships FIGURE 1.7 Source of Health Care by Wealth Quintile and Type of Service Provider for Households in Sub-Saharan Africa 100 100 Other nonformal 90 90 Friends / relatives Traditional 80 80 49.2 Public 33.1 practitioner Informal 70 70 Shop 60 60 Other formal percent average percent 50 50 Religious hospital Community health 40 40 worker 30 50.8 Private 66.9 Formal 30 Mobile clinic 20 20 Private doctors Pharmacy 10 10 Hospitals 0 0 All providers Private sector Poorest Poorer Middle Richer Richest providers Source: Analysis of DHS surveys; latest survey year available included; Montagu 2010. Note: All data are drawn from the sum of all Population-Weighted Sub-Saharan Africa Demographic and Health Surveys conducted after 2000. Source of treatment is a summary of respondents with children under 5 years of age reporting treatment in the prior two weeks for diarrhea and fever/cough. not know the limits of their practice.55 Some gest in Lesotho and received around US$100 mil- unscrupulous TMPs mix up pharmaceutical lion in investment, it is governed by different rules products into so-called “herbal medicines” with- than most other health care providers. This col- out regard for dosage, side effects, drug interac- laboration, and similar, specific partnerships, pro- tions, or toxicity. vides an opportunity for improved engagement The highly informal care that some providers with the private health sector. offer to friends and family will likely remain Different rules also apply to the nonprofit sec- beyond the reach of regulation. This is true not tor, especially faith-based organizations (FBOs). just in Africa. But the relative size of the informal These differences tend to persist even as the lines sector can be influenced by registration policies of separation between the subsectors fade or dis- and practices. At the other end of the spectrum appear. Here, too, the structure and history in are large private hospitals that are often in a posi- each country matters. Nongovernmental organi- tion to collaborate directly with the Ministry of zations (NGOs) are nonprofit organizations, Health. They are often subject to very specific although many are quite lucrative. Faith-based rules and therefore are also outside the normal providers, in particular, are often assumed to dom- regulatory framework. The very scale of the collab- inate the private health sector, but in-depth assess- oration for these large institutions may necessitate ments in several countries show FBOs constitute such special treatment. The new Queen Elizabeth a smaller proportion than is generally assumed. II hospital in Maseru, Lesotho, is such an example. In Kenya, for instance, 43 percent of the facil- The collaboration between the government and a ities in the Ministry of Health database in 2006 consortium led by Netcare, a leading private were privately owned, 41 percent were publicly health care provider in South Africa that manages controlled, and just 16 percent were nonprofits, the hospital, has received much attention and which includes faith-based facilities. Although been seen as a model. Since the hospital is the big- the majority of the private sector facilities were Healthy Partnerships | 17 smaller clinics, the utilization data (determined too common. The opportunities to engage in over- by a 2003 household survey) revealed that out- and underservicing, false billing, and price goug- patient visits to the private commercial sector ing are especially damaging when many of the exceeded those of FBOs in both urban and rural patients are poor, badly informed, or illiterate. settings. These figures are consistent with the Cases of self-referral, in which patients are fact that there are 1,400 more (280 percent directed to other services in which the provider more) private commercial facilities than FBO has a financial interest, are frequent.59 And, just facilities in Kenya.56 like their public sector counterparts, even respon- The private health sector assessment in Ghana sible private health care providers sometimes fail found that private providers (both self-financed to deliver an appropriate level of care.60 and faith-based) produce 56 percent of all ser- The overall impact of private-sector providers vices used by Ghanaian consumers, as measured on health systems and on equity is itself a much- by the respective shares of self-reported utiliza- debated issue. Several studies have shown that tion. Only 7 percent of the total comes from the the quality of care provided by the private health faith-based sector.57 sector in underregulated developing countries Though the relative share of private self-financ- can be poor. This can adversely affect health out- ing, private nonprofit, and public providers differs comes, including disease control and drug resis- considerably between countries, the results shown tance.61 But poor quality is also a challenge for in figure 1.8 for Ghana and Kenya are indicative of public providers, and consumers often prefer the the regional averages. An earlier study on the private sector due to perceived better quality, regionwide share of health spending captured by easier access, and greater responsiveness. Evi- for-profit or self-financing providers compared to dence from recent multicountry studies suggests nonprofit providers came to a similar conclusion.58 that quality of care and provider competence are roughly equivalent in the public and private The private health sector offers health sectors (figure 1.9).62 the full spectrum of quality of care A recent cross-country analysis of Sub-Saharan The care provided by the private sector is not Africa found that private sector participation is always as good as it should be. In countries where positively and significantly associated with better the private health sector is large and diverse, health system performance, improving access, and examples of unethical business practices are all reducing disparities between rich and poor and FIGURE 1.8 Distribution of Facility Ownership 7% 16% 41% Public 44% Private self-financed 43% 49% Private nonprofit Kenya, 2006 Ghana, 2005–06 Source: Barnes, et al. 2010; Results for Development Institute, forthcoming. Note: Kenya data were obtained from the Kenya Ministry of Health data. Ghana data represents provider choice for most recent consultation in Ghana Living Standards Survey–5. 18 | Healthy Partnerships FIGURE 1.9 urban and rural populations. The results are robust to controlling for per capita gross domestic prod- Contributions of the Private Health Sector uct and maternal education, two important confounding factors that are correlated with COMPLEMENTARY both increased private sector participation and Services provided by private and public health sectors complement each other; they are overall equivalent in terms of improved health care access (figure 1.9).63 A large private sector share may raise concerns —Quality of delivered care —Out-of-pocket payments required to receive care about user fees thought to be associated primar- At the systems level, higher private sector participation in Sub-Saharan ily with the provision of private health services. African countries is not associated with reduced access or higher User fees suggest that increasing the role of the disparities in access. private sector will limit the use of health care among the poorest, who cannot afford to pay, consequently reducing access and equity.64 Evi- SPECIFIC & ADDITIONAL dence suggests, however, that these concerns are Private health sector also offers unique contributions to the health system, namely not limited to the private health sector. Indeed, (i) technology and innovation; across the region, a considerable amount of “pri- (ii) needed financial capital; vate business” takes place in supposedly free pub- (iii) competition, which can raise overall system performance; lic health care facilities. Visits to public clinics or (iv) management skills; and dispensaries across the region usually require the (v) flexibility to adapt to difficult and often fast-changing circumstances. patient to part with some amount of money for Plus, there are examples of engagement (e.g. for specific interventions) the doctor or health care provider.65 In some set- which have achieved tangible results quickly. They are discussed tings, this is a normal practice that is condoned below in Observation 3. (though not openly sanctioned) by the Ministry Source: Das, Hammer, and Leonard 2008; Yoong et al. 2010; Results for Development of Health to retain poorly paid public sector Institute, forthcoming; Patouillard, Goodman, and Hanson 2007. health workers. In other countries, such “under- the-table” payments in state-owned facilities are frowned upon or even criminalized. Overall, Making best use of available resources there is no systematic evidence on whether user This Report does not to argue for a greater share of fees in the public sector are even lower than in privately provided care, but for acknowledging the the private sector.66 For example, patient exit sur- private sector as an important component in the veys conducted as part of a 2009 study in Ghana provision of health care to all. While public spend- found that the amount of out-of-pocket pay- ing on health care is sometimes believed to mostly ments patients pay is similar in public and private benefit the poor, the opposite is true. It is frequently facilities (figure 1.9).67 the wealthy, not the poor, who disproportionately The best approach to improving access to care benefit from public spending, and not just in Africa. is to build on the resources of a private health sec- A 2010 study found that 17 percent of the benefits tor that is already responsible for a large part of from public health spending globally accrue to the the current levels of access, especially in light of poorest quintile compared with 23 percent to the the resource constraints of existing health sys- richest quintile (see figure 1.10). In Sub-Saharan tems.68 Beyond financial resources, the private Africa, the disparity is even more pronounced: the health sector can bring innovation, competition, poorest quintile benefits from only 13 percent of responsiveness to patients, and management public money for health care compared to almost capacity into the system. A range of interventions 29 percent benefiting the richest quintile.70 designed to improve use and equity through Another study recorded a similar benefit distribu- engagement of self-financed providers has been tion in Ghana: one-third of public health spending shown to be successful (figure 1.9).69 benefits the richest quintile, while just 12 percent of public health spending benefits the poorest quintile. The numbers are similar for Tanzania.71 Healthy Partnerships | 19 FIGURE 1.10 cal where an entirely different medical infrastruc- Benefit Incidence of Public Health Spending ture has been evolving for more than half a century. Privately provided care should be a wel- Poorest Richest come addition to government programs. Global (%) 16.9 23.2 Sub-Saharan Africa (%) 12.9 28.6 OBSERVATION 3 A minimum level of engagement is Breakdown for SSA by type of health care facility an important part of the solution Primary health care (%) 15.3 22.7 Governments are responsible for improving Health centers (%) 14.5 23.7 national health systems, a duty that is enshrined in Hospitals (%) 12.2 30.9 the constitutions of most countries. But the lack of public resources, and the size of the private Source: Davoodi et al. 2010. health sector in Africa, suggests that governments Note: SSA = Sub-Saharan Africa. Analysis includes 12 countries: cannot fulfill this responsibility unless they prac- Côte D’Ivoire, Djibouti, Ghana, Guinea, Kenya, Madagascar, Malawi, Mauritania, Mozambique, South Africa, Tanzania, and Uganda. tice some minimal level of engagement. Indeed, basic elements of engagement are the most impor- tant—making the private health sector a fully rec- The evidence cited here suggests that the pri- ognized partner in policy setting, planning, and vate health sector has a positive contribution to implementation. make to meet the formidable challenges that Afri- Section 2 offers evidence from our assessments can health systems are facing, even as concerns across the region of whether and how govern- with private delivery remain. Appropriate collabo- ments are currently engaging with the private ration and partnerships within the health system health sector in each country. Consistent qualita- are needed to leverage the contributions effectively. tive evidence illustrates the mostly positive effects Despite the private sector’s large role, much of engagement. Similarly, the data show how a of what it does is not aligned with national health lack of engagement will hamper the effectiveness priorities. In Kenya, for example, a frequently of public health interventions. voiced frustration from all parties is that hospital bed occupancy rates differ dramatically between The government’s role in shaping the operating environment public and private facilities: while several private hospitals in Kenya have empty beds, public hospi- Engagement is not the only factor that shapes the tals are overcrowded.72 In some instances, these environment within which the private health sec- overcrowded public hospitals are adjacent to tor operates. Just as important are the characteris- underused private hospitals. Elsewhere, the dif- tics of the overall health system, and general ferential bed occupancy rates may be reversed, government policies toward the private sector and but the main point holds: in an environment in the health sector. To present a more complete pic- which overall resources are scarce, inefficiencies ture, measures of engagement are compared with are especially costly, pointing to the need for bet- other aspects of the broader business operating ter coordination. environment. The country snapshots in Appendix The question we seek to address is how the pri- 1 illustrate a selection of these measures for each vate health sector’s contributions to the public country individually. interest can be improved. Replacing privately pro- One of the government’s principal roles is to vided services with publicly provided care— create a business environment conducive to invest- which, it is often argued, should be less expensive, ment and growth and to create a “level playing easier to access, and of better quality—is impracti- field” for all private firms. This overall business environment will also impact private providers in the health sector. But how well are governments 20 | Healthy Partnerships FIGURE 1.11 Comparison of Selected Business Environment Measures across Regions SSA: 644 Time to enforce a contract (days) LAC 0 EAP 1,100 ECA MENA SA OECD SSA: 317 Time to prepare and pay taxes (hours per year) 400 0 SA MENA EAP ECA LAC OECD SSA: 96 Cost of business start up (% of income per capita) 0 ECA EAP MENA 100 OECD SA LAC SSA: 44 Time to start a business (days) 60 0 OECD MENA EAP LAC ECA SA Source: World Bank, Doing Business 2011. Note: EAP = East Asia and Pacific; ECA = Europe and Central Asia; LAC = Latin America and the Caribbean; MENA = Middle East and North Africa; OECD = Organisation for Economic Co-operation and Development; SA = South Asia; SSA = Sub-Saharan Africa. fulfilling this role? The World Bank’s Doing Busi- In Section 2, where the operating environment ness indicators provide measures of the business for private health providers is examined in more environment for the private sector overall, as dis- detail, we see that important differences emerge cussed in box 01 in the Introduction. The regional between the private health sector and the non- Doing Business averages show that Africa lags health private sectors. behind in these measures and in its overall operat- Infrastructure and the availability of essential ing environment. Figure 1.11 shows selected proxy services like water and electricity matter for any measures for the Africa region compared enterprise, including health providers. Whether to other regions and to countries belonging to the such services are available, especially in rural areas, Organisation for Economic Co-operation and will significantly impact the cost of doing busi- Development (OECD). The average among SSA ness. Given the distributed benefits of providing countries for number of days it typically takes to these services,vi ensuring their availability is usu- enforce a contract is similar to the averages in ally a responsibility of the government. Access to other regions. In terms of paying taxes and starting clean water and provision of sanitation, as well as up a business, however, the measures are signifi- other inputs, are especially critical for private cantly worse for Africa. Only in Latin America and the Caribbean does it take longer to pay taxes or vi. That is, because many benefit from the services, any single person will not want to bear the costs of providing them. Therefore, a mechanism start a business. When it comes to the cost of start- is needed through which many collectively can bear the cost, since ing a business relative to income, Africans have to many will reap the benefits. In short, public financing is needed. pay the most by far. Healthy Partnerships | 21 FIGURE 1.12 example. Extending the provision of goods that Availability of Supporting Services in Sub-Saharan Africa are to be distributed to the private sector can improve the effectiveness of these public health 80 interventions. Box 1.2 discusses this example 70 from the perspective of private health providers. 60 Impact on outcomes 50 Evidence of the need for engagement at the sys- 40 tems level is instructive, but understanding the 30 impact on intermediate outcomes (access, 20 equity) or even health outcomes (maternal mor- tality, under-five mortality, life expectancy, and 10 so forth) may be the ultimate test. Such esti- 0 mates are part of the future research agenda. In % population % population Adult female with access to with access to literacy rate the meantime, the evidence in the program eval- improved improved (%) uation literature offers clues to the impact of sanitation water including the private health sector in specific Source: World Bank, World Development Indicators, 2010. interventions. Program evaluation evidence from maternal and child health literature An overarching theme of the maternal and child operators who want to provide uninterrupted health (MCH) literature is that strategies must care to patients. As proxy measures for the avail- first identify capacity to build on it.73 There is ability of key services, we include the World growing evidence and an emerging consensus that Bank’s World Development Indicators on water these strategies must be targeted at the commu- and improved sanitation. These are also featured nity level and executed by local stakeholders. This in the country snapshots. As an additional proxy approach has accelerated improvements in out- measure for supporting services by the govern- comes across Sub-Saharan African countries.74 ment, we include the rate of female literacy. Successful maternal health interventions using Mothers who can read are not only an important the private sector show how initiatives can be determinant of child health—the education of scaled up to achieve better health outcomes. The women is an indirect way for the government to following three interventions have benefited from improve the welfare of children—but is also a extensive evidence and support in maternal health proxy for the degree to which the private health literature: sector’s patients are in a position to make more informed decisions. • Family planning: Ample evidence demonstrates As figure 1.12 shows, the private sector in that family planning is key to improving MCH Africa cannot rely on much support in terms of outcomes and that family planning ideally the availability of essential services. The connec- lends itself to scale-up through the private sec- tion between the engagement indicators and the tor. One-third of maternal deaths could be pre- other indicators of the operating environment is fur- ventable if all families had access to family ther elaborated on in Appendix 4. planning technology.75 For example, private One relatively uncontroversial avenue for sector distribution of condoms and oral contra- engaging the private sector is providing financial ceptives has been under way with good results or technical assistance for activities that have large in several countries for decades. Indeed, around public health benefits. The control of vaccine- 57 percent of the developing world’s expendi- preventable and other infectious diseases is a good ture on family planning is made by consumers 22 | Healthy Partnerships BOX 1.2 Government Financial or Technical Support for Public Health Activities in the Private Health Sector W e surveyed private clinics in Ghana and Kenya to assess whether they received any financial or tech- nical assistance from the government for conducting activ- Observation 2, above), by targeting only public facilities, a significant fraction of the poor population may not benefit from public health interventions. This is especially unfortu- ities that had potential public benefits, including childhood nate in light of the scarce available resources for such immunization programs, control of HIV/AIDS, and antima- interventions, since in effect excluding indigent patients of laria or tuberculosis initiatives. Figure B1.2 shows that in private providers is likely to decrease the returns on the both Ghana and Kenya, relatively few private clinics report public funds spent. receiving assistance for these key public health activities. For example, in Kenya, roughly 20 percent of clinics said FIGURE B1.2 they received support for providing childhood vaccinations, Private Providers Receiving Financial or Technical Assistance for Delivering Public Health Services, 36 percent said they received support for HIV/AIDS preven- Ghana and Kenya tion, and about 25 percent said they received support for 100 malaria or tuberculosis activities. In Ghana, government 90 engagement with the private health sector for these key Ghana health activities is even lower. Only 12 percent of private 80 Kenya clinics received financial or technical assistance for child- 70 Percent hood vaccinations and only about 15 percent received assis- 60 tance for HIV/AIDS, malaria, and tuberculosis programs. 50 These data suggest that existing government engagement 40 with the private health sector for key public health activities 30 is relatively limited. 20 Increasing the level of engagement is likely to provide 10 significant benefits, given that a large share of the popula- tion in Ghana and Kenya, and Sub-Saharan Africa more 0 Provide Control of Control of generally, accesses health care at private facilities. Since a childhood HIV/AIDS malaria or TB significant share of low-income households seeks health vaccinations care from private facilities in Sub-Saharan Africa (see Source: “Healthy Partnerships” provider survey, 2010. themselves,76 with the private sector capturing is not intended to discourage a movement the vast majority of that spending. In terms of toward more facility deliveries, but it is a prac- quality, community workers, who include tical, scalable, and relatively inexpensive pharmacists, health workers, volunteers, and intervention that can reduce severe, life- dispensers, have been shown to safely and threatening PPH, and can buy a woman time effectively administer injectable contraceptives to reach a facility. Extensive evidence sup- at the household level.77 ports expanded efforts either through govern- ments or NGO partners to train TBAs and • Misoprostol home deliveries for prevention of other community health workers to adminis- postpartum hemorrhaging: The efficacy of ter misoprostol to women in labor in the misoprostol in the treatment of postpartum home.79 Scale-up of these efforts requires the hemorrhaging (PPH) has been established by implementation of safeguards to ensure that the obstetrics research community for settings misoprostol is not administered until the third where oxytocin is not available.78 Misoprostol Healthy Partnerships | 23 stage of laborvii and to ensure against diversion The stories of Yaaba and Efue at the beginning of misoprostol for alternative uses.viii Second- of this section showed the importance of generation studies abound that model deaths obstetric support and the availability of emer- averted80 and costs saved from community- gency obstetric care. The best ways to ensure based TBA training in misoprostol administra- quality of care are through midwifery training tion, all of which confirm a high degree of programs or through obstetricians where cost-effectiveness.81 they exist, the financing of private-practice establishment, franchising, and strengthening • Expanding skilled birth attendance: Expectant accreditation. 83 mothers are much more likely to live if a skilled attendant is present at childbirth and an obste- In addition to the positive effects of the inclu- trician is available for backup at a hospital.82 sion of the private health sector in interventions, the opposite has been documented: when inter- vii. Administration prior to the third stage is associated with a higher risk of uterine rupture. ventions are designed and implemented without viii. Misoprostol’s potential use as an abortifacient has led to black the private health sector in mind, they are less market sales of the drug. Well-intentioned distribution of miso- effective. Box 1.3 presents an example in the area prostol to prevent maternal hemorrhage without safeguards could trigger removal of the drug in settings where anti-abortion activ- of child health. ists are likely to exploit any evidence of misoprostol diversion. BOX 1.3 What Happens When We Ignore the Private Health Sector? A n example of what happens when we ignore the private health sector is the Inte- grated Management of Childhood Illness (IMCI) The IMCI program encountered several strate- gic and systemic failings. Most important, how- ever, it failed to expand community outreach program, which is designed to promote improve- activities or achieve sustainable results. While ments in child health in developing countries. It treatment quality in frontline public clinics has is based on the concept that treatment of the improved in some countries, measurable improve- common childhood illnesses should be provided ments in child health attributable to IMCI have in an integrated and holistic manner, maximizing only been found in Tanzania. Equally critically, the the health benefits of each contact the sick program has generally not explored the role and child has with public health facilities. IMCI was potential contribution of the private sector, widely introduced between 1996 and 2001 in because the IMCI approach has really only most countries with moderate-to-high levels of included activities to improve services provided in child mortality and formally targeted three areas: public clinics, even in countries where private pro- (a) the quality of clinical care, (b) the functional- viders were actually seeing the large majority of ity of basic facilities, and (c) the effectiveness of sick children. Program designers apparently outreach activities. This usually involved the believed that if they could substantially improve training of frontline staff in how to treat the the services offered, the large number of people most common childhood illnesses, public facility who were going elsewhere (or not seeking care) improvements such as staff supervision and would quickly switch to them. But much evidence drug availability, and efforts to expand commu- shows that people continue to go to providers in nity education about good health practices in the community that they trust and find conve- the home. nient—and these providers are very often private. Source: Harding, forthcoming. 24 | Healthy Partnerships Contracting or purchasing Dangers of excessive engagement A major, recurring question is whether the private Not all government intervention or engagement is sector should be employed to deliver health care benign. As we advocate for improved government goods and services on behalf of the public sector. engagement with the private health sector, it is While this is only one part of engagement, the important to acknowledge that potentially nega- results from our research show the relationship tive impacts from inappropriate intervention by between the public and private health sectors is the government are real. Some governments fail frequently dominated by that question. Interest in their basic duties to provide oversight in the has been growing in financing mechanisms that economy. This can be a matter of capacity, but focus more on outputs or the services produced, also of corruption or willful neglect. In consider- and less on the inputs or the costs associated with ing the options for effective engagement, such operating a facility, for example. The private constraints must be taken into account. Examples health sector is far more inclined to organize seri- of such inappropriate intervention, often in the ously and work with the government if there is a form of excessive rules, abound in Africa for the realistic chance of being contracted to provide private health sector. Section 2 presents a number clinical services. From the government’s perspec- of these examples. tive, purchasing services from providers, whether Beyond the health sector, much of the work on public or private, offers an alternative to simply improving the investment climate in developing allocating budgetary funds to public facilities. The countries focuses on keeping the points of contact government can also use limited resources on the between the government and the private sector to most needed services, choosing flexibly from pub- a necessary minimum (box 1.4). Each contact lic or private facilities. However, such financing point is an opportunity for delays, arbitrary appli- arrangements also require the capacity to oversee cation of rules, graft, or for capacity constraints by them. Practical toolkits have been developed to the government to impede the development of help governments with contracting.84 the private sector. When it comes to health care, Impressive results have been recorded when not every additional contribution by the private purchasing or contracting is done well. A system- sector requires more government involvement. In atic review of studies in developing countries85 Mauritania, only citizens can own private health identified eight cases that showed measured sector facilities and only citizens of a few addi- improvements in quality, access, or both, from tional countries can freely work in them. This has contracting services in maternal and child health. thwarted the attempts by foreign investors and Indeed, the studies found that contracting physicians to set up much-needed private clinics. improved coverage in all cases, even in poor and In Comoros and the Democratic Republic of remote areas, with median coverage increasing in Congo, the private health sector has faced tax program areas by 3.4 percent to 26.0 percent over increases and has been denied investment incen- control areas. Based on measures of both coverage tives, burdens that were not inflicted on the pri- and quality of care, six of the studies found that vate sector more generally.87 contractors were more effective than government There is a fine line between government providers. An evaluation of Rwanda’s pay-for- engagement with the private sector and burden- performance (P4P) scheme by Basinga et al. some intrusion. Greater attention to improved (2001) found statistically significant improve- engagement is to be understood relative to the ments in the maternal and neonatal health indica- current, prevailing approach to engagement in the tors of institutional delivery and quality of prenatal region. The appropriate amount and type of care, which increased by 21.0 percent and 7.6 engagement is defined in the regional context, as percent, respectively, over the baseline in the P4P box 1.4 discusses in more detail. districts.86 Healthy Partnerships | 25 BOX 1.4 How Much Engagement Is the Right Amount? T he framework for assessing engagement was designed to be relevant in the African context (see Appendixes 3 and 4 for more details on the This framework is less relevant for most West- ern European countries, where these basic build- ing blocks have been in place for decades, and the framework and the indicators). In general, public- level of engagement is advanced. As one senior private engagement in Africa is very low, so we official at the OECD noted, the private health sec- looked for the presence of the most basic build- tor in OECD countries “cannot breathe without ing blocks. The goal was not to assess and con- the government being involved.” There is, of trast sophisticated levels of engagement, but to course, an ongoing debate about the appropriate identify policies that provide the foundation for a level of engagement in OECD countries as well; in basic level of interaction. This approach makes some instances, there may be too much of it. sense for two reasons: (a) the observed variation Notwithstanding these caveats, the frame- in levels of engagement in Africa suggests this is work provides useful and important insights also the appropriate level to focus on for now, and (b) for the health systems in Africa’s higher-income we can safely say that these building blocks are countries, such as Botswana, Mauritius, and important for health systems with a sizable pri- South Africa. They are more akin to OECD coun- vate sector. By extension, Africa’s mixed public- tries in terms of the organizational capacities of private health systems are more likely to perform the private and public health sector. And yet, better when these basic elements are in place. while these countries receive fairly good scores in general, our assessments still highlight areas Source: “Healthy Partnerships” data, 2010. where engagement can and should be improved. Not all oversight requires government Examples of successful self-regulation can also intervention be found in Latin America.90 In the Dominican The government is not always best placed to fill an Republic, a coordinating organization for more oversight role of the private health sector. Indeed, than 100 NGOs, INSALUD, participates in the self-regulation and third-party accreditation have National Commission for NGO Qualification and often proven to be more effective.88 A prominent Accreditation. It works in partnership with the example from the United States is The Joint Com- government to ensure that NGOs receiving pub- mission on Accreditation of Healthcare Organiza- lic funding comply with minimum requirements, tions, which was created by American and standards, and norms. Similarly, the Ministry of Canadian medical professionals and hospital asso- Health in El Salvador contracted with an NGO to ciations to provide voluntary accreditation for establish quality-of-care requirements and assess health facilities. The Joint Commission accredits compliance. and certifies more than 18,000 health care organi- Similar examples from Africa, where self- zations and programs in the United States. Joint regulation is slowly becoming more widespread, Commission accreditation and certification is rec- are discussed in Section 2. Social franchising, a ognized nationwide as a symbol of quality that particular form of accreditation carried out with- reflects an organization’s commitment to meeting out government influence or control, is discussed certain performance standards.89 in box 1.5. 26 | Healthy Partnerships BOX 1.5 (Social) Franchising as a Way to Expand Quality Improvements F ranchising is the use of a successful business model and common brand across several firms. For private health providers, it can be a return, the franchisees are obligated to comply with quality standards, report sales and service statistics, and, in some cases, pay franchise fees. good approach to benefit from brand recogni- Social franchise models of service delivery exist tion in exchange for adhering to strict standards in several African countries. Many of the wider in terms of quality processes, prices, or both. A networks focus on provision of family planning derivation of this concept is called social fran- and reproductive health services; others provide chising, in which a successfully tested model of general health care services. Whether the private service delivery is offered by the franchisor. The provider operates fully under the auspices of the participating providers, or franchisees, replicate franchise or not, the training received has been the model and often receive assistance to ensure found to improve quality of those services cov- they are able to adhere to the required stan- ered. This is expected to diffuse into the other dards. The social goal, sometimes coupled with aspects of care offered by these providers. subsidies for the service delivery, is a particular Although the current evidence for the effective- element of this approach. However, as in com- ness of social franchising as a quality improve- mercial franchising, the participating firms in ment tool is limited, preliminary results from pro- social franchising can capitalize on a recogniz- gram evaluation suggest that the model holds able brand name or logo that identifies partici- considerable promise. pating service delivery points to consumers. In Source: World Health Organization and the United States Agency for International Development 2007; Bishai et al. 2008; Koehlmoos et al. 2009; Prata et al. 2005. Obstacles to engagement, but also for managing public providers of health especially at the systems level care services) or because of the structure of donor- Engagement between the public and the private funded programs. Engagement must begin with health sectors does not happen automatically, and recognition of the size of the private sector, and a cannot happen without political will. For both willingness to set aside stereotypes, especially sides, significant obstacles exist. The transaction with regard to for-profit or self-financing provid- costs of engaging remain high and, as others have ers. Interviews conducted for this Report revealed pointed out,91 developing effective government a lingering suspicion of the for-profit health sector engagement with the private sector is challenging. in many, though not all, countries in the region. Many questions remain. Yet, many private providers offer good-quality From the government’s side, the obstacles to services to patients who need them, extending engagement include limited capacity on the one access well beyond the reach of underfunded gov- hand and a relative lack of incentives to engage on ernment providers. the other. In addition, there is a lack of trust, as we Notwithstanding our relative focus on the role discuss below. This Report argues that precisely of the government, engagement is a two-way pro- because the government’s capacity is limited, cess. Intermediaries, such as health insurance smart engagement with the private sector—for authorities, may even turn engagement into a example, to kick-start a productive dialogue—is multiparty process. But certainly private providers worthwhile, despite the up-front costs. Incentives must be ready to reciprocate when the govern- for the government to engage may also be missing, ment extends a hand, even if the hand is not com- due either to conflict of interest (the Ministry of pletely open and was, perhaps, partly forced Health has responsibility not just for setting policy by international donors. Part of the engagement Healthy Partnerships | 27 Trust and predictability as key ingredients Trust among government, the private sector, and intermediaries is essential92 for a productive oper- ating environment. Stability within government is a critical first step to increasing trust and improv- ing public-private collaboration.93 Conversely, uncertainty has a negative effect on business investments. Along with inappropriate policies and practices, which we discuss in Section 2, unpredictable changes in taxation, legislation, reg- ulatory enforcement, and subsidy allocations are a major obstacle to scaled-up investments. Such changes create instability in private health deliv- ery markets in Africa, increasing the cost of capital and slowing both investment and growth.94 The high degree of authority vested in governmental leadership in many African countries means changes in government often result in about-faces on legislation, partnerships, or developing rela- tionships. In Sierra Leone, for example, a public- private partnership, which had been initiated by the private sector itself, aimed to create a dialysis center in a government hospital, for the private and public sectors to use jointly. Even though room had been allocated and the equipment had been purchased, the partnership was abandoned because of a change in leadership at the Ministry of Health.95 Instability resulting from change at the Minis- try of Health is a common problem in the region. The Gambia had four health ministers, five per- manent secretaries, and three directors during 2009 alone. In Niger, the Minister of Health changed 10 times in seven years (2003 to 2010). In several countries in the region, the average ten- process will necessarily be an articulation early in ure of health ministers is a mere six or seven the process of what each side has to gain. months. For private providers, engagement can be diffi- Adding to the instability, distrust between the cult if there is no organization to coordinate the public and private sectors remains a hindrance, effort, and because of the time and effort required and partly prevents the allocation of public to attend meetings, review documents, and so resources to the private sector commensurate forth. The private sector is typically diverse, and it with the scale of private financing and provision.96 is this diversity that makes organization difficult. Perceived profit motives by the private sector The cost of engaging can be especially prohibitive remain a limiting factor on contracting, facilitat- if the private health sector does not clearly under- ing legislation, and formal recognition by govern- stand what the benefits will be. ments, leading to unregistered facilities and dual 28 | Healthy Partnerships practice (that is, working in both the public and government is actively courting professionals private sectors), among government-employed and investors from the private health sector, both clinicians.97 Private practitioners, themselves, fur- domestically and internationally, to further ther distrust government for fear of regulation, develop high-quality health services. In other taxation, or rent taking by formal or informal countries, the process of rebuilding trust and means.98 When nonstate providers operate with- predictability is not far behind. out security or predictability, the incentives for The recognition of mutual reservations can be growth and investment are sharply curtailed.99 a positive initial outcome of such a process. On Corruption, whether real or perceived, is a the private sector side, it is a matter of getting past major impediment to government engagement the view that the government is responsible for with the private sector in many countries.100 When everything yet lacks the capacity or will to do any- real, it introduces tremendous inefficiencies and thing. On the government side, it is a matter of disincentives into the health market, which rejecting the notion that the private sector is only increases operating costs for private providers, interested in profit and lacks the ability or willing- reduces quality because of nontransparent criteria ness to work toward public health goals in good for subsidy and operation, and greatly increases the faith. Surrendering or softening such views and barriers to entry and expansion of care-providing gaining a basic understanding of the financial and entities. Whether real or perceived, corruption organizational constraints of both parties is the reduces trust and transparency in the relationship first step toward real engagement. between government and private partners and so Building sustained partnerships between the limits the effectiveness of the engagement. government and the private health sector is a two- way process. Ultimately, engagement will yield Building trust and predictability positive results only if both the public and private Despite these impediments, improvements in sectors are willing to work together and are com- trust between the public and private health sec- mitted to furthering public-private collaboration. tors is not only possible but is actually happening In Section 2, we examine engagement from the in several countries, leading to increased dia- government perspective first: How should the logue. In Ghana, Kenya, and Mali, for example, steward of the health system approach this issue? dialogue has evolved from the exchange of gen- In the latter part of Section 2, we highlight the eral thoughts and priorities to specific instances role the private health sector itself must play in of collaboration and reform. In Mauritius, the the engagement process. Healthy Partnerships | 29 30 | Healthy Partnerships Section 2: What our research tells us about engagement From Dakar to Dar es Salaam, policy makers across the Sub-Saharan Africa region are searching for effec- tive ways to tackle the most pressing health challenges. As Section 1 noted, part of the solution will be to engage all actors in the health system, including the private sector. T here is at least some government engage- The overall messages are as follows: ment with the private health sector in every • Government engagement at country, evidenced in examples of public- the systems level is underway. private collaboration to improve the quality, Governments are already working with the accessibility, and efficiency of health care. At the private health sector, to some degree. Nota- same time, the overall level of engagement is ble examples include widespread collabora- low in many countries, and there is a noticeable tion with faith-based organizations (FBOs) lack of engagement with for-profit or self- and with private providers for specific disease financing providers. Policy makers are becoming or immunization programs. increasingly aware of this, and are looking for ways to increase and improve collaboration. • The level of engagement with self- Many opportunities exist, and it will be up to financing providers is low. policy makers to follow through. Government engagement with for-profit pro- This section analyzes how governments are viders at the systems level needs urgent currently engaging private providers within the improvement. Even though policies may be context of the five domains discussed earlier. in place for engaging such providers, imple- The results, a summary of which are presented mentation is generally weak, and self-financ- in table 2.1, are based on original research con- ing providers often are not included unless ducted for this Report.ix connected to a specific disease or immuniza- TABLE 2.1 A Brief Glance at the Results Policy and dialogue Governments have private health sector policies in place, but implementation is a challenge; more dialogue is required to improve collaboration. Information exchange Information exchange is weak and needs to improve, but there is good cooperation for disease surveillance. Regulation Private sector regulations are in place but may be outdated or inconsistent; enforcing regulations is a major problem. Financing Governments are using some (limited) financing to engage providers in many countries and are open to more. Public provision of services There is good cooperation on referral systems and immunization and other disease programs. ix. Unless otherwise stated, all data cited in Section 2 are based on the “Healthy Partnerships” Report data collection, carried out between February and July 2010. Healthy Partnerships | 31 tion program. (See box 2.1 for a brief discus- vate sector, and each interacts with the others. sion of why we concentrate on self-financing The policy and dialogue domain concerns the providers.) underlying policy framework for the private health sector and its implementation, and the • There is much opportunity for increasing level of dialogue between the public and private systemic public-private collaboration. sectors. The other domains cover the range of Further engagement is not a question of rein- policy instruments that governments can use to venting the wheel. If governments seek to engage private providers: information exchange, leverage the capabilities of the private health regulation, financing, and public provision of sector, much can be achieved by including pri- services. More information on the methods vate providers in already existing arrangements. behind the engagement data, including the selection of indicators, and on the conceptual Data collection and assessment framework development of the framework, can be found in This section provides background on the assess- Appendixes 3 and 4. ment framework used to measure engagement. As The overall assessment framework is shown noted in the introduction, data were collected in in table 2.2. Since engagement consists of both 45 countries between February and July 2010 policy and its implementation, the framework through in-country visits. The results presented contains both de jure and de facto indicators to here are based on interviews with more than 750 fully capture how governments are engaging government officials, policy makers, regulators, pri- private providers. De jure indicators rely on vate providers, and other experts across the region. fact-based measures that focus on the existence As explained, the assessment framework of policies, laws, or regulations. De facto indica- developed to measure government engagement tors are based on expert opinion of policy imple- includes five domains, each describing a key mentation or inclusion of private providers in aspect of the government’s relationship with government programs or structures. the private health sector. Each domain can be seen as bidirectional, that is, to and from the pri- BOX 2.1 Placing the Focus on the Self-Financing Providers T he results presented in this chapter refer to government engagement with the for-profit or self- financing sector only. They do not analyze engagement with the nonprofit sector. There is more engagement with the nonprofit sector than self-financing providers across all domains in all countries. In many countries, FBOs are indistinguishable from the public sector. Many FBO facilities serve as pub- lic reference hospitals. The high level of integration between the public sector and FBOs makes cross- country analysis difficult because FBOs are considered an extension of the public sector in many coun- tries. Their partnership is discussed in more detail at the end of this section. Source: “Healthy Partnerships” data, 2010. 32 | Healthy Partnerships TABLE 2.2 Overall Assessment Framework Domains Subdomains Indicators Policy and Policy • Policy for engaging the private health sector dialogue • Level of policy implementation in practice Dialogue • Formal dialogue mechanism with the private health sector • Level of dialogue in practice Information Information flows • Governments include the private health sector in their information flows. exchange Private health sector inclusion in the • The private health sector is required by law to provide health-related data. national health information system • Governments are receiving this information from the private health sector. Private health sector inclusion • The private health sector is included in a country’s national disease surveillance in national disease surveillance program. program • Governments are sending out regular surveillance updates to the private health sector. Regulation Quality of the registry of private • Quality of the registry of private health sector facilities health sector providers Quality of regulatory framework • Reported judgment of quality regulation framework • Standardized rules for opening private health clinics • Inspection process for private health sector clinics in place • Same regulations for inspections as for the public and private sectors • Continuing medical education (CME) requirements for private health sector professionals • Policy for traditional medicine Enforcement of regulation • Regulation is enforced as intended. • Inspection process for private health sector clinics is carried out. • Public sector CME training is open to the private health sector. Financing Contracting • Contracts in place with private health sector facilities or private practitioners (at any level of government) Financial incentives • Government offers financial incentives specific to private health sector facilities. Level of private provider coverage • Percentage of population covered by public or private health insurance paying through health insurance (potentially) reimbursements for services provided at private facilities Public Distribution of vaccines or • Government provides the private health sector with vaccines or medicines from production medicines to private health sector a government or a government-sanctioned program. Functioning referral system • Functioning referral process between the public and private sector Source: “Healthy Partnerships” data, 2010. FIGURE 2.1 Results from the data collection Good Practice and Results in Policy and Dialogue Policy and dialogue The policy and dialogue domain concerns the pri- Good practice in this domain is to have four elements in place: vate sector policy framework on paper and in prac- • A government policy to work with the private sector as a partner in tice, and the level of dialogue between the public the delivery of health care services and private sectors. This domain summarizes over- • A high level of day-to-day implementation of the policy of engagement all government engagement, since policy and dia- • A formally instituted dialogue mechanism • An ongoing dialogue between the government and the private logue provide the foundation for the other domains. health sector See figure 2.1 for description of good practice and summary of results in policy and dialogue. Our research revealed the following: The top-performing countries (a score of 8 or • More than 85 percent of countries in Sub-Saharan Africa have an more out of 10) in this domain are Kenya, South explicit policy toward the private health sector. Africa, Burkina Faso, Ghana, Mauritius, Nigeria • Implementation of policies, however, is severely lacking in a majority (Lagos State), Rwanda, and Tanzania. See box 2.2 of the countries. for a good practice example in Ghana. • Levels of dialogue are low across the region but are growing. Source: “Healthy Partnerships” data, 2010. Healthy Partnerships | 33 BOX 2.2 Good Practice Example on Policy and Dialogue: Ghana T he level of engagement between the Government of Ghana and the private health sector has greatly increased in recent years. While implementation, for This policy has been implemented on various fronts, most prominently with the inclusion of private providers in the Ghana National Health Insurance Scheme. Though example of suitable regulation, is not yet where it should many challenges remain, respondents noted the positive be, it is an example of good practice in the domain of impact of the recently revived dialogue process. Even policy and dialogue. The Ghana Private Health Sector Pol- though the private sector policy existed before, it was not icy prescribes in detail how the public and private sectors until the recent reactivation of the dialogue that the policy can work together to meet national health priorities. It really became operational. The private sector, in turn, has covers the key issues affecting private sector growth and responded by forming an umbrella organization of private participation in the health sector, the rationale and objec- providers, with the representatives coming from the health tives of the policy, the specific policy areas for public-pri- subsectors and professional groups. vate collaboration, and strategies for implementation. It also details the composition and capacity of the private Source: “Healthy Partnerships” data, 2010. sector. FIGURE 2.2 Results Map of Policy and Dialogue in Sub-Saharan African Countries The policy and dialogue domain presents an encouraging picture, overall. A number of coun- tries score highly by combining a good private sec- tor policy framework with implementation in practice. The top performers include more devel- oped countries like Mauritius and South Africa, but also low-income states like Burkina Faso and Rwanda (figure 2.2). This suggests that not just resources, but also a broader commitment to engagement, backed by positive actions, are important to successful engagement. Country grouping The difference in performance among coun- (domain score) tries is generally the degree of implementation. Top (8–10) Although many countries have policies or dia- Upper middle (6–7) Lower middle (3–5) logue mechanisms, implementation is a big Bottom (0–2) challenge and is lacking in many places. For example, Zambia has a number of private health sector initiatives, including a public-private partnership (PPP) policy and a task force to pro- mote PPPs. It also held a private health sector trade fair. Implementation, however, is lacking for various reasons, including an uneven politi- Source: “Healthy Partnerships” data, 2010. cal environment. Implementation of any policy is difficult, not just in Zambia, but also in coun- 34 | Healthy Partnerships tries such as The Gambia and Niger, where Implementing the policies is a big challenge health ministers and permanent secretaries While having a private health sector policy is an change frequently and with them their priori- element of good engagement, implementation ties and their views on the private health sector. matters more. Countries can generally be placed Across the region, the overall picture remains into one of four groups, as figure 2.3 indicates. broadly positive, however, and most policy mak- Countries in the two upper bars in figure 2.3 ers understand the need to make tangible public- implement policy well. A snapshot of Rwanda private collaboration a priority. illustrates this. All Rwandan health policy and strategy documents over the last several years Private sector policies are often in place include the private health sector. The latest stra- The majority of countries in the region (more tegic plan (2009–12) states the importance of than 85 percent) have a private health sector pol- “engaging all private providers to improve access icy. Both Ghana and Sudan stand out for having and quality.” To further this end, the Ministry of specific stand-alone policies (indeed, Sudan has Health has created the Private Medicine desk to two policies—one for the self-financing or for- act as the focal point for private providers. In profit sector and one for the nonprofit sector). terms of implementation, there is a clear com- Other countries are moving toward a specific pol- mitment to following the policy. The public sec- icy, even though the private health sector is tor has explicitly included private providers in a already included in other strategic documents. In range of major public health initiatives, includ- South Africa, the public and private sectors are ing for HIV, tuberculosis (TB), family planning, jointly developing a “Charter for the Public and and human resources for health. In the area of Private Health Sectors.” Both Ethiopia and Uganda health financing, there is also close public-pri- are in the process of ratifying stand-alone policies, vate collaboration. Private providers are involved and Mali and the Republic of Congo are currently in the government’s performance-based financing drafting a specific policy. program, and they can apply for accreditation to Elsewhere, private health sector policy is usu- participate in the public health insurance ally contained within the Ministry of Health’s scheme that covers 86 percent of the population. strategic plan. The level of detail regarding the private health sector in such documents varies. For example, in Angola, the policy is found in an FIGURE 2.3 addendum to the national constitution and sim- ply recognizes the role of the private health sec- Engagement Policy and Practice tor. By contrast, the Tanzanian private sector is given a prominent role in the country’s strategic Have a written policy; good implementation plan. Going beyond simple recognition, it details in practice the role private providers can play in the coun- No written policy; try’s overall health strategy. It also sets out poten- implementing a tial areas for public-private collaboration to policy in practice achieve national health goals. Have a written Six countries do not have a private sector policy; weak implementation policy for health. This does not necessarily mean that there is no engagement in practice, but that No written policy; no implementation such engagement neither benefits from a guid- in practice ing document nor is underpinned by a policy framework. This makes good engagement all the 0 5 10 15 20 25 30 more difficult. As the assessment framework Number of countries suggests, the majority of countries without a Source: “Healthy Partnerships” data, 2010. policy perform less well across the domains. Healthy Partnerships | 35 Lesotho and the Seychelles are unusual in that 50 percent of countries have a mechanism at pres- they do not have an explicit private health sector ent, in a wide variety of forms. In Ghana and policy but score highly on implementation. Leso- Kenya, for example, a specific public-private tho boasts many examples of constructive public- health sector mechanism is in place to further private collaboration, most prominently the PPP develop collaboration. Dialogue mechanisms developed for the new Queen Elizabeth II Hospi- should be the first step in countries without a tal. In the Seychelles, where most people go to a strong foundation of public-private engagement. well-run public sector, and where the private sec- In Mali and the Republic of Congo, a dialogue tor is small (less than 10 private providers), the mechanism was put in place to build momentum Ministry of Health has developed areas of collabo- for future collaboration. ration with private providers when needed, with- Elsewhere, in the absence of a specific mecha- out explicit guidance or reference in the overall nism, the private health sector is often included health sector plan or strategy. in a larger dialogue mechanism that includes all Countries in the two lower columns in figure actors in the health sector. In Uganda, the private 2.3—approximately 75 percent of those studied— health sector plays a prominent role in the have difficulty implementing a private sector national health coordinating mechanism that health policy, if one exists. The majority of meets four times per year. Private providers in countries fit this category. While some public- Rwanda take part in an annual meeting with all private collaboration may exist in these coun- stakeholders to review progress and chart strate- tries—for example, with disease programs or gies and priorities for the following year. referral processes—implementation at the sys- Even though a dialogue mechanism is a sign tems level is poor when measured against stated of good engagement, actual levels of communi- policy intentions. Governments are missing sig- cation are low in many places, as figure 2.4 indi- nificant opportunities to engage or include the cates. Strong levels of dialogue exist in Kenya private sector. and Mauritius, with Ghana and another 13 coun- tries following close behind with reasonable lev- Dialogue mechanisms but a lack of dialogue els. In the top-performing countries, there is Ongoing dialogue between the public and private constant dialogue between the public and pri- sectors is a key element of good engagement, and vate sectors—often not just through a mecha- a specific public-private dialogue mechanism can nism, but also through private sector involvement help institutionalize the process. Approximately in Ministry of Health committees or other forums. In Mauritius, the private sector has been involved in Ministry of Health committees for nutrition, tobacco, and contingency planning. FIGURE 2.4 Many of those interviewed for this report said increased dialogue improved trust between the Dialogue in Practice public and private sectors and provided a foun- 2 dation for systemic engagement. The majority of Strong dialogue countries that have strong or reasonable levels of 11 dialogue perform notably well across all the 14 Ongoing dialogue; room for improvement domains. This is as we had expected, since a pol- Some dialogue; weak overall icy framework established outside of a dialogue 18 Very low dialogue or no ongoing with the private health sector is unlikely to be dialogue supported by action in the longer term. Beyond these countries, levels of public- Source: “Healthy Partnerships” data, 2010. private dialogue overall are low. A substantial number of countries (18) have poor communi- 36 | Healthy Partnerships cation, held back in some instances by the Results absence of a public-private mechanism. Most The exchange of information between the public dialogue in these countries is ad hoc or occurs and private sectors is generally weak across the only when considered necessary, for example, region. As figure 2.6 shows, few countries have a during a disease outbreak. In such cases, the dia- comprehensive information exchange. Those that logue is usually the product of a donor mandate, perform best in this domain, such as Burkina Faso such as from the Global Fund related to public- and Rwanda, keep the private sector well informed private collaboration on HIV/AIDS, TB, or and include private providers in existing public malaria. Respondents in several countries, such information channels, such as for HMIS data. The as Botswana and Madagascar, said public-private weak information exchange in many countries is a dialogue occurs primarily or even exclusively concern to both public and private providers, within such programs. albeit for different reasons. The public sector must Although outcomes of the dialogue process be aware of what is happening in the private sec- were not measured, respondents in a few coun- tor to have a more complete picture of how the tries said the extensive time and effort involved health system is performing. The private sector in fostering communication did not result in tan- needs to be kept up to date on issues that affect its gible public-private collaboration. In Niger, the operating environment. Respondents in nearly public and private sectors have met frequently to every country noted the need to improve infor- develop a “contracting strategy” within the 2005 mation exchange, especially given its relevance for Health Development Plan. Since then, however, the other domains. no practical steps have been taken to implement this strategy, even though regular meetings con- tinued for some time. It was not obvious what all FIGURE 2.5 the root causes of this inaction were. Since then, much momentum has been lost and, as a result, Good Practice and Results in Information Exchange private providers have stopped attending meet- ings. Although Niger is one example of how Good practice in this domain is to have five elements in place: implementation can fail, respondents in other • Information flows between the government and the private health countries noted a similar feeling as it became sector, in both directions. clear no action was forthcoming. The driving • There is a legal requirement for the private health sector to provide force behind a dialogue mechanism should be health-related data. • The information from the private sector actually reaches the tangible public-private collaboration, not simply government. talk and no results. • The private health sector is included in a country’s national disease surveillance program. • The government sends out regular surveillance updates to the Information exchange private sector. The information exchange domain concerns infor- mation flows between the public and private sec- tors, and private sector inclusion in governmental Our research revealed the following: programs for national health management infor- • Information exchange is weak in most countries; a majority of mation systems (HMIS) and disease surveillance. countries have less than half of their basic elements in place. See figure 2.5 for description of good practice and • Private provider data are not reaching the government, despite legal requirements. summary of results in policy and dialogue. • There are somewhat higher levels of inclusion for disease-surveillance The better-performing countries in this domain programs. (score of 6 or more out of 8) are Mauritius, the Seychelles, Botswana, Burkina Faso, Ethiopia, Source: “Healthy Partnerships” data, 2010. Liberia, and Rwanda. See box 2.3 for a good prac- tice example in Burkina Faso. Healthy Partnerships | 37 BOX 2.3 Good Practice Example: Burkina Faso I n citing an example of good practice, information exchange was assessed as being poor in almost all countries in the region. Among them, Burkina Faso made and the compliance rates with this requirement seem to be good (estimated at 80 percent by some respondents, with a consensus that a majority complies). The private sector is some positive changes and seems to be addressing generally included in the disease surveillance program, remaining issues. In recent years, the government has though larger clinics are curiously less represented. The made a concerted effort to improve the policy and regula- Ministry of Health has a toll-free number for reporting tory environment for the private sector, in general. A few emergencies, but it is currently available to only a fraction years ago, the Ministry of Health established a Public Pri- of the private health sector. Although the government does vate Dialogue Framework and a Private Sector Directorate not report disaggregated data for the public and private at the central level, which has dedicated staff at the dis- sectors, the private health sector is generally kept informed. trict level who act as focal points for the private sector. In A recent decision by the general tax directorate recog- the wake of these reform efforts, there is a consensus nized private health facilities as “civil enterprises,” thereby among respondents that the exchange of information is allowing them to avoid a commercial label for tax purposes. reasonably good and will continue to improve. This change likely contributes to the relatively good rela- The key to a strong information exchange is not to tionship between the government and the private sector create parallel structures for private providers, but to and, in turn, is likely a positive influence on the high levels include them in already existing arrangements. In Burkina of compliance with information provision. Faso, the private sector is required to provide information, Source: “Healthy Partnerships” data, 2010. FIGURE 2.6 Information flows across the region are very poor Map of Information Exchange in Sub-Saharan African Governments do a poor job of keeping private Countries providers informed of vital information. As fig- ure 2.7 shows, only two countries—Mauritius and the Seychelles—have strong information flows, through which the government sends out information on changing regulations, treatment protocols, and other programs, while also receiv- ing feedback from the private sector. Another 12 countries are also quite strong in this domain. For example, in South Africa, the Department of Health website contains updated regulations Country grouping and forms pertinent to the private sector. (domain score) Elsewhere, information flows are weak, and Top (7–8) Upper middle (5–6) government information channels do not routinely Lower middle (3–4) include the private health sector. In Cameroon, for Bottom (0–2) example, a Ministry of Health official who also runs a private hospital said he only became aware of certain regulations that should have guided his private practice when he started working for the ministry. In almost a third of countries, there is Source: “Healthy Partnerships” data, 2010. no tangible information exchange between the 38 | Healthy Partnerships FIGURE 2.7 Information Flows Across the Region 2 14 Strong, comprehensive information flows 12 Ongoing reasonable information flows; room for improvement Weak information flows; restricted to subsectors 17 Very low or no ongoing information flows Source: “Healthy Partnerships” data, 2010. public and private sectors. Private providers in BOX 2.4 Burundi said they received no information at all from the Ministry of Health. In Sudan, private providers said health inspectors visit facilities Good Collaboration for the 2010 FIFA World bearing regulations and guidelines they have never Cup in South Africa seen before. In one instance, a private provider said he had not heard of the new private sector health policy. In such circumstances, it is difficult T here is often no inherent reason why information exchange might be poor. We see this confirmed in instances where external events focus the efforts of the stakeholders. to expect the private health sector to comply with regulations or use treatment guidelines of which One example relates to the preparations for the World Cup they have not been informed. See box 2.4 for an 2010. The public and private sector in South Africa worked closely example of a marked improvement of informa- to prepare to host the Fédération International de Football Asso- tion exchange under special circumstances. ciation (FIFA) World Cup. Among other things, the government created an online “Notifiable Medical Conditions Early Warning Private providers’ data is not reaching Surveillance System,” where the private sector (and the general the Ministry of Health public) could track and upload incidences of disease outbreak. Since the private health sector provides a sizable Source: “Healthy Partnerships” data, 2010. percentage of care in many countries, collecting key HMIS data is necessary to give policy mak- ers a full picture of national trends. Most coun- tries require private firms to provide HMIS data, However, when compliance with provision of but in practice few do. Figure 2.8 shows that, of data is incentivized by the provision of consum- the countries where private providers are ables like anti-retroviral drugs or vaccines, the pri- required to provide data, only a small number vate providers have been found to comply well. actually do so. In a few countries, no require- Medicines or vaccines are provided to private ment even exists. health facilities on the condition that they report The lack of private sector data is a concern for how much has been delivered and to whom. Such policy makers, especially in countries where pri- improved compliance was observed as a part of vate operators supply a large percentage of care. In donor-funded HIV treatment programs, as well as Uganda, the private sector provides up to 58 per- regular public health interventions. For example, cent of health services, but compliance rates for in the city of Bulawayo in Zimbabwe, the munici- HMIS data are less than 20 percent. In the Demo- pal health department provides vaccines to pri- cratic Republic of Congo, the private sector sup- vate health facilities for distribution in exchange plies 46 percent of care but the compliance rate is for timely provision of information. On a monthly less than 10 percent. basis, the facilities have been submitting informa- Healthy Partnerships | 39 FIGURE 2.8 Why is private health sector data not reaching Health Information Requirements and Provision in the Ministry of Health? Sub-Saharan Africa Many reasons were given to explain why private sector data are not reaching the government. In Not required to provide some countries, public and private respondents information PHS is were not clear whether a requirement exists to 12 required to provide Information provide HMIS data. This, predictably, prevented is not reaching information the MoH virtually any data from flowing. Elsewhere, the 33 30 information requirements are so heavy that many private providers simply do not comply. Table 2.4 Information is shows the requirements for Burundi and Tanza- reaching the MoH 3 nia. In each of these countries, compliance rates Source: “Healthy Partnerships” data, 2010. Note: MoH = ministry of health; PHS = private health sector. are low, at least in part, because private providers see the requirement as exceptionally onerous. Tanzanian private providers said they had to dedi- cate one staff member to the task full time to tion on vaccine usage, which in turn gets aggre- compile all of the data. For smaller-scale clinics, gated at the national level. this kind of resource commitment is simply not Including private providers in overall HMIS, possible, so their data never reach the Ministry of however, is a challenge even in countries that per- Health. At the same time, some policy makers form well in the information domain. Data from believe the requirements should be even higher. private health sector surveys in Ghana and Kenya In Nigeria, a senior official stated that all facilities provide a further glimpse of data provision rates should provide all of their data on a weekly basis, for private hospitals and clinics. Table 2.3 shows even though most providers feel that the current that fewer than 50 percent of private clinics sub- monthly requirement is already excessive. mit their data on a regular basis in Kenya; this In many other countries, there is no HMIS data drops to just over a third in Ghana. These infor- exchange system in place. Many private respon- mation gaps make it difficult for the national Min- dents complain of the difficulty of providing istry of Health to analyze how the health system information when no forms or guidance are pro- is performing. Although the data submission rate vided on how the data should be presented. Even is higher for private hospitals, there are fewer pri- when a system is in place, disagreements often vate hospitals than clinics across the region. For arise. In Zambia, forms are provided to private that reason, the hospitals tend to be more promi- providers, who then expect the Ministry of Health nent and may even have contracts with the public to come and collect the information. The Ministry sector, which would require the submission of of Health, on the other hand, says private provid- information. ers are responsible for bringing the data to them. The result is a stalemate in which no private sec- tor HMIS data are reaching the ministry. TABLE 2.3 Private Providers that Submit Data to the Ministry of Health on a Regular Basis, TABLE 2.4 HMIS Data Reporting Requirements, Ghana and Kenya Burundi and Tanzania Country Hospital Clinic Country Requirement Ghana 7/10 (70%) 12/33 (36%) Burundi 27 forms per month Kenya 2/3 (67%) 17/35 (49%) Tanzania 12 reporting books per month Source: “Healthy Partnerships” provider survey, 2010. Source: “Healthy Partnerships” data, 2010. 40 | Healthy Partnerships Private respondents were also dismayed at the mation exchanges are an element of good lack of feedback in some countries. In Madagascar, engagement, the challenge is to elevate this to a interviewees said they hardly ever hear how their more systematic approach. In Benin, for exam- data are used after they take it to the local district ple, private providers are sent a disease surveil- health office. With so little feedback, they are lance report annually, but this is the exception not inclined to share their information with the and not the rule around the region. See box 2.5 government. for how Cape Verde handled communication In addition, there are financial disincentives for during a dengue fever outbreak. some private providers to share information. In the Central African Republic and Niger, the tax rate for Regulation private health providers is linked to service utiliza- The regulation domain focuses on the ability of tion rates; that is, the more patients a facility treats, the government to design and implement a regu- the higher the tax bracket. As a result, many facili- latory framework for the private health sector. ties are reluctant to provide HMIS data to the Min- As a proxy for all private health facilities, the istry of Health. Resolving this issue is difficult focus is on private clinics. See figure 2.9 for unless the disincentive is removed. description of good practice and summary of results in regulation. Good levels of private sector inclusion in The top-performing countries in this domain national disease surveillance programsx (score of 11 or more out of 13) are South Africa, Private sector participation is better in national the Seychelles, Mauritius, and Namibia. See box disease surveillance programs, and many respon- 2.6 for a good practice example in South Africa. dents noted good public-private collaboration in this area. In two-thirds of the countries, private Results providers are included in the national surveillance Most governments see regulation as the most programs. Even when they are included, however, important element of engagement with the pri- private facilities are typically less involved than vate health sector. Regulation is clearly essential, public facilities: disease surveillance officers in but our research shows most governments have a Liberia visit all public clinics but only 40 percent difficult time designing and implementing an ade- of private facilities. In Mauritius, it is up to district quate regulatory framework. Most countries do health officers to choose a small number of private providers to take part in the program. During BOX 2.5 emergencies or outbreaks, such as the H1N1 flu epidemic, public-private collaboration in this area intensifies. Angolan private providers are still part Beating Dengue Fever in Cape Verde of a special phone network—a legacy of civil-war- era emergency information systems—that permits the rapid transmission of surveillance information. Respondents in nearly every country said C ape Verde provides another example of how close collabo- ration is possible when the two sides are willing or moti- vated by external events. During a 2009 outbreak of dengue governments do a far better job of distributing fever in Cape Verde, the public and private sectors—including information during disease outbreaks. In Mauri- clinics, pharmacies, and laboratories—were in constant contact, tius, even small private facilities are invited to sharing information in real time to coordinate their response to meetings to receive updates. While such infor- the epidemic. Both public and private respondents said the close collaboration allowed them to contain the outbreak faster than they otherwise might have. x. The most common type of disease surveillance program is one in which private providers are required to supply information only in Source: “Healthy Partnerships” data, 2010. cases of notifiable diseases. The next-most-common program is one in which a percentage of facilities act as sentinel reporting units. Healthy Partnerships | 41 FIGURE 2.9 Good Practice and Results in Regulation Good practice in this domain is to have the following ten elements in place: • The government knows who is operating where, by way of a registry that is updated to contain all private facilities currently in operation. • The regulatory framework is well designed and appropriate. • Standardized, written rules exist for opening private health facilities. • There is an inspection process for private health facilities. • There is no explicit discrimination against private facilities in terms of quality oversight. • There is an effort to include all groups of providers that are relevant in the health sector (as a proxy, the focus is on traditional medicine) with a designated policy or office. • There is good enforcement of regulation. • An inspection process for private facilities is actually carried out. • There is a requirement for private health sector professionals to do continuing medical education (CME) before renewing their professional operating license. • CME training for public sector professionals is also open to health professionals from the private sector. Our research revealed the following: • The registry of functioning private providers is poor in most countries. • Regulations are often in place but are inappropriate or outdated in many cases. • The enforcement of regulations is weak across the region. Source: “Healthy Partnerships” data, 2010. not have a comprehensive list of private providers It ensures that the Ministry of Health is aware of in their national health network. Regulations are who is doing what in the health sector. Yet most usually in place, but they are frequently outdated governments are not aware of the scale of private or inappropriate and do not adequately address provision of health services, as figure 2.11 sum- quality of care. Most of the problem, however, lies marizes. Only six countries across the region have with enforcement of regulations. Most govern- a comprehensive registry. In these countries, the ments lack the capability to exercise even a mini- registry is a working document that is compre- mum amount of oversight. As figure 2.10 shows, hensive and updated frequently. This includes only a handful of countries perform well in the Cape Verde and the Seychelles, small countries regulation domain overall, and the results would with few private providers. be even worse if enforcement was weighted more These two island nations are the exception, not heavily. Even private providers complained about the rule. Most registries are woefully incomplete the lack of regulatory oversight, which can have and often inaccurate. Some countries try to update serious implications for quality of care: quacks can their registries regularly but do not do a very good operate freely, damaging the reputation of the job. In Niger, for example, one government depart- whole sector. ment said there was no list of private providers; a second department said one existed but only for The quality of private sector registries is pharmacies; a third claimed there was a list but it extremely poor across the region had not been updated since early 2009; and a The concerns with regulation across the region fourth finally produced a reasonably updated list, are encapsulated by the poor quality of the regis- but for the Niamey region only. In another coun- tries of private clinics. An accurate registry is one try, three public sector respondents named three of the fundamental elements of good engagement. different units responsible for the registry, and 42 | Healthy Partnerships BOX 2.6 Good Practice Example: South Africa S outh Africa is unique in the Sub-Saharan health context in that its private health sector is regularly rated as one of the most advanced and best performing in the world. Compared with other countries in the region, regulation is at an advanced level in South Africa, and there is consen- sus that the enforcement of regulation is generally good. However, the private health sector is used by only 14 per- Since enforcement is the responsibility of provincial depart- cent of the population, primarily the wealthy. Aside from ments of health, the quality of enforcement varies some- the fact that the capacity of both government and private what depending on the resources of the province (Gauteng health organizations is high, the private sector is primarily and Western Cape have far more capacity than the Eastern funded through insurance. This builds in a strong incentive Cape, for example). for compliance with rules and regulations. The strong legal Respondents also felt that the inspection regime is gener- and regulatory frameworks in place have ensured that ally well designed on paper, and that in practice it is well coor- there is a plethora of regulation in South Africa—some dinated, fair, and transparent. There is an initial inspection and would say overregulation. It has also led to a strong, at subsequent annual inspections, and although some private times even combative, private sector, which, in 2010, (suc- sector respondents stated that they are treated more strictly cessfully) took the Department of Health to court to fight a than the public sector, there is no explicit discrimination. regulation that would have compelled them to use a refer- Opening a private health facility in South Africa follows ence price list for pharmaceuticals. standardized rules. Nonhealth professionals can open a pri- South Africa scores the maximum in terms of the ele- vate facility, and most private hospitals and clinics or chains ments identified as good practice. Echoing the sentiment of hospitals or clinics are owned by corporations listed on of the Organization for Economic Co-operation and the stock exchange. Health professionals must register with Development (OECD) official cited earlier in the report, the Health Professions Council every year and do continu- one respondent said “everything is regulated to the nth ing medical education (CME). Failure to comply with this degree in South Africa.” requirement results in removal from the registry. This is The registry of private facilities is fully updated. A con- strongly enforced because health insurance is only allowed, tributing factor in South Africa is health insurance, since by law, to reimburse currently registered doctors. insurance companies can only reimburse facilities licensed In line with World Health Organization recommendations, by (and registered with) the Department of Health. Opin- the Department of Health established a Directorate of Tradi- ions diverged among respondents about the regulatory tional Medicine in 2006 and passed a Traditional Health Prac- framework. Public sector respondents felt that there was titioners Act in 2007. The government has also provided fund- too little or inappropriate regulation compared to other ing for research and development of how traditional advanced economies, while private sector respondents practitioners can be integrated into disease control and man- felt that they were overregulated. agement programs. Source: “Healthy Partnerships” data, 2010; Worrall-Clarre 2008. none could produce it. Other countries make only Conditions are especially bad in countries with passing attempts to update their registry; Gabon’s a large informal sector, where many providers are Ministry of Health does so only every three years. not registered and are largely out of sight of the In a few countries, there is no working registry of government. Even many private providers said any kind. Some governments think they are more the informal sector needed to be supervised and aware of the scope of private sector activity than regulated. Encouraging unregistered providers to they really are, as illustrated by the situation in come forward and engage with the government Mauritius described in box 2.7. will be an important part of proper oversight of Healthy Partnerships | 43 FIGURE 2.10 the entire private health sector. Health facility Map of Regulation in Sub-Saharan African Countries surveys that include all types of public and private providers are another way to address this need for better information in the shorter term. Regulations for basic functions are in place, but overall regulatory quality is poor Governments frequently have rules for basic health care functions. For example, all countries in the region have standardized regulations for open- ing a private health clinic and for monitoring or inspecting private facilities. Although this is an Country grouping element of good engagement, it does not tell the (domain score) whole story. Both public and private respondents Top (11–13) in most countries say the quality of the regulatory Upper middle (8–10) framework is low, inconsistent, frequently out- Lower middle (5–7) Bottom (0–4) dated, and full of gaps. Respondents are satisfied with the quality of the regulatory framework in only 15 percent of countries. In Mauritius, Namibia, and South Africa, for example, respondents said regulations address- Source: “Healthy Partnerships” data, 2010. ing clinical standards are based on current interna- tional best practice, and are updated regularly to ensure both public and private providers perform FIGURE 2.11 to the highest standards. A number of countries have begun to replace their outdated regulations. Quality of Registry of Private Clinics Benin, Equatorial Guinea, and Togo have imple- mented completely new private health sector 6 Quality of registry of private clinics frameworks. These have often been developed by 4 Registry may exist, but cannot engaging private providers and seeking their input be produced. during the development of the regulations. By 14 Registry exists, and it is in use. contrast, respondents in 85 percent of countries Registry exists, it is in use, and we studied said the regulatory framework is inap- 21 it is updated. propriate. Some countries’ regulatory frameworks Registry exists, it is in use, and for the private health sector have not been updated it is comprehensive. in nearly 50 years. Cameroon, Chad, and Lesotho, Source: “Healthy Partnerships” data, 2010. for example, have regulatory frameworks that date back over 40 years, and in the Democratic Repub- lic of Congo, the main regulations have not changed since before independence, in 1960. In other places, respondents believed regula- tions were inadequate. In São Tomé and Principe, for example, the only regulations for the private health sector pertain to opening a clinic. Else- where, the regulatory system for inspections— which exists in every country—is often not adequate to address quality of care. 44 | Healthy Partnerships BOX 2.7 The (In)Complete Registry in Mauritius M auritius has a good regulatory framework and scores relatively well across the indicators. Yet there is a gap in oversight when it comes to registering private of clinics, but it exists all the same. It is a gap that should not matter much in a country where publicly provided health care is, in theory, available to all residents at no health care providers. A medical doctor in good standing cost, as is the case in Mauritius. But, also in many other (that is, one with a current registration with the Medical countries, anecdotal evidence suggests that despite the and Dental Council) can open a private practice without free care at public facilities, a significant proportion of registering anywhere. This is not considered a clinic, for care is provided through the individual providers, though which there is a complete list, but merely a consultation exact figures or official statistics do not exist. room, for which the government has no list at all. This particular gap in the regulation is not reflected in the Source: “Healthy Partnerships” data, 2010. scores, since our assessments are focused on the registry Private sector respondents also noted different people in need of treatment visit a TMP before quality standards for the public and private sector; going to a conventional doctor. The existence of a more than half of countries make a clear distinc- policy or program for this important group of pro- tion between the two. In Ethiopia, the private sec- viders indicates the government has a compre- tor is held to stringent inspection standards, yet hensive framework for all private players, not just private respondents said public sector facilities private clinics and pharmacies. would not pass similar inspections. This situation was noted elsewhere, including in Angola, where No CME or renewal requirements and lack private providers said they were held to higher of CME opportunities standards than their public counterparts. Continuing medical education requirements for The regulatory framework should also include licensed health professionals are much in vogue the entire range of actors found in the health sys- and are a requirement in most developed health tem. What it means to have a comprehensive systems. However, they are currently a require- framework in place will differ among countries. ment in only 20 percent of countries in our study. Given the high importance of traditional medi- There is a clear need for reform of requirements cine across the region and its existence at the for medical licenses in some countries. Some coun- relative fringes of the policy framework (that is, tries do not require that medical licenses get most of the rules, as well as the [self-]regulatory renewed at all. In Senegal and Togo, among others, bodies deal with allopathic medicine only), the it is currently not necessary to renew a medical question of its inclusion in a country’s policy license, let alone to attend CME classes. A medical framework becomes a useful proxy. license is valid for life once granted. This stark Approximately 75 percent of countries have omission is tempered somewhat by the recogni- some form of policy or program to engage with tion among policy makers of the benefits of CME providers of traditional medicine. Just as for the requirements, and medical councils in several overall policy, however, the important part lies in countries are planning to introduce them. the implementation, which was not assessed sepa- Private providers can attend government CME rately for traditional medicine policies. Having a training in two-thirds of the countries, allowing policy for traditional medical practitioners (TMPs) them to fulfill the requirement relatively easily. is an important first step though, because they are Actual attendance by private providers is, how- a major presence in many countries. In Swaziland, ever, rather low, often for avoidable reasons. Many there are about 11,000 TMPs and only 200 physi- providers in Lesotho complained about receiving cians. In Equatorial Guinea, about 80 percent of invitations on the same day of the training, or Healthy Partnerships | 45 BOX 2.8 Time It Takes to Open a Clinic T here are clear differences across the region in the length of time it takes to open a clinic. For example, a clinic can be opened in a few days in Rwanda and Uganda, often within countries, depending on the size and type or service level of the facility. In some countries, the main registration requirements, and therefore the most time in while respondents in Chad said a decision from the gov- the process, is dedicated to the professional accredita- ernment can take almost nine months. Given the delay, tion; in other countries, such requirements and time for many providers ignore the official channels and open compliance are imposed primarily on the facility. Defining anyway. It should be noted that a standardized measure a unique case that would be a suitable proxy across the for ease of opening a private health clinic in Africa is not region is therefore not feasible. In addition, the data col- (yet) feasible, even though the time it takes to register a lection for such a measure would be tricky, since our data firm is considered an important proxy for assessing the collection showed that typically only a few individuals general, nonhealth business environment (for example, know the existing requirements or how they are enforced the Doing Business indicator “starting a business”), as in practice. discussed in Section 1. Entry regulations for private health clinics vary dramatically among countries, and Source: “Healthy Partnerships” data, 2010; World Bank, Doing Business 2011. even after the event had taken place. In Guinea, Enforcement of regulations is a major problem the level of disorganization of publicly offered Enforcement of health care regulations is poor training has forced private practitioners to go else- almost everywhere in Africa. That regulation is where in the region, or even to France, to access well enforced in only six countries, based on our CME opportunities. research, indicates the breadth of the problem. Even in countries where a CME requirement Indeed, most government respondents readily exists, actual levels of participation can be low. admitted regulations are not well enforced. Table 2.5 shows the percentage of private provid- Figure 2.12 highlights the lack of enforcement ers who had been invited to public-sector CME across the region. Although every country has training over the last three years in Ghana and written rules governing inspections, in practice Kenya. The figures for private clinics in both they occur regularly in only five countries. They countries show that many private providers are take place infrequently in other countries, if at all. not being invited to public sector training. Yet, In Niger, for example, private respondents said no both Ghana and Kenya have a CME requirement inspections had taken place in more than 10 years. for medical doctors and courses offered to public A private provider in Madagascar said facilities sector professionals. The relatively low invitation had not been inspected in 15 years, even though rates in these two countries are emblematic of the they were located in the capital city. Elsewhere, experience of private providers in many countries inspections seemingly are only carried out if a across the region. problem is brought to the attention of the Minis- try of Health. TABLE 2.5 Private Providers Invited to Public Regulation can be especially difficult if several Sector CME Training over the Last Three Years, agencies have overlapping oversight mandates for Ghana and Kenya the sector. In Kenya, the Medical Practitioners and Country Hospital Clinic Dentistry Board, the Ministry of Health’s Depart- Ghana 2/10 (20%) 12/33 (36%) ment of Standards and Regulation, and the local Kenya 2/3 (67%) 9/35 (26%) District Health Office all have some regulatory Source: “Healthy Partnerships” provider survey, 2010. responsibility for the private health sector, but Note: CME = continuing medical education. there is no clear agreement on who conducts 46 | Healthy Partnerships FIGURE 2.12 TABLE 2.6 Resource Problems for Inspections Inspections—Paper Compared to Practice Congo, Dem. Rep. Inspectors routinely have not been paid in months and so facility inspections rarely take place. Côte d’Ivoire Inspectors are performing inspections out of their own means. Inspection regime Inspection exists on paper regime is not Ethiopia No Ministry of Health vehicles are available to carried out inspectors so they have to use public transportation 45 40 at their own expense to monitor over 400 private clinics in Addis Ababa. Inspection regime is Uganda Private providers have to pay for inspectors to come carried out in practice and do the inspections if they want to open their 5 clinic on time. Source: “Healthy Partnerships” data, 2010. Source: “Healthy Partnerships” data, 2010. inspections. In Lesotho, the Ministry of Health, the African private health sector. One example is the Maseru City Council, and the District Health team sophisticated hospitals that are seeking recogni- all have responsibility for inspecting private medi- tion for their efforts through accreditation by cal facilities in the Maseru area, and all frequently international accrediting bodies, as discussed in expect the other to do it. Often, it is not done at all. box 2.9. On the flip side, District Medical Officers in sev- eral countries are responsible for overseeing the Financing quality of care in all public and private facilities in The financing domain covers the revenues that their district, while also being responsible for the are actually or potentially available to the private management of public facilities. This dual role cre- health sector and the government’s influence of ates a clear conflict of interest for them. such funds through various mechanisms. See fig- Lack of resources is a major reason regulations ure 2.13 for description of good practice and are not properly enforced in many countries, summary of results in financing. according to public-sector respondents. Table 2.6 The top-performing countries in this domain illustrates this point. (score of 4 or more out of 6) are Cape Verde, While resources are important, other coun- Rwanda, Burundi, Equatorial Guinea, Ghana, tries have tried various methods to improve Mauritania, Mauritius, and Sudan (Khartoum enforcement of regulation. In Botswana and State). Ghana, inspections by the insurance authority In the financing domain, however, the mea- for accreditation (to become eligible to receive sures are imperfect proxies for the constructs reimbursements) have become the dominant they are designed to capture: strategic purchas- oversight mechanism for the private health sec- ing, attention to the investment climate, and tor. In Liberia, the Private Clinics Association ini- access for the broader population to the care tiated discussions with the Liberia Medical Board they seek. Developing better standardized mea- to participate in the regulation of facilities run sures should be possible but was beyond the by health professionals who are not doctors. scope of this report, since more work is needed There is much need for this kind of oversight, to obtain an accurate picture of this critical because the Medical Board does not have the domain. In the meantime, however, the chosen capacity to carry out the large-scale inspections proxies provide a good overview of the trends. needed to identify and bar unlicensed profes- We do not propose an overall good practice sionals from practice. example here or show a heat map for the conti- Initiative among larger providers who seek to nent. However, even though public financing of improve their quality is on the rise among the private providers is contentious in terms of Healthy Partnerships | 47 BOX 2.9 Voluntary Certifications by Third-Party Organizations International Standards Organization (ISO) Joint Commission International (JCI) Certification The JCI is the international arm of The Joint Commission The Nairobi Hospital in Nairobi, Kenya, was opened in on Accreditation of Healthcare Organizations. It has 1954. It has earned recognition as a center for medical accredited over 350 organizations outside the United practice excellence in many respects. The hospital has also States, where The Joint Commission was founded in 1951, demonstrated a commitment to delivering high-quality and has accredited over 18,000 health care organizations health care to its patients, by going beyond what was and programs in the United States. locally required to comply with international standards and The International Clinical Laboratories in Addis Ababa, acquire ISO’s certifications. It is ISO 9001:2008 certified; Ethiopia, was first accredited by the JCI in 2004 and has that is, its Quality Management System has been certified. been reaccredited twice. As of 2010, it was the only facility In addition, the hospital achieved ISO 2200:2005 Food in Africa with JCI accreditation. Other facilities mentioned Safety Management System and ISO 14001:2004 Environ- plans to acquire this mark of international quality, mostly mental Management System certifications. The multiple to be able to attract patients from outside their borders. certifications show the commitment of the Nairobi Hospital management to quality improvement principles. ISO relies Source: International Standards Organization 2011; Joint Commission International 2011; The Nairobi Hospital 2011; International Clinical on the individual organization to establish, document, Laboratories 2011. implement, and maintain a quality management system and continually improve its effectiveness. FIGURE 2.13 overall benefit to the health system, there is Good Practice and Results in Financing strong interest on the part of policy makers in further exploring ways to provide publicly Good practice in this domain is to have three elements in place: financed services through private providers • The government is committed to improving the effectiveness of (that is, public financing of privately provided public funds by partly using the private sector to deliver services (existence of any ongoing contracts to pay private providers for services), and it is undoubtedly a motivating services with public funds used as a proxy). factor for private providers. • The government seeks to improve the investment climate for the A critical dimension in financing is finding an private health sector (existence of any financial incentives specific effective mechanism that lets poor people have to private health sector facilities as a proxy). access not only to public health services but also • A significant part of the population can access the private health to private services, if that is where they seek sector without having to pay out-of-pocket (the level of private provider coverage by public or private health insurance used as care. This should not result in financial ruin for a proxy). the patient or in sustained losses for the private provider. Although, in principle, patients who cannot pay can be turned away, in practice, this Our research revealed the following: is not easy to do. When someone cannot pay or • A third of governments are contracting with self-financing providers; things go wrong during the course of treatment, half of those are also making financial incentives available. it is often the provider that has to bear the bur- • Another seven countries offer financial incentives but no contracts. den of the bad risk. It is often not easy to trans- • The level of private provider coverage through health insurance is small but growing; a clear momentum is building. fer or refer patients who cannot pay to a public facility. Source: “Healthy Partnerships” data, 2010. 48 | Healthy Partnerships Contracting is increasingly common, and Scarcity of specialized resources does not policy makers are eager to explore it further always lead to collaborative efforts, however. In Fifty percent of governments have contracts with Comoros, respondents recalled a time when a private providers in a wide variety of forms, evi- radiologist was not available at the main public dence that there is substantial collaboration sector hospital. Even though the expertise was between the public and private sectors.xi In sev- available in the private sector, and private provid- eral countries, public-private partnerships involve ers were available to help, the Ministry of Health entire facilities, as table 2.7 highlights. refused to enter into an agreement with them. As Some countries practice smaller-scale con- a result, respondents said the hospital could not tracting that involves specific clinical services or perform surgeries for over two weeks. procedures. In Rwanda, for example, the decen- In other cases, governments have eschewed tralization of budget management in the public public-private collaboration in favor of competing sector has allowed public hospitals to subcon- with private providers. In Sudan, computerized tract some clinical services to private facilities. In tomography (CT) scans were only available in the Nigeria, what started out as an informal agree- private sector at a relatively high cost of US$100. ment between Lagos State University Teaching This dropped to US$60 after the public sector Hospital and Saint Nicholas Hospital has led to a purchased CT scanners and offered the service at formalized contract to carry out kidney trans- US$50. Instead of compromising with the private plants for the public sector. In Guinea-Bissau, sector to provide public CT scans, the govern- governments have engaged private laboratories ment is now competing with the private sector. to perform tests for HIV patients. In Angola, the Some respondents said patients tend to prefer the Ministry of Health has entered into several con- private sector, even though it is more expensive. tracts with private providers for hemodialysis. The Sudanese Ministry of Health does have an Especially for smaller-scale contracting, both agreement with private providers for kidney dial- public and private respondents noted general ysis treatment, however. satisfaction with the agreements in place. xi. The indicator only measured government contracting for clinical services and not contracts with the private sector for ancillary ser- vices in public facilities. TABLE 2.7 Selected PPPs across the Region Lesotho A PPP hospital with Netcare (South Africa) is to replace the old Queen Elizabeth II Hospital. The PPP comprises the hospital and two satellite clinics. Madagascar The IMM Clinic in Antananarivo is a PPP between a private provider, General Electric Corporation (GE), and the government. The government supplied the building and GE supplied the equipment. A private provider manages the facility, which offers reduced-fee services. Nigeria Abuja’s Garki Hospital is also a model PPP hospital, where a private provider manages a government structure. Patients get higher-quality services than at public hospitals and at cheaper rates than other private centers. South Africa The Settlers Hospital in the Eastern Cape is a PPP among Nalithemba Hospitals, Netcare, and the Eastern Cape Health Department. Previous collaborative efforts involving the group have resulted in the construction and successful running of Port Alfred Hospital. Sudan The Ministry of Health has turned over several public facilities to private providers for free in exchange for offering reduced-fee services to the public and helping to train Sudanese medical students. Source: “Healthy Partnerships” data, 2010. Note: PPP = public-private partnership. Healthy Partnerships | 49 Financial incentives are sometimes available to Elsewhere, the operating environment for pri- private providers, but the private health sector is vate health providers is more difficult. Private often treated harshly firms that find themselves in such circumstances The range and scope of financial incentives varies say it is not a case of seeking favors but of being considerably across the region, but private provid- treated the same as other private sector businesses ers can access at least one incentive in 33 percent (box 2.10). The Comorian government, for exam- of countries.xii The most common types of incen- ple, taxes the private health sector more heavily tives are duty exemptions, value added tax (VAT) than other private sector businesses. exemptions, and general corporate tax exemp- tions, as shown in table 2.8. Some countries, such Level of private provider coverage through as Ethiopia and Rwanda, offer all of these incen- health insurance at a glance tives to private providers, while other countries As part of our data-collection effort, respon- are much less generous. Many private sector dents were asked to estimate the percentage of respondents, especially small clinics, said such people covered by health insurance schemes, incentives are often crucial to the financial viabil- whether public, private, or community based, ity of their facility. They also should be easy to that would reimburse for treatment received in access. Private providers in Lesotho said the a private facility. administrative burden for taking advantage of Table 2.9 provides a country breakdown of these incentives is so high that most private pro- current coverage levels. For the most part, cover- viders prefer not to deal with them. age levels are low. In the four countries with cov- Several countries have developed incentive erage greater than 50 percent, the government programs to engage the private health sector stra- has enacted a public insurance scheme that cov- tegically. For example, both Ethiopia and Sudan ers the majority of citizens and allows them offer incentives to private facilities that are willing some access to private providers. Ghana and to locate outside Addis Ababa or Khartoum. By Rwanda are recent examples. Patients have the offering reduced (or in some cases free) land and option of going to public or private facilities reduced property taxes, the government hopes to (which have to be accredited before they can lessen the concentration of private providers in participate), and the health insurance authority the capital city. Governments can also use an reimburses private providers. As the example of incentive program to ensure increased access for Tanzania shows, the private sector can become populations who could not otherwise afford it. In an important participant in public health Madagascar, the government offers private pro- schemes (box 2.11). viders tax reductions if they agree to treat a cer- While private sector respondents were mostly tain number of indigent patients. positive about taking part in insurance schemes, Ghanaian respondents noted instances of late TABLE 2.8 Most Common Incentives to reimbursements. Clearly, private sector partici- Private Providers pation in public programs is dependent on being Type of incentive Incidence able to bill public insurers and being sure of Duty exemptions on medicines or 17 timely reimbursement. Private participation can medical equipment bring other benefits. For example, the Botswana VAT exemptions 13 Insurance Authority plays an important role in General tax exemptions 9 fostering public-private dialogue and also col- Source: “Healthy Partnerships” data, 2010. lects data on service utilization in the private Note: VAT = valud added tax. health sector. xii. We measured financial incentives that are available specifically to Only in Mauritius, Namibia, and South Africa the private health sector. In addition, in a number of other coun- are more than 10 percent of the population cov- tries, private providers can benefit from general incentives offered to all private industry, even though there is nothing specific to the ered by private—as opposed to public—schemes. private health sector. These countries are not included in this figure. Botswana and Senegal have small but growing 50 | Healthy Partnerships TABLE 2.9 Level of Health Insurance Coverage Where Reimbursement for Privately Provided Services Is Theoretically Possiblea Country Public Private Community Total Angola — 2–4 — 2–4 Benin — 1–2 — 1–2 Botswana 7–9 8–9 — 15–18 Burkina Faso — 1–2 — 1–2 Burundi — 12 <1 12 Cameroon — 2–4 <1 2–4 Cape Verde 55 5 — 60 Central African Rep. — 1–2 — 1–2 Chad — 1–2 — 1–2 Comoros — 3–5 <1 3–5 Congo, Dem. Rep. — 1–2 <1 1–2 Congo, Rep. — 1–3 — 1–3 Côte d’Ivoire 10–12 3–5 <1 13–17 Equatorial Guinea 25–28 1–2 — 26–30 Ethiopia — 1–2 — 1–2 Gabon 55–60 1–2 — 56–62 Gambia, The -- — — 0 Ghana 60 1 — 61 Guinea — 1–2 — 1–2 Guinea–Bissau — 1–2 — 1–2 Kenya 9–18b 1–2 <1 10–20 Lesotho — 3 — 3 Liberia — 1 — 1 Madagascar — 5–10 — 5–10 a. The table reflects the answers of key respondents. The numbers have been Malawi — 1–2 — 1–2 verified through desk research and by Mali — 3–5 <1 3–5 consulting independent experts. They are not, however, intended to fully capture Mauritania 8–10 5–8 — 13–18 the complexities of health financing Mauritius — 10–15 — 10–15 (reimbursements that are available in theory may not fully cover expenses, for example, Mozambique — 1 — 1 and, therefore, private providers may not Namibia 1 15–19 — 16–20 accept them), and they do not take into Niger — 1 — 1 account availability of public services without insurance. Rather, they show the Nigeria 1 3–5 — 4–5 level of private provider coverage through Rwanda 86 6 1 93 health insurance at the time of the data collection (Spring 2010), as defined within São Tomé and Príncipe — — — 0 each country. Senegal 5–8 8-10 — 13–18 b. The wide range in the estimate for Seychelles — — — 0 coverage of public insurance in Kenya (National Hospital Insurance Fund, NHIF) is Sierra Leone — 1–2 — 1–2 based on two sources. While earlier studies South Africa 0 14 — 14 based on Demographic and Health Survey (DHS) data and interviewed experts Sudan 10–12 5–8 — 15–20 estimated the total coverage to be around Swaziland — 1–2 — 1–2 10 percent, more recent studies find the coverage to be significantly higher. This Tanzania 5–8 1–2 — 6–10 results in a wide range for total coverage Togo — 1 — 1 of between 10 and 20 percent. The Uganda — 1–2 — 1–2 discrepancy in this particular estimate illustrates the lack of reliable data and, Zambia — 1–2 — 1–2 therefore, the difficulty of making precise Zimbabwe — 8 — 8 estimates. Source: “Healthy Partnerships” data, 2010. Note: — = not available. Healthy Partnerships | 51 BOX 2.10 Incentives for Some but not All in the Democratic Republic of Congo I n the Democratic Republic of Congo, an incentive program that offers a reduction in the cost of infra- structure services is open to private companies but not to the private health sector. In addition, the incen- tives that would in theory be available to the private health sector are not applied equally to providers. Virtually all private sector respondents recalled how the government offered many incentives, including free ambulances, for the construction and operation of a high-profile hospital owned by a famous expatriate Congolese citizen while ignoring clinics that have been serving communities for more than 20 years. Source: “Healthy Partnerships” data, 2010. BOX 2.11 of a public system. Notwithstanding the diffi- culty of implementing such a system, there was Private Sector Participation a consensus across the region that health insur- in Public Schemes— ance coverage levels would increase substan- The Evidence from Tanzania tially over the next five years. This would also benefit private providers who can participate in T he Tanzanian national insurance author- ity accreditation has a built-in bias against the private health sector with pre- the system. The introduction and expansion of health insurance, when successful, has been found to accreditation of public facilities. Despite this be a game changer in many countries that have bias, consumers predominantly choose the gone down this path. This is especially true private health sector to provide their care. when the program includes premium subsidies Seventy-five percent of accredited facilities to allow the poor to be part of the program and belong to the public sector, yet 75 percent of when accompanied by changes in the providers the reimbursements go to the 25 percent of that are eligible for reimbursement and in the facilities in the private sector. payment system used to reimburse them. In Source: “Healthy Partnerships” data, 2010. Ghana and Nigeria, introduction of premium subsidies for the poor under their current health insurance system led to a significant increase in private health insurance sectors. Private health utilization of health services among poor peo- insurance exists in the Democratic Republic of ple. In Nigeria, people who are covered through Congo mostly for people who can access treat- their health maintenance organizations (HMOs) ment abroad. have more choice among the health care provid- The issue of health insurance is high on the ers from which they can seek care. Provider agenda across the region. Many countries are behavior changes significantly when the reim- interested in introducing some form of public bursement system shifts from fee-for-service to risk-pooling, and are looking at the systems in case mix or capitation payments, as was seen, Ghana or Rwanda for inspiration. The introduc- for example, in Hungary and other East Euro- tion of a public scheme is at an advanced stage pean countries. Similar changes were also seen in Ethiopia, Kenya, Nigeria, and Uganda. Other among providers after Ghana shifted from fee- countries are actively considering the feasibility for-service to case mix reimbursements. 52 | Healthy Partnerships Public provision of services ing the private sector, the Ministry was able to The public provision of services domain focuses significantly increase the supply of ARVs in the on how a government uses the direct production country. The Tanzanian government has also of health care inputs and health services to col- extended such collaboration to small-scale drug laborate with the private health sector. See figure shops, working with them as Accredited Drug 2.14 for description of good practice and sum- Dispensing Outlets. The national rollout strat- mary of results in public provision of services. egy offers training and accreditation to drug Many countries score well in this domain. In retailers in exchange for supplying quality drugs addition to most of the high-performing countries and participating in consumer awareness efforts. mentioned in earlier domains, this category The program increases the availability of good includes Angola, Cameroon, Mali, and Uganda. drugs and helps to bring smaller drug shops into the formal sector through accreditation and Good public-private collaboration: training. Specific disease or vaccine programs A related form of engagement is supranational The private sector participates widely in govern- financing to subsidize vital technologies with sig- ment disease and immunization programs across nificant externalities, taking advantage of the pri- the region, marking one of the better areas of vate health sector for disease-specific interventions, engagement. Private providers are included in for example. One prominent example of this is these programs in 66 percent of countries. Donor the Global Fund’s Affordable Medicine Facility programs such as the Global Fund are a big driver for malaria (AMFm), discussed in box 2.12. of such collaboration, and extensive programs for HIV and TB are present throughout Africa. Sig- Referral systems in place but not nificant, positive spillover effects emerge from this always smooth collaboration, especially in terms of increased dia- The referral process between the public and pri- logue and information exchange. But more can be vate sectors can also be an area of collaboration in done. On a broader scale, public-private collabora- every country. The most common type of referral tion on disease-specific programs can be a catalyst for further engagement. For example, Ethiopian FIGURE 2.14 respondents said the country’s widely supported Public Private Mix—for Directly Observed Treat- Good Practice and Results in Public Provision of Services ment—short course (PPM-Dots) program for tuberculosis, which involves the public and private Good practice in this domain is to have the following two sectors, was the starting point for further engage- elements in place: ment that is now culminating in the development • The government takes advantage of the private health sector for of a specific private health sector policy. Once gov- public health programs (distribution of vaccines or medicines for public health programs through private sector facilities used as a proxy). ernments see the tangible benefits of working with • The public and private facilities work together when necessary the private health sector, the motivation to extend (existence of a referral process between the public and private sector the engagement to other areas increases. used as a proxy). In Angola, private providers are included in the government-funded program on malaria. If patients choose private health providers, they Our research revealed the following: may have to pay a nominal consulting fee for the • There is good public-private collaboration for disease and physician’s time; the drug itself is free of charge. immunization programs. Similarly, in Tanzania, the Ministry of Health • There is some form of a referral system in all countries. approached the Association of Private Health Facilities to distribute anti-retroviral drugs Source: “Healthy Partnerships” data, 2010. (ARVs) through their member clinics. By engag- Healthy Partnerships | 53 is a patient moving from a small private facility to (table 2.11). In Malawi, the Mwaiwathu Hospi- a larger public one for more advanced treatment. tal regularly receives patients from the Queen The process is more systematic in some countries Elizabeth public hospital, including referrals for than others. In Ethiopia, for example, private pro- serious cases or for government officials, who viders fill out a referral form that the patient can might otherwise have been treated abroad. take to the public hospital to ensure some level of Since the services are less expensive domesti- continuity of care. cally than abroad, the government saves money. Many patients are also referred from the This is not a common practice throughout the public sector to the private, although the traffic region, however, and some private sector respon- is generally less in this direction. Countries with dents said governments preferred sending high- private providers able to offer highly advanced profile patients abroad rather than treating them treatment often receive patients from the pub- in-country. lic sector. In Botswana, the Gaborone private Governments can also use the referral pro- hospital receives cancer patients from Prince cess to bring informal providers into the system. Marina public hospital who require radiother- In Guinea-Bissau, the Ministry of Health worked apy. This type of practice is fairly common with matronas (traditional birth attendants), across the region (table 2.10). offering them formal training to improve the Referrals can also be an alternative to sending quality of deliveries and mitigate the risk of public sector patients abroad for treatment complications. A key part of the training was to BOX 2.12 High-Level Subsidy for Malaria Drugs R ecognizing that most people in poor coun- tries are treated for malaria in the private sector, in 2005 the Institute of Medicine (IOM) Facility–malaria (AMFm) were authorized. The high level of indirect subsidy is a first. It is indirect because the manufacturer receives the subsidy; called for new funds to subsidize coformulated an importer, wholesaler, retailer, or consumer artemisinin-based combination therapy (ACTs) simply sees a less-expensive product traveling for the entire global market to achieve end-user through the supply chain system, as would any prices in the range of US$0.20 to US$0.50 per other drug. There remains uncertainty regarding course of treatment, the current cost of chloro- the impact of AMFm. Early results from Ghana quine. This recommendation describes a global and Kenya suggest, however, that retail prices subsidy that enters the system high in the drug have indeed dropped dramatically for ACTs. Retail distribution chain, meaning that highly subsi- prices in Accra were about US$0.70 per adult dized drugs would be available to all high-level treatment, which is sharply lower than the pre- purchasers, both public and private sector. In AMFm retail prices of up to US$9.00. In Kenya, this way, drugs would enter the existing public some outlets sold the ACTs for about US$0.60, sector and private commercial channels much as which is also considerably less than the pre- any other drug, including chloroquine. AMFm average price of US$6.00. In May 2010, the first purchase orders for ACTs subsidized under Affordable Medicines Source: Global Subsidies Initiative 2008; The Global Fund 2011. 54 | Healthy Partnerships TABLE 2.10 Intramural Private Practice in The referral process is also susceptible to Public Facilities manipulation by doctors who work in both the Namibia Private doctors are allowed to use public public and private sectors. Public sector respon- facilities to see private patients in exchange dents in many countries complained of self- for time dedicated to treating public sector referrals—the tendency of doctors who work in patients for free. both sectors to refer public patients to their pri- Zambia Prince Marina public hospital has invited private doctors to commit some hours each vate clinic instead of continuing treatment in week to public sector work. the public sector. Although this can speed up Zimbabwe Private doctors can admit their patients in treatment for the patient, the cost is usually public hospitals if they agree to charge less. much greater. Source: “Healthy Partnerships” data, 2010. A different type of engagement: TABLE 2.11 Selected Public-to-Private Referrals How governments partner with faith- across the Region based organizations across the regionxiii Angola Partnerships with private clinics for hemodialysis prevent the need for As noted, government engagement with FBOs is medical evacuation to Brazil or Portugal. more extensive than with other private players Guinea-Bissau Clinica Madrugada is the reference across all domains and for all countries.xiv This cardiology facility in the country. It is close collaboration is partly explained by the per- privately owned and receives patients from public facilities. ception among policy makers that the public sec- South Africa The Department of Health has engaged tor and FBOs share similar social goals and are private hospitals to clear up public sector committed to public health goals. Research also waiting lists for certain services, such as shows that some FBOs have intrinsic motivation magnetic resonance imaging scans. to serve poor people.101 Faith-based facilities in Source: “Healthy Partnerships” data, 2010. many countries predate public health care deliv- ery, especially in rural areas, and FBOs sometimes help matronas identify difficult cases and refer charge less than other private providers. Faith- pregnant women to formal public or private based associations of providers also tend to be clinics. well organized and have a leadership structure Referral processes can of course be improved. that provides policy makers with a clear point of Both public and private respondents complained contact. about inefficiencies. Information is not always Notwithstanding the relatively high levels of shared when a referral is made, so patients may integration between the FBOs and the govern- have to start treatment again in the public sector ment, the engagement is not without consider- or undergo tests they have already paid for in the able challenges. Lack of resources in the public private sector. In some cases, there is a strong bias sector often spill over to FBO facilities and against people coming from the private sector. cause financing shortfalls or duplication of over- Private sector respondents in Mali described sight and information systems. patients who arrive at a public hospital in their High levels of engagement, in practice, are ambulances only to be refused treatment. In the fueled by the full or partial public financing of Seychelles, a patient referred from the private sector must pay to access the public sector. There xiii. As was noted earlier, the majority of nonprofit providers are FBOs. is no charge if coming from another public sector This section focuses on FBOs, though the discussion and the higher levels of engagement are largely applicable to secular non- facility. profit organizations. Prominent examples of this, for example for Liberia or in the domain of financing, are noted below. xiv. There are no faith-based facilities in the Seychelles. Healthy Partnerships | 55 FBO facilities, which occurs in 75 percent of In some countries, the FBOs are responsible for countries. This usually goes beyond providing collecting the information and sending it on. public funds to one facility for a particular ser- For example, in certain Democratic Republic of vice, as is often the case with individual for- Congo health zones, public sector health centers profit or self-financing providers. Rather, the send health-related information to a higher-level, public sector will provide financing for the faith-based facility. entire network of FBO facilities. Although they often continue to be managed by staff in the Regulation faith-based group, such facilities are treated as In many countries, the FBO umbrella organiza- an extension of the public sector and are consid- tion has a comprehensive registry of all the facili- ered as such by the general population. This, as ties under its jurisdiction. Often, the umbrella box 2.13 shows, changes the nature of engage- organization will also have its own inspection ment. Faith-based facilities are integrated into regime for its facilities, and the government will the public sector as a matter of course—for defer to it to ensure quality control. For example, example, larger facilities often act as reference in Uganda the Catholic Medical Bureau’s own hospitals for the public sector. group of inspectors reviews their facilities twice a Many of the indicators in the assessment year. They keep records of their visits and pass on framework are included in the contract or agree- all relevant information to the Ministry of Health ment with the faith-based providers, as exam- representative at the district level. Generally, pub- ples from across the domains show. Even when lic inspectors do not visit facilities already cleared there is no agreement in place, engagement with by the umbrella organization. In Liberia, where FBOs is consistently higher because of the per- secular nonprofit organizations provide a large ceived alignment of social goals. share of health care in the country, it is the umbrella bodies for nonprofit providers that are Policy and dialogue responsible for managing entire health zones, and In many countries, contracts or agreements are the inspection process is left entirely to them. essentially policy frameworks for FBOs. They pro- vide the foundation for engaging in practice by Financing comprehensively setting out the roles and respon- Public money flows to the FBOs in many ways, sibilities of private sector providers. The imple- beyond the contracts and service agreements. In mentation of such agreements requires close many countries, some form of budget support is coordination between the Ministry of Health and available to subsidize the operations of FBO opera- the FBO, illuminating the intensity of engagement, tors. This can be through direct financial support, as in the Lesotho example. Frequent meetings although in many countries it takes the form of occur in most countries to coordinate activities human resources, as in Zimbabwe, where the gov- and monitor performance of the contract. ernment provides nurses to small nonprofit health centers. A similar situation occurs in Rwanda, Information exchange where the government provides community health Where FBOs are closely integrated into the public- workers and attaches them to small nonprofit provision network, faith-based facilities are typically health outposts in rural areas. In addition, FBO pro- fully included in the national health management viders are often able to benefit from financial incen- information system. Providing information is gen- tives, such as reduced rates of tax or exemptions erally required as part of any agreement. The same from customs duties on equipment and medicines. is true for their involvement in the national dis- ease surveillance program. Often, FBO providers Public provision of services follow the same process as public sector facilities Many of the agreements reviewed for this Report in providing information to the Ministry of Health. call on the government to provide vaccines or 56 | Healthy Partnerships BOX 2.13 The Christian Health Association of Lesotho T he Christian Health Association of Lesotho (CHAL) pro- vides 40 percent of health care in the country. In 2007, a memorandum of understanding (MOU) was signed Although the regulatory framework is outdated, CHAL abides by the same rules as public sector facilities. There is a Ministry of Health (MOH) accreditation process for all their between the government of Lesotho and CHAL that pro- CHAL hospitals and clinics. If they do not perform well, the vided public funding for 80 percent of CHAL’s budget in government can remove funding for a specific facility. CHAL return for standardizing quality of health services and abid- officials form part of joint inspection teams that regularly ing by the same rules as all public facilities. CHAL retains conduct oversight of all public and faith-based facilities in a management control of hospitals and clinics. health district. The MOU integrates the faith-based group fully into A key part of the MOU stipulates that CHAL must charge the public system. The Joint Commission for Coopera- the same price for services as public sector facilities. CHAL tion, consisting of Ministry of Health and CHAL officials, must also bring salaries in line with the public sector. The acts as the official coordinating mechanism for the agree- government also supplies CHAL with drugs and vaccines as ment. Monthly meetings are held to evaluate perfor- part of national programs. mance and raise issues of joint concern. The difference in engagement between the government CHAL facilities must submit HMIS data monthly and and a CHAL facility, on the one hand, and the government and are fully involved in the disease surveillance program. a purely for-profit provider, on the other, illustrates the special Information is exchanged just as it would be with any treatment that is accorded faith-based providers. The differ- public facility. ences in Lesotho mirror the differences elsewhere in Africa. TABLE B2.13 CHAL Facility Requirements Compared to those of Self-Financing Providers Domain CHAL facility Self-financing providers Policy and dialogue • MOU as policy • No explicit policy • No dialogue mechanism Information exchange • Requirement to submit data • No requirement to submit data • 100% compliance rates • Very few private providers submitting data voluntarily • Full involvement in disease surveillance program • Not involved in disease surveillance program Regulation • CHAL facilities following public sector regulation, • Outdated and inappropriate regulatory framework which is outdated • Regulated to charge same price as public facilities Financing • Government provision of 80% of CHAL’s funding • Contracts with some individual private • No explicit incentives practitioners for specialized services • No explicit incentives available Public provision of • Strong involvement in disease programs • Strong involvement in disease programs services • Act as public sector reference facilities • Referral system functioning but weak Source: “Healthy Partnerships” data, 2010. other medicines to the nonprofit sector. In terms Increased engagement does not come of the referral process, many of the secondary or without challenges or problems tertiary faith-based facilities act as public refer- Getting engagement right is a constant process, ence hospitals and so are an essential part of the including with respect to the relatively close col- national referral system. In Rwanda, two of the laboration between faith-based providers and the five public reference hospitals in Kigali are non- public sector. Public financing, for example, does profit facilities that have long-standing agree- not always arrive promptly. In Lesotho, the Chris- ments with the Ministry of Health. tian Health Association of Lesotho said payments Healthy Partnerships | 57 from the Ministry of Health routinely arrive late, In terms of setting priorities for reform, post- affecting its ability to provide uninterrupted ser- conflict countries face particularly tight con- vices. Similar concerns were also raised about straints. They are often faced with the question: drugs and other commodities. In addition, the If the ministry of health has the capacity to do administrative burden increased, not just for only one or two things, what should they be? HMIS data but in terms of general financial Letting associations and umbrella organizations reporting and other requirements imposed by the carry out some of the activities that our frame- government. In the Democratic Republic of work identified as good practice can be a rela- Congo, the manager of one midsize FBO hospital tively effective approach, even where such said all of her time is spent dealing with the paper- examples of self-regulation are not initiated by work required for the contract; she hired extra the government. In the midst of conflict, large staff just for this purpose. In Lesotho, Zambia, and and fragmented private health sectors arise elsewhere, some respondents said quality of care when the government cannot continue to pro- has actually fallen in faith-based facilities since vide essential health services. Such private pro- public funding began. viders are often individuals running their own practices and various types of nonprofits. The individual practices could be owned by skilled Engagement in low-resource professionals or by unqualified people who environment would otherwise not be in business, leading to a When the government has very few resources, particularly wide range of providers. Especially which is the case in many African countries, the in the aftermath of war, government capacity prioritization of its activities or responsibilities and oversight mechanisms take a long time to toward the private health sector becomes espe- develop. Thus, the existing organizations either cially important. continue to provide services in different areas or 58 | Healthy Partnerships they coordinate themselves to fulfill what may to run the county health systems. The NGOs traditionally be seen as the oversight by the currently work with the various county health ministry of health. departments to develop their stewardship In Liberia, the private providers came capacity. At an even earlier stage of its develop- together to form an association that performs ment is South Sudan, as box 2.14 illustrates. self-regulatory functions. The Private Clinics Association of Liberia was established by physi- Level of organization of the private cian assistants, certified midwives, and registered health sector matters nurses. To combat the high degree of informal- ity that characterized their ranks, they began a One of the key ingredients for successful public- process of self-regulation to complement the private collaboration is the organization of the activities of the underresourced Liberian Medi- private sector. As discussed earlier, both public cal Board. With permission from the Medical and private respondents called lack of organiza- Board, which has the mandate for registering all tion one of the biggest barriers to further engage- private clinics, the Private Clinics Association ment. Even measured at a very basic level of performs the initial inspection to ensure that organization, the private sector is organized in the professionals are duly licensed and that the only 40 percent of countries in the region. In the facilities are worthy of certification. They also rest, there is either no organization or it is dor- perform inspections before facilities can have mant (figure 2.15). their licenses renewed by the Medical Board. Some countries have an umbrella organiza- The Private Clinics Association is able to reach tion covering the entire private sector, while areas the Medical Board would otherwise not others have one or more organizations repre- have been able to inspect, and they have the senting different areas of private health provi- mandate to close facilities that are not run by sion. Umbrella organizations for the entire appropriately licensed professionals, thus main- private sector exist in Ghana, Kenya, Nigeria, taining quality within their professional ranks. and South Africa. The group in Kenya, which In a more deliberate initiative, the govern- was only recently formed, played a role in the ment of Liberia runs a system where nongovern- development of the government’s health care mental organization (NGOs) are given contracts financing strategy. BOX 2.14 The Example of South Sudan T he historic peace agreement between the govern- ment of Sudan and the Sudan People’s Liberation Movement in 2005 created the semiautonomous South period, it is no surprise that the health system is still in its nascent stages. The government of South Sudan is heavily reliant on donors for both funding of the Ministry of Health Sudan. In view of the independence referendum in and for health service delivery. Over 80 percent of all health 2011, the “Healthy Partnerships” interview team visited services are delivered by nongovernmental organizations Juba in March 2010, even though it was not yet a sepa- that are connected with the state. There is also a small but rate country. The current assessment is about the state growing self-financing or for-profit health sector, concen- of government engagement in Sudan as a whole, using trated in Juba. In any case, the Ministry of Health appears Khartoum state as a proxy where the federal system open to the private sector and recognizes that it is going to necessitates it. be a vital partner in the coming years. Since South Sudan is emerging from decades of civil war, and most infrastructure was destroyed during that Source: “Healthy Partnerships” data, 2010. Healthy Partnerships | 59 FIGURE 2.15 TABLE 2.12 How Private Sector Organizations Private Health Sector (PHS) Organization Have Positively Influenced Public-Private Collaboration Republic of Congo The Pharmacists Association has PHS Organization successfully lobbied to be included PHS is organized; representative in selling ARVs at a reasonable cost. 19 organization exists and is active. Tanzania The Association of Private Health 26 PHS is not organized; no Facilities of Tanzania was engaged organization exists or is active. by the government to distribute vaccines and other goods from public health programs to private Source: “Healthy Partnerships” data, 2010. providers who make them available to patients. Togo The Association of Private Medical In many countries, poor organization of the Practitioners took the lead in setting the rules for the cost of general private health sector creates a challenge for pol- medical consultation for their icy makers who are willing to engage beyond members in 1993 and reviewed individual contracts or have relationships with them in 2009. more than just high-profile providers. In Angola, Source: “Healthy Partnerships” data, 2010. private providers were excluded from discus- sions about new health regulations because they Not surprisingly, the level of private health did not have an industry association. By con- sector organization is highly correlated with the trast, Côte d’Ivoire’s well-organized Private level of policy and dialogue; the better the orga- Medical Practitioners Association and its Trade nization, the better the dialogue. While this may Union of Private Medical Practitioners con- be unsurprising, good levels of private sector vinced the Ministry of Health to include their organization can also have benefits for other input in the National Health Sector Strategic domains; there are many examples where good Plan for 2009–13. In a few cases, as in Lesotho, private health sector organization has played a countries can suffer from too many industry key role in encouraging public-private collabo- associations, leaving the Ministry of Health ration. Box 2.15 provides specific examples. In a unsure of whom to work with. Table 2.12 pro- more general sense, private health sector organi- vides evidence of how private sector organiza- zations can exercise some self-regulation and tions have positively influenced public-private therefore lessen the burden on the public sector collaboration. to do everything. 60 | Healthy Partnerships BOX 2.15 Trade Associations as a Conduit for Engaging with the Private Sector T o shed light on the question of whether trade associa- tions are an effective conduit for engaging with the private sector, we report data from a survey of private Figure B2.15b shows the extent to which trade associa- tions help their members communicate with the govern- ment and register with statutory authorities. Roughly three health care providers in Ghana and Kenya that examines quarters of providers in Ghana and Kenya say trade associa- (a) the popularity of trade associations in the private tions act as a communication intermediary between facili- health sector, and (b) to what extent trade associations ties and the government, with a slightly higher fraction of engage with the government. Ghana’s facilities reporting this type of support. By contrast, The data in figure B2.15a show that the vast majority only 25 percent of Ghanaian providers say they received of private providers in Ghana—nearly 80 percent—are help with registration. A larger percentage of Kenyan facili- members of trade associations. The picture for Kenya is ties received this kind of assistance from their association. dramatically different: less than 20 percent of private pro- Overall, the data suggest that trade associations can viders report trade association membership. Interestingly, provide a diverse range of private providers with a common the data also show that in both Ghana and Kenya, trade voice. However, both trade association membership and association membership does not vary much by type of the role associations play can vary significantly across coun- facility. This suggests that trade associations might be an tries. In at least some countries, such as Ghana, engaging equally effective conduit for communicating with differ- with trade associations may be an important and efficient ent types of providers, including hospitals, clinics, and way for governments to work with the private sector. pharmacies. FIGURE B2.15a Trade Association Membership FIGURE B2.15b Role of Trade Associations in Ghana and Kenya in Engaging with the Government 100 100 Ghana 90 Kenya 90 Ghana Kenya 80 80 70 70 60 Percent 60 Percent 50 50 40 40 30 30 20 20 10 10 0 0 Hospital Clinic Pharmacy Total Communicates Helps with with the government registration on behalf of the facility Source: “Healthy Partnerships” provider survey, 2010. Healthy Partnerships | 61 62 | Healthy Partnerships Section 3: Conclusions and action plan for stakeholders The central argument of this Report is that public-private engagement can play a positive role in enhancing the efficient use of scarce resources for health and can improve access to quality care in Sub-Saharan Africa. As Section 1 noted, improvements in health systems are urgent and cannot be left to the public sector alone. The private health sector is already making significant contributions to health systems in Africa. Therefore, improvements in the efficiency of these systems and their overall performance need to include the private sec- tor. But not all government intervention or engagement with the private health sector is good. How should governments approach this challenge? T he results in Section 2 provide insights into the framework helps to highlight. The good the breadth and depth of government practice elements identified per domain can be engagement with the private sector and high- used as a checklist to identify these gaps. They light good examples of public-private collabora- include needed improvements of the regulatory tion. There is a general positive trend toward framework, including a mechanism for regular improved coordination between the public and inspection of all facilities, and insufficient atten- the private health sectors across the continent. tion to the continued education of private med- What is needed is the support of all stakeholders ical professionals. Integration of all private to accelerate this process and to approach public- providers into the national health management private engagement in a systematic manner. information system is also urgently needed. How does the assessment across domains These are the priorities for reform. They are also help in prioritizing reforms going forward? the priorities identified by stakeholders in As an illustrative example, we look at Rwanda. It is encouraging that, thanks to strong Rwanda. As described in Section 2, Rwanda per- political commitment to public-private collabo- forms relatively well across all five domains; it ration, policy makers in Rwanda have begun to has the highest scores, on average, for a low- address exactly these issues. income country. This finding is not unexpected The key recommendations from this study and is supported by previous studies of the are provided in the following sections. Ideas on health sector in Rwanda102 and by recent reports how the findings can be used to inform policy on documented improvements in the business reform are offered first. Then, we put the assess- environment.103 Based on these external studies, ment framework in the context of health and in line with the results from our assessment, systems components. We offer conclusions along the government of Rwanda seems to have done the five domains and propose key actions well in engaging with the private health sector for different stakeholder groups to strengthen (figure 3.1). public-private engagement in Africa. We end Despite the good scores, however, there are with an action plan for the research agenda still many remaining challenges in Rwanda that following from this Report. Healthy Partnerships | 63 FIGURE 3.1 Reforms as a political process at Detailed Domain Scores: Rwanda Example the country level After years of benign neglect, policy makers are Policy and Dialogue Rwanda* SSA* increasingly open to working with the private 100 *normalized scores health sector. The framework offered here pro- (0–100) 50 vides a useful starting point for the process. Not- Public Provision of Information withstanding the conclusions that follow, however, Exchange Services 0 it is important to keep in mind that reforms hap- pen in the context of a particular country and are subject to its political process. Financing Regulation This Report offers a framework for policy mak- ers and stakeholders more generally to approach Policy and dialogue this critical issue. Instituting the necessary changes, Policy exists for engaging with PHS ✓ however, is generally not a technical issue, but a De facto implementation of engagement policy ✓¾ political one. Therefore, the political process Formalized mechanism for dialogue with PHS ✓ De facto dialogue ✓¾ demands as much attention as the technical con- tents. Technically sophisticated solutions are use- Information exchange PHS included in information exchange ✓¾ less if they are not translated into changes in the PHS required to provide information to MoH beyond DS ✓ national health system. To navigate the political De facto information provision by PHS to MoH beyond DS ✖ process of reform, stakeholders can build on the PHS included in Disease Surveillance Program ✓ PHS receives DS updates from MoH in emergencies ✓ cumulative experience of countries that have Regulation gone through this process, as the examples men- Quality of private health sector providers registry ✓¾ tioned earlier attest. Reforms can also build on the Reported judgment of quality of regulation ✖ experience obtained through the “Health in Regulation is enforced as intended ✓ Africa” initiative’s ongoing support of the policy Standardized rules exist for opening PHS clinic ✓ Quality control process for clinics—de jure ✓ process in several African countries.104 Translating De facto quality control executed for PHS clinics ✖ technical solutions into realized changes also Quality control is the same for PHS and public ✖ requires vigilance; governments and the private Continued medical education requirement for license renewal ✖ Continued education open to PHS professionals ✓ health sector must continue to work together Policy/engagement toward traditional medicine exists ✖ throughout the policy cycle. Financing The goal is to have the private sector fully Government uses contracts with PHS ✓ embedded in the overall health system so that all Incentives are provided for PHS operators ✓ providers, public and private, compete for funds Overall population covered by health insurance ✓ 4/4 from public and private sources by offering high- Public provision of services PHS receives vaccines, medicines or similar for distribution ✓ quality services. The establishment of appropriate A functioning public-private referral process ✓ structures and capacities to handle such a system ✖ = no or score of 0 for this indicator takes time. All stakeholders—governments, the ✓ = yes or score of 1 for this indicator private health sector, but also donor and third- ✓ ¾ or ✓ 4/4 = score of 3 or 4, respectively, for this 1-4 or 0-4 indicator party organizations—will need to adjust. This is Source: “Healthy Partnerships” data, 2010. also true for faith-based providers who engage Note: PHS = private health sector; MoH = ministry of health; DS = disease surveillance. more closely with national governments, currently often through informal arrangements. In terms of prioritizing reforms, the political process also matters. Having manageable, con- crete elements to engage on improves the chances for sustained change, since successful reforms are the key ingredient to further successful reforms. 64 | Healthy Partnerships FIGURE 3.2 Alignment between Framework Domains and Health Systems Building Blocks Policy and dialogue Leadership and governance—Largely covered for PHS Information exchange Information—Largely covered for PHS Regulation Service delivery—Largely covered for PHS Financing Financing—Largely covered for PHS Public provision of services Health workforce—Not fully covered in this Report Medical products, etc.—Not fully covered in this Report Close overlap Partially covered Some aspects covered Source: “Healthy Partnerships” data, 2010; World Health Organization 2010a. Note: PHS = private health sector. And since some of the changes, such as overseeing As seen in figure 3.2, there is considerable contracts with the private sector, require develop- alignment between the domains of our frame- ment of the appropriate capacity, starting with work and health systems building blocks. As men- some concrete and relatively easy steps is the right tioned in the introduction to the Report, input thing to do from both a political and a technical markets are not the focus here, and so the ele- point of view. ments of “health workforce” and “medical prod- ucts, and so forth” are only partially addressed here. We expect to highlight the particular issues Engagement through health systems regarding public-private engagement in input strengthening approach markets in follow-on work. Since the health systems approach is now widely accepted as a logical way of strengthening sector Key conclusions by domain performance, the recommendations can also be considered in the context of the health systems The conclusions offered here, and the action plan building blocks, as per the classification of the below, relate to the entire private health sector, World Health Organization (WHO). Another including faith-based organizations (FBOs) that compelling reason for using the health systems are also looking for reforms. Indeed, the push for approach is that not all countries undertake sec- better engagement offers a good opportunity for torwide reforms all the time. This is particularly FBOs to redefine and develop their current work- true of donor-supported projects that tend to ing relationship with governments. Improving focus on specific issues or systems. Adoption of engagement is about bringing all the relevant this approach allows stakeholders to engage actors in a country’s health system to the table to meaningfully in partial reforms. As a recent establish a more efficient way of working together WHO report notes, within the national priorities. To achieve their goals, all health systems have to Policy and dialogue carry out some basic functions, regardless of how they are organized: they have to provide services; Policy and dialogue between the government and develop health workers and other key resources; the private health sector are the foundations of mobilize and allocate finances, and ensure health effective engagement. Our research shows that system leadership and governance (also known as many countries have policies on paper but are stewardship, which is about oversight and guid- lacking in implementation. ance of the whole system).105 Healthy Partnerships | 65 • A meaningful dialogue between the private • Information disclosure and availability of infor- health sector and the government about mation that allows patients to make informed mutual expectations and constraints sets the choices is important for the entire health sys- stage for follow-on actions by stakeholders. tem. The tendency toward secrecy in the pri- Setting up a formal process helps, but it is far vate sector is still too common. more important to ensure that the dialogue • Health facility surveys that include all facility takes place on an ongoing basis. types in the private health sector can provide a • Implementation matters. Concrete steps are basic level of information for planners. needed to show that the intention of engaging with the private health sector and with the Regulation government is real. A mechanism to monitor • A complete and up-to-date registry of private actual implementation, for example, by a third health facilities is a basic precondition for effec- party, can build trust. tive health system planning. Where such a reg- istry is not yet feasible in the medium term, • The organization of the private sector itself is alternatives are available for updating the infor- critical in establishing a dialogue. The private mation on “who does what,” such as the surveys health sector needs credible representation for mentioned above. It may not be necessary for the government to engage with. the Ministry of Health to fulfill this function directly, because other umbrella organizations Information exchange can play an important function here and subse- • Existing information systems remain incom- quently share their data with the ministry. plete if they do not include the private health sector. Having separate or designated informa- • Overly complex frameworks that are contradic- tion systems for the private health sector is nei- tory or that cannot be put into practice as ther necessary nor more effective. intended create uncertainty and opportunities for arbitrary enforcement. While a full-on over- • Excessive reporting requirements for the pri- haul will not be feasible in the near term, identi- vate sector are not useful. Requirements should fying and correcting the most urgent “mistakes” be aligned with the following: in the regulatory framework is. Therefore, – What the private health sector can reason- review and revision of the regulatory framework ably be expected to provide is needed to ensure that: – What the public sector can reasonably use – It is appropriate for the country’s health sys- and give feedback on (that is, data that are tem, including the size and type of the pri- collected but not processed, analyzed, or vate health sector. reported in a meaningful way create an – It establishes a straightforward regime of undue burden on private providers) licensing of professionals and of facilities – National priorities. that is appropriate and aligned to the coun- In all of these three points, dialogue with the try’s health care needs. Restrictions on com- private health sector is important. petition, for example, through protection of current practitioners from foreign practitio- • Private providers can be incentivized to pro- ners or investors, deserve particularly close vide data to the Ministry of Health, for exam- scrutiny for relevance. ple, through the inclusion in public health interventions. At a minimum, the motivation – It is appropriately simple and aligned with can involve the provision of feedback and enforcement capacity. At least part of the results of analysis of data submitted. oversight functions can be fulfilled by pri- vate organizations or associations; enforce- 66 | Healthy Partnerships ment capacity is to be understood in that classified as noncommercial enterprises for tax broader sense. reasons if, for example, they are committed to – It addresses issues of quality in some fash- also serving the poor and therefore provide ion through facility-based (inspections) or partly public services. profession-based (continuing medical edu- • The expansion of health insurance toward uni- cation [CME] requirements and offerings versal coverage—ongoing in several African for all professionals) approaches. The recog- countries—has the potential to fundamentally nition of voluntary approaches has been change the dynamics in, and improve perfor- successfully used to incentivize quality mance of, national health systems. Insurance, improvements. For example, facilities can be especially when appropriate focus is put on awarded a certificate or other recognition expanding coverage to the indigent, not only that can be displayed for patients or other decreases the financial risk of impoverishment visitors to see. from ill health. Higher levels of private pro- • Self-regulation can substitute for enforcement vider coverage through health insurance also by the government. In dialogue with private offer a more easily predictable revenue stream provider associations or third-party organiza- for providers, which improves the business tions, the extent and type of authority can be case for increased investment in the health sec- determined. tor. In addition, the accreditation process required to receive insurance reimbursements Financing has proven to generate powerful incentives for The key to financing is to ensure that there is a providers to focus on improving quality. The mechanism that allows poor people to have access intermediation of the insurance system’s to services, and that public funds buy value for accreditation process (or similar function) alle- money from either public or private services that viates capacity constraints in the government compete on a level playing field. The principle of for enforcing regulations. strategic purchasing (buying services from the • Using financing as an instrument for engage- best providers regardless of ownership) is espe- ment is difficult, both technically and politi- cially important to consider in countries where cally. While the appetite for big changes (for the private sector is large. example, insurance) is clearly present, small • The inclusion of the private health sector in changes provide the opportunity to build tech- public health programs including (partial) nical capacity and (political) trust in the con- public funding for privately provided services cept. Starting to contract out for ancillary can improve health systems performance. services at public hospitals, for example, if it Where the private sector provides health ser- has not been instituted yet, can provide experi- vices efficiently and to the poor population, it ence before launching major service delivery can be a well-placed channel for publicly contracts. financed care. Public provision of services • Taxation regimes that disadvantage the private In areas where there are no viable markets or health sector, including excessive import tariffs when there are large externalities, there is a need on inputs (pharmaceuticals, equipment, and so for the public sector to step in and ensure the forth) are damaging to the health system over- availability of both basic services and institutional all. Taxation and incentive issues can become support. Like the private sector in general, the pri- highly technical, which calls again for dialogue vate health sector also depends on publicly on priority areas between government (for financed services such as water, electricity, and example, the tax authority) and the private basic education. health sector. Private health facilities may be Healthy Partnerships | 67 • Similar to the financing domain, our research • Conduct a basic analysis of the private health suggests that the inclusion of the private health sector, including the composition and capacity of sector in public health programs, including private providers. This need not be a sophisti- public provision or financing of goods and ser- cated, time-consuming, or expensive analysis. vices, can benefit health systems performance. Establishing a basic level of information and Immunization programs, for example, will be understanding of the private health sector is crit- less effective if the private health sector and ical. Without it, policy makers will not be able to their patients are excluded. carry out their work in a strategic manner. • On a related note, the explicit inclusion of pri- • Start with manageable, concrete changes; suc- vate providers in the health system maps of cess builds on success. Technical and political local governments (for example, municipal, hurdles, for example, in using financing as an county, district, or province) and associated instrument, can be tackled by building trust in referral channels will benefit the efficiency of the engagement process itself. the whole health system, especially if it is accompanied by public-private dialogue to LONG TERM work out technical modalities. • Formulate a policy for engagement if one does not exist, or revive and revise the existing pol- icy if there is one; the policy should focus on Recommended actions by group of what is feasible and most desirable to be imple- stakeholders mented. The following are guidelines for an action plan for • Use the full range of instruments, across all five each group of stakeholders: governments, the pri- domains, to engage with the private health sec- vate health sector, donors, and intermediaries or tor. The framework presented here includes third-party organizations. The action plans are the basic elements and provides a useful guide summarized in figures 3.3, 3.4, 3.5, and 3.6, to engagement. It can also help identify the key respectively. areas of reform. Beyond these initial guidelines, it is imperative for governments to develop a Governments more comprehensive reform agenda appropri- SHORT TERM ate for the particular country context. • Stop interventions that are inadvertently harm- • Simplify the regulatory framework. The key is ful to the private health sector; keep the effects to prioritize and align with the priorities identi- on the private health sector of all interventions fied in dialogue with the private health sector. in mind. Effective engagement with the private health sector is not always about doing more; • Encourage the private health sector and third- sometimes the solution is to do less. Section 2 party organizations to take an active role in points to a number of government interven- addressing the issue of quality of care. If respon- tions that create massive distortions; they sibilities and authorities are clearly defined, should be eliminated as soon as possible. self-regulation or similar mechanisms may be effective in promoting quality while avoiding • Establish a mechanism for ongoing dialogue unnecessary burdens on private providers. with the private health sector to define com- mon priorities and strengthen partnerships. • Ensure that health professionals have access to There is an urgent need for increased commu- CME courses offered by public or private insti- nication in many countries. The good practice tutions. In particular, professionals from the example of Ghana highlights the advantages of private sector should have similar access to (re-)establishing a specific public-private health such courses as their colleagues from the pub- sector dialogue. lic sector. 68 | Healthy Partnerships FIGURE 3.3 FIGURE 3.4 Summarized Action Plan for Governments Summarized Action Plan for the Private Health Sector • Establish or strengthen ongoing dialogue with • Form a credible and representative organization, including an private health sector. umbrella organization, if needed. • Formulate or refine policy of engagement. • Seek meaningful dialogue with government. • Know at a basic level what the private health • Build capacity toward credible and fair self-regulation on issues sector does. discussed with the government, especially quality of care. • Simplify regulatory framework to match • Strengthen facility–internal quality control and business enforceable standards. management at private facilities. • Challenge private sector organizations to take on some oversight responsibilities. Source: “Healthy Partnerships” data, 2010. • Level the playing field between public and private providers. • Start with small, concrete steps to develop dence of private health sector organization capacity when reforms are politically or technically difficult. across the region, it is insufficient in most coun- tries. Where more than one organization of the same facility type exists, the private sector Source: “Healthy Partnerships” data, 2010. should consider merging or forming an umbrella organization that gives the public sector a single focal point for interaction. The representative • Establish or revive a basic oversight function body’s role will also be to effectively communi- for the private health sector, including moni- cate the contributions that private providers are toring and evaluating the impact of govern- making to national health goals. ment policies on it. Ideally, a focal point should • Seek meaningful dialogue as a first step in exist within the Ministry of Health that deals improving public-private engagement. The solely with the private health sector. previous section showed how private sector • Establish an up-to-date and comprehensive initiative has driven the engagement process in registry of private sector providers in the health some countries. system. This is a central element of good • Collaborate with the government to address engagement. Encouraging informal providers the issue of quality of care. Provider networks, to at least undertake basic registration is crucial capacity building in clinical practice (through if governments are to accurately map the scale CME), and business management training are and scope of who is doing what in their health all ways that private groups can help improve system. Registration will be effective only if it the care offered by their members. is simple, cheap, and fast. • Offer credible solutions to shift some oversight • Develop the capacity for strategic financing responsibility from the government to the rep- and contracting of services to the private health resentative body. While the government sector. This can be used to fill the access gaps remains the steward of the health system, that exist in specific health services within effective self-regulation can improve the sector regions or population groups. It may also overall and ease the capacity constraints of the include preventive care, which the private sec- government. tor often does little of, since most of the reve- nue comes from out-of-pocket payments. • Strengthen internal quality control and business management processes at private facilities. Espe- Private health sector cially in terms of business management prac- • Form a representative body to participate in the tices, most private providers have a lot to catch engagement process. While there is some evi- up to. Associations of private providers have a Healthy Partnerships | 69 role to play in providing guidance and support also help prevent long-term losses, for example, for improvements at individual facilities. through temporary elimination of domestic markets for health care goods or services being • For FBOs: Seek to review and develop the created out of short-term gains. existing relationship with the government as part of the overall engagement process. • Ensure that donor funding does not do more harm than good; for example, donor efforts on Donors malaria control that have supported the provi- Donors can play an important role in supporting sion of high-quality drugs at highly subsidized both the public and private sectors as they seek to prices can negatively affect local manufactur- improve engagement. ing of generic drugs (which may have a better chance of longer-term sustainability for the • Include the private sector in bilateral discus- countries involved). sions and design of projects; support the engagement process; take an active role in Third-party organizations improving communication. Third-party organizations can be insurance author- • Provide funding for activities that are aligned ities, civil society organizations (for example, con- with overall development goals. Funding for sumer advocacy groups), and others. service delivery should be appropriately bal- • Support and urge the increased organization of anced to enhance the relative advantages of the private health sector. both the private and public sectors. The main driver should be national health priorities. • Provide training and support to private provid- ers who need it, including on the management • Ensure that donor harmonization processes do or business aspects of their work. not cling to preconceived ideas about the rela- tive merits of public compared to private ser- • Support the ability of patients to make inform- vice delivery. ed choices. Third-party organizations are often effective in providing actionable information to • Improve the predictability of donor funding consumers of health care about the quality of and increase the duration of commitments. various providers and about the rights and This will support long-term planning. It will options that individual patients have but may not know about. FIGURE 3.5 FIGURE 3.6 Summarized Action Plan for Donors Summarized Action Plan for Third-Party Organizations • Include private health sector in discussions and design of new projects. • Support the increased organization of the • Support dialogue between government and private sector; align private health sector. projects with national priorities defined by such dialogue. • Provide training and support where needed, • Ensure that donor funding does not undermine local markets in also in business management. health care goods and services. • Support improved information for consumers. Source: “Healthy Partnerships” data, 2010. Source: “Healthy Partnerships” data, 2010. 70 | Healthy Partnerships Action plan for future research • Thematic expansion. Three points are among the agenda items for future (and currently In addition to the action plan suggested for all ongoing) research. stakeholders, we consider the action plan for tak- ing this work forward: what is the follow-up in – The report focused on service delivery. Addi- terms of analytical work from this report? The fol- tional analytical work is underway to further lowing elements are under consideration on the highlight the role of the private sector in analytical side (see figure 3.7 for a summary). input markets (for example, manufacturing, importing, and distributing and retailing • Replication. The work presented here consti- pharmaceuticals and medical equipment). tutes an important first step toward assessing The private sector also has a major role to the policy environment of the private health play in the education of the health work- sector and how engagement is shaping the force. The framework for assessing engage- environment. We expect that in future work, ment can contribute to the discussions in this the relative levels and types of engagement can area, as well. be assessed again to measure and discuss the – Africa is becoming a destination for foreign progress made and the relative effectiveness of investors in the health care market. While various reforms. It will be important that future this Report has not focused on the foreign iterations build on the work done here while direct investment dimension, such consider- refining and further developing the framework ations will be increasingly on the agenda for and the individual indicators. policy makers. Several countries in the • Estimating impact. The link between engage- region have already devoted significant ment and intermediate outcomes (access, qual- efforts to attracting investors, for both final ity, equity) or health outcomes (for example, service delivery and input markets. maternal or child mortality) can start to be – Subregional dimension: This report has only examined, based on the developed indicators. discussed the national level. Policy makers As the measures of engagement are refined, in Africa are exploring the potential of sub- such analyses can improve our understanding regional coordination. This exists on the of what type of engagement achieves the best business side with the West African Organ- results. isation pour l’Harmonisation en Afrique du FIGURE 3.7 Summarized Action Plan for Future Research • Replicate assessment to measure progress. • Further develop framework/indicators. • Estimate impact of engagement on outcomes. • Expand assessment thematically to include (a) private sector role in input markets and health worker education, (b) foreign investment in the health sector, (c) sub-regional dimension. • Expand geographically to apply framework to developing health systems in other regions. Source: “Healthy Partnerships” data, 2010. Healthy Partnerships | 71 Droit des Affaires (OHADA). The move In conjunction with the other available toward similar frameworks for the private resources and with the expertise at the country health sector holds great promise to lever- level, this Report should be used as an advocacy age scarce oversight capacity. tool in the reform process. The framework devel- oped here and used to assess engagement across • Future rounds of this work may address how Sub-Saharan Africa provides a starting point for the framework and the indicators developed developing a country-specific reform agenda, here are applicable to developing countries in and better engagement can lead to reforms in the other regions. health sector more broadly. Even though the challenges are enormous Toolkit for further guidance and improvements in African health systems are urgent, the willingness—and even demand—to A toolkit is available online to provide further look at health systems in a new way is reason to guidance to stakeholders interested in improving hope. When public and private sectors work in the public-private engagement in health. See partnership, improved access to affordable, www.wbginvestmentclimate.org/health. high-quality care is achievable in Africa. 72 | Healthy Partnerships APPENDIXES APPENDIX 1 – Country snapshots 76 APPENDIX 2 – Data tables 126 APPENDIX 3 – Conceptual background on engagement framework 133 APPENDIX 4 – Methodology for data collection 140 APPENDIX 5 – Scoping the private health care market 144 Healthy Partnerships | 73 APPENDIX 1—Country snapshots General notes on the country snapshots 1. The banner The banner provides basic information on the country and This appendix contains country snapshots with its high-level health outcomes. Total population and income selected indicators for each of the 45 Sub-Saharan per capita (as defined by the World Development Indicators) provide an indication of the (potential) size of the health African countries covered in the Report. Collec- market. Life expectancy and the measures for Millennium tively, the indicators provide a snapshot of the Development Goals (MDGs) 4, 5, and 6 are displayed to reflect operating environment for the private health sec- the high-level health outcomes of the population. The MDGs are also the most prominent goals in terms of population tor. Along with the new data on engagement dis- health. Note that the standard indicator for MDG 6 reflecting cussed throughout the report, the operating diagnoses of the communicable diseases HIV, TB, and environment is shown from the private sector side malaria has been transformed into percentage terms. (also affecting nonhealth private firms) and from Data sources: World Development Indicators (WDI), 2010 (note the health side (also affecting public health provid- that the data quoted in the WDI may in fact be a few years older than the WDI year); United Nations Statistics Division for ers). In order to complete the logical framework, notified cases of malaria.107 further discussed in appendix 4, intermediate and ultimate outcomes are included as well. 2. Engagement Many of the indicators are proxy or tracer indica- The engagement data are the newly collected data discussed in tors. They are not meant to fully capture the theme detail in the Report. The normalized scores for each domain in a given country are presented in the pentagon spider figure for for which they are chosen. Instead, they represent a representation of relative strengths and weaknesses of the best existing standardized data for cross-country domains in a given country. Averages across the Sub-Saharan assessment. The fact that the indicators are imper- Africa countries are also represented in the pentagon graph fect proxies illustrates the dearth of reliable data in (indicated by the blue line) for a comparison. It should be noted that the Sub-Saharan Africa average is calculated in this table general. For example, robust data for fundamental and in subsequent tables for the 45 countries covered by the vital registration indicators (births and deaths, research, in each instance across all countries for which data including cause of death) barely exist in many coun- is available. tries in Sub-Saharan Africa.106 Policy makers face Data source: Healthy Partnerships data (methodological details for each of the engagement indicators are in Appendix 4). the daunting task, therefore, of improving health systems often despite lacking basic information, such as who has died from what. Improving the availability of data for decision making is critical, as is making the best use of existing data. While com- prehensive and reliable information is scarce, the snapshots and the data in Appendix 2 constitute a big improvement over what has been available so far for assessing the contributions of the private health sector and its operating environment. The following explains the sections included in each snapshot. Table A1.1 at the end of the country snapshots provides further details on the indicators used in the snapshots that are derived from third-party sources. 74 | Healthy Partnerships Angola Population: 18.5 million MDG 4 Under-5 mortality rate (per 1,000) 161 GNI per capita (Atlas method): US$3,330 GN MDG 5 Maternal mortality ratio (per 100,000 live births) 610 1 Lif Life expectancy: 47 years MDG 6 (% of HIV prevalence (among ages 15–49) Tuberculosis incidence 2.1 0.3 population) Malaria (notified cases) 21.6 4. Health expenditure 2 Engagement E Health Expenditure 4 Data on the type of expenditure by the typical Policy and Dialogue Angola* SSA* A Angola SSA Average consumer/patient provides more detail on the 100 Health expenditure per capita in current $ 85.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 80.3 49.5 health market: how much is currently being Public Provision of 50 Information Private sector share of total expenditure (%) 19.7 50.5 spent on each person (per capita spending on Exchange Out-of-pocket expenditure 100.0 72.4 Services 0 (% of private expenditure) health) and who is spending it (the relative share of private and public in total expenditure on Financing Regulation Business Environment 5 health). The high average share, of private Score Maximum Angola SSA Average spending coming from out-of-pocket payments Policy and dialogue 6 10 Time to enforce a contract (days) 1,011 644 shows the extent to which especially the poor Information exchange 4 8 Time to prepare and pay taxes (hours per year) 282 317 population is vulnerable to potential financial Regulation 5 13 Time to start a business (days) 68 44 Financing 3 6 Cost of business start-up 163 96 impoverishment due to ill health. It is generally (% of income per capita) Public provision of services 2 2 also an indication of the kind of funding that private providers have relied on most heavily. I In Intermediate Outcomes 3 Access and Quality Ac Supporting Services 6 Data source: World Development Indicators, Immunization coverage Im 2010. 100 100 90 90 80 80 5. Business environment 70 70 Selected measures from the World Bank’s Doing 60 60 Business indicators illustrate how easy or difficult 50 50 it is to operate as a private company. Four 40 77 40 30 73 30 57 57 measures that are most relevant to health 50 20 47 20 providers are selected. Private health providers 10 10 are typically required to register as private 0 DPT (% of Measles (% of % births attended 0 Adult female % population % population businesses, a process that can take considerable children ages 12–23 months) children ages 12–23 months) by skilled health staff literacy rate (%) with access to with access to improved water improved sanitation time and money. They also have to pay taxes Angola SSA Angola SSA and, occasionally, seek the enforcement of contracts. How easily these things are done for SSA = Sub-Saharan Africa average the private sector in general, therefore, affects 76 | Healthy Partnerships private health providers as well. Data source: Doing Business 2011. 3. Intermediate outcomes: Access and quality 6. Supporting services For countries where data from the Demographic and Health Survey (DHS) are available, Availability of basic services, such as water and the snapshots provide measures of access and quality as the intermediate outcomes. electricity, significantly impact the cost of doing The measures chosen for the snapshot are, again, only proxies. Appendix 2 provides a business for any private enterprise, especially more comprehensive set of measures for intermediate outcomes. Access to health care private health providers. Measures of coverage for is measured in terms of self-reported source of care for children with symptoms of clean water and sanitation serve as proxies, in the acute respiratory infection (ARI). To proxy for the quality of care that is available in a absence of a similar measure for electricity. In country, the snapshots show the percentage of women who received all five of the addition, the availability of education has a basic prenatal services at some point during their pregnancy (blood pressure checks, significant impact on the customers of the private blood tests, urine tests, weight check, and discussion of complications). Data on providers and, therefore, indirectly on private percentage of births that are attended by a skilled health staff (WDI data) are shown providers. As a proxy, we use female literacy, as an additional proxy for quality of available health services. which is also strongly associated with positive For countries where DHS data are not available, the snapshots report immunization health outcomes. coverage rates for diphtheria, pertussis, and tetanus (DPT) and measles as an imperfect Data source: World Development Indicators, proxy for the DHS access measures. 2010. Note that averages for DHS data include only the 27 countries for which the relevant data are available. Data sources: World Development Indicators, 2010; Demographic and Health Surveys, year varies by country (see Table A1-1). Healthy Partnerships | 75 Angola Population: 18.5 million MDG 4 Under-5 mortality rate (per 1,000) 161 GNI per capita (Atlas method): US$3,330 MDG 5 Maternal mortality ratio (per 100,000 live births) 610 MDG 6 HIV prevalence (among ages 15–49) 2.1 Life expectancy: 47 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 21.6 Engagement Health Expenditure Policy and Dialogue Angola* Angola SSA Average 100 SSA* Health expenditure per capita in current $ 85.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 80.3 49.5 Public 50 Private sector share of total expenditure (%) 19.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 100.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Angola SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 1,011 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 282 317 Regulation 5 13 Time to start a business (days) 68 44 Financing 3 6 Cost of business start-up 163 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 40 77 40 73 30 30 57 57 47 50 20 20 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Angola SSA Angola SSA SSA = Sub-Saharan Africa average 76 | Healthy Partnerships Benin Population: 8.9 million MDG 4 Under-5 mortality rate (per 1,000) 118 MDG 5 Maternal mortality ratio (per 100,000 live births) 410 GNI per capita (Atlas method): US$700 MDG 6 HIV prevalence (among ages 15–49) 1.2 Life expectancy: 61 years (% of Tuberculosis incidence 0.1 population) Malaria (notified cases) 35.6 Engagement Health Expenditure Policy and Dialogue Benin* Benin SSA Average 100 SSA* Health expenditure per capita in current $ 31.9 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 51.8 49.5 Public 50 Private sector share of total expenditure (%) 48.2 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 94.9 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Benin SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 825 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 270 317 Regulation 8 13 Time to start a business (days) 31 44 Financing 2 6 Cost of business start-up 153 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 35 80 80 70 47 70 69 60 60 50 50 39 17 40 74 40 75 30 30 9 20 20 36 28 22 26 10 10 16 12 0 0 Benin: Benin: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Benin SSA facility facility Benin SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 77 Botswana Population: 1.9 million MDG 4 Under-5 mortality rate (per 1,000) 57 GNI per capita (Atlas method): US$6,550 MDG 5 Maternal mortality ratio (per 100,000 live births) 190 MDG 6 HIV prevalence (among ages 15–49) 23.9 Life expectancy: 54 years (% of Tuberculosis incidence 0.7 population) Malaria (notified cases) 0.6 Engagement Health Expenditure Policy and Dialogue Botswana* Botswana SSA Average 100 SSA* Health expenditure per capita in current $ 372.0 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 74.6 49.5 Public 50 Private sector share of total expenditure (%) 25.4 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 27.3 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Botswana SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 625 644 Information exchange 6 8 Time to prepare and pay taxes (hours per year) 152 317 Regulation 6 13 Time to start a business (days) 61 44 Financing 3 6 Cost of business start-up 2 96 Public provision of servicess 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 95 96 95 94 40 40 84 30 30 60 20 20 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Botswana SSA Botswana SSA SSA = Sub-Saharan Africa average 78 | Healthy Partnerships Burkina Faso Population: 15.8 million MDG 4 Under-5 mortality rate (per 1,000) 166 MDG 5 Maternal mortality ratio (per 100,000 live births) 560 GNI per capita (Atlas method): US$480 MDG 6 HIV prevalence (among ages 15–49) 1.6 Life expectancy: 53 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 45.3 Engagement Health Expenditure Policy and Dialogue Burkina Faso* Burkina Faso SSA Average 100 SSA* Health expenditure per capita in current $ 29.3 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 56.1 49.5 Public 50 Private sector share of total expenditure (%) 43.9 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 91.3 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Burkina Faso SSA Average Policy and dialogue 8 10 Time to enforce a contract (days) 446 644 Information exchange 6 8 Time to prepare and pay taxes (hours per year) 270 317 Regulation 8 13 Time to start a business (days) 14 44 Financing 2 6 Cost of business start-up 50 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 23 90 80 80 70 16 47 70 71 60 60 50 50 17 40 40 76 30 2 61 30 54 No data 20 20 36 27 10 10 6 11 0 0 Burkina Burkina SSA % women % births Adult female % population % population Faso: Faso: receiving all attended literacy rate (%) with access to with access to Poorest Richest basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Burkina Faso SSA facility facility Burkina Faso SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 79 Burundi Population: 8.3 million MDG 4 Under-5 mortality rate (per 1,000) 166 GNI per capita (Atlas method): US$140 MDG 5 Maternal mortality ratio (per 100,000 live births) 970 MDG 6 HIV prevalence (among ages 15–49) 2.0 Life expectancy: 50 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 48.5 Engagement Health Expenditure Policy and Dialogue Burundi* Burundi SSA Average 100 SSA* Health expenditure per capita in current $ 17.3 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 37.7 49.5 Public 50 Private sector share of total expenditure (%) 62.3 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 60.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Burundi SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 832 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 211 317 Regulation 5 13 Time to start a business (days) 32 44 Financing 4 6 Cost of business start-up 129 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 92 40 91 40 72 30 30 60 20 20 46 34 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Angola SSA Burundi SSA SSA = Sub-Saharan Africa average 80 | Healthy Partnerships Cameroon Population: 19.5 million MDG 4 Under-5 mortality rate (per 1,000) 154 MDG 5 Maternal mortality ratio (per 100,000 live births) 600 GNI per capita (Atlas method): US$1,140 MDG 6 HIV prevalence (among ages 15–49) 5.1 Life expectancy: 51 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 27.8 Engagement Health Expenditure Policy and Dialogue Cameroon* Cameroon SSA Average 100 SSA* Health expenditure per capita in current $ 54.3 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 25.9 49.5 Public 50 Private sector share of total expenditure (%) 74.1 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 94.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Cameroon SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 800 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 654 317 Regulation 6 13 Time to start a business (days) 19 44 Financing 1 6 Cost of business start-up 51 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 29 80 80 70 47 70 69 60 60 40 50 50 17 40 40 74 30 63 30 68 6 20 20 47 31 36 26 25 10 10 0 0 Cameroon: Cameroon: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Cameroon SSA facility facility Cameroon SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 81 Cape Verde Population: .5 million MDG 4 Under-5 mortality rate (per 1,000) 28 GNI per capita (Atlas method): US$2,830 MDG 5 Maternal mortality ratio (per 100,000 live births) 94 MDG 6 HIV prevalence (among ages 15–49) — Life expectancy: 71 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 0.02 Engagement Health Expenditure Policy and Dialogue Cape Verde* Cape Verde SSA Average 100 SSA* Health expenditure per capita in current $ 132.3 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 74.6 49.5 Public 50 Private sector share of total expenditure (%) 25.4 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 99.7 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Cape Verde SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 425 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 186 317 Regulation 8 13 Time to start a business (days) 11 44 Financing 6 6 Cost of business start-up 19 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 40 77 78 40 79 84 73 30 30 54 20 20 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Cape Verde SSA Cape Verde SSA SSA = Sub-Saharan Africa average 82 | Healthy Partnerships Central African Republic Population: 4.4 million MDG 4 Under-5 mortality rate (per 1,000) 171 MDG 5 Maternal mortality (per 100,000 live births) 850 GNI per capita (Atlas method): US$410 MDG 6 HIV prevalence ratio (among ages 15–49) 6.3 Life expectancy: 47 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 35.8 Engagement Health Expenditure Policy and Dialogue Central African C.A.R. SSA Average Republic* 100 Health expenditure per capita in current $ 16.5 95.3 SSA* *normalized scores Public sector share of total expenditure (%) 34.7 49.5 50 (0–100) Public Private sector share of total expenditure (%) 65.3 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 95.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum C.A.R. SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 660 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 504 317 Regulation 6 13 Time to start a business (days) 22 44 Financing 1 6 Cost of business start-up 228 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 40 40 67 62 30 54 30 44 20 20 41 34 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Central African Republic SSA Central African Republic SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 83 Chad Population: 11.2 million MDG 4 Under-5 mortality rate (per 1,000) 209 GNI per capita (Atlas method): US$540 MDG 5 Maternal mortality ratio (per 100,000 live births) 1,200 MDG 6 HIV prevalence (among ages 15–49) 3.5 Life expectancy: 49 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 39.5 Engagement Health Expenditure Policy and Dialogue Chad* Chad SSA Average 100 SSA* Health expenditure per capita in current $ 31.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 56.3 49.5 Public 50 Private sector share of total expenditure (%) 43.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 96.2 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Chad SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 743 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 732 317 Regulation 4 13 Time to start a business (days) 75 44 Financing 0 6 Cost of business start-up 227 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 80 80 70 47 70 76 60 60 50 90 50 17 40 40 30 30 3 50 20 20 36 10 21 10 22 8 14 2 3 9 0 0 Chad: Chad: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Chad SSA facility facility Chad SSA SSA = Sub-Saharan Africa average 84 | Healthy Partnerships Comoros Population: .7 million MDG 4 Under-5 mortality rate (per 1,000) 104 MDG 5 Maternal mortality ratio (per 100,000 live births) 340 GNI per capita (Atlas method): US$750 MDG 6 HIV prevalence (among ages 15–49) 0.1 Life expectancy: 65 years (% of Tuberculosis incidence 0.0 population) Malaria (notified cases) 24.6 Engagement Health Expenditure Policy and Dialogue Comoros* Comoros SSA Average 100 SSA* Health expenditure per capita in current $ 23.5 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 57.2 49.5 Public 50 Private sector share of total expenditure (%) 42.8 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 100.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Comoros SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 506 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 100 317 Regulation 6 13 Time to start a business (days) 24 44 Financing 1 6 Cost of business start-up 177 96 Public provision of services 0 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 95 83 40 79 40 68 30 62 30 20 20 36 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Comoros SSA Comoros SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 85 Democratic Republic of Congo Population: 66.0 million MDG 4 Under-5 mortality rate (per 1,000) 199 GNI per capita (Atlas method): US$150 MDG 5 Maternal mortality ratio (per 100,000 live births) 670 MDG 6 HIV prevalence (among ages 15–49) — Life expectancy: 48 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 37.4 Engagement Health Expenditure Policy and Dialogue Democratic Rep. Congo, DR SSA Average of Congo* 100 SSA* Health expenditure per capita in current $ 9.2 95.3 *normalized scores Public sector share of total expenditure (%) 20.8 49.5 (0–100) Public 50 Private sector share of total expenditure (%) 79.2 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 51.7 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Congo, DR SSA Average Policy and dialogue 2 10 Time to enforce a contract (days) 625 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 336 317 Regulation 5 13 Time to start a business (days) 84 44 Financing 1 6 Cost of business start-up 735 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 25 80 80 47 70 47 70 60 60 50 50 62 17 40 29 74 40 30 30 56 46 20 20 36 24 23 10 18 10 13 0 0 Congo,DR: Congo,DR: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Congo, Dem. Rep. SSA facility facility Congo,DR SSA SSA = Sub-Saharan Africa average 86 | Healthy Partnerships Republic of Congo Population: 3.7 million MDG 4 Under-5 mortality rate (per 1,000) 128 MDG 5 Maternal mortality ratio (per 100,000 live births) 580 GNI per capita (Atlas method): US$1,980 MDG 6 HIV prevalence (among ages 15–49) 3.5 Life expectancy: 54 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 34.3 Engagement Health Expenditure Policy and Dialogue Republic of Congo, Rep. SSA Average Congo* 100 SSA* Health expenditure per capita in current $ 51.8 95.3 *normalized scores Public sector share of total expenditure (%) 70.4 49.5 (0–100) Public 50 Private sector share of total expenditure (%) 29.6 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 100.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Congo, Rep. SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 560 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 606 317 Regulation 6 13 Time to start a business (days) 160 44 Financing 1 6 Cost of business start-up 111 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 17 90 80 80 70 47 70 27 66 60 60 50 50 17 84 40 40 4 71 30 56 30 No data 20 20 30 36 32 30 10 10 0 0 Congo, Rep.: Congo, Rep.: SSA % women % births Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Congo, Rep. SSA Congo, Rep. SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 87 Côte d’Ivoire Population: 21.1 million MDG 4 Under-5 mortality rate (per 1,000) 119 GNI per capita (Atlas method): US$980 MDG 5 Maternal mortality ratio (per 100,000 live births) 470 MDG 6 HIV prevalence (among ages 15–49) 3.9 Life expectancy: 57 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 36.5 Engagement Health Expenditure Policy and Dialogue Côte d’Ivoire* Côte d’Ivoire SSA Average 100 SSA* Health expenditure per capita in current $ 40.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 24.0 49.5 Public 50 Private sector share of total expenditure (%) 76.0 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 88.7 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Côte d’Ivoire SSA Average Policy and dialogue 5 10 Time to enforce a contract (days) 770 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 270 317 Regulation 6 13 Time to start a business (days) 40 44 Financing 2 6 Cost of business start-up 133 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 40 40 80 81 30 67 30 57 44 20 20 10 10 23 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Côte d’Ivoire SSA Côte d’Ivoire SSA SSA = Sub-Saharan Africa average 88 | Healthy Partnerships Equatorial Guinea Population: .7 million MDG 4 Under-5 mortality rate (per 1,000) 145 MDG 5 Maternal mortality ratio (per 100,000 live births) 280 GNI per capita (Atlas method): US$14,980 MDG 6 HIV prevalence (among ages 15–49) 3.4 Life expectancy: 50 years (% of Tuberculosis incidence 0.1 population) Malaria (notified cases) 27.7 Engagement Health Expenditure Policy and Dialogue Equatorial Eq. Guinea SSA Average Guinea* 100 SSA* Health expenditure per capita in current $ 347.5 95.3 *normalized scores Public sector share of total expenditure (%) 80.4 49.5 (0–100) Public 50 Private sector share of total expenditure (%) 19.6 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 75.6 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Eq. Guinea SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 553 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 492 317 Regulation 7 13 Time to start a business (days) 136 44 Financing 4 6 Cost of business start-up 104 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 89 40 40 30 66 30 51 No data 20 20 33 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Equatorial Guinea SSA Equatorial Guinea SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 89 Ethiopia Population: 82.8 million MDG 4 Under-5 mortality rate (per 1,000) 104 GNI per capita (Atlas method): US$280 MDG 5 Maternal mortality ratio (per 100,000 live births) 470 MDG 6 HIV prevalence (among ages 15–49) 2.1 Life expectancy: 55 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 11.5 Engagement Health Expenditure Policy and Dialogue Ethiopia* Ethiopia SSA Average 100 SSA* Health expenditure per capita in current $ 9.2 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 58.1 49.5 Public 50 Private sector share of total expenditure (%) 41.9 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 80.6 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Ethiopia SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 620 644 Information exchange 6 8 Time to prepare and pay taxes (hours per year) 198 317 Regulation 7 13 Time to start a business (days) 9 44 Financing 2 6 Cost of business start-up 14 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 80 80 70 47 70 64 78 60 60 50 50 17 40 40 30 14 30 20 3 20 38 36 19 22 23 10 10 3 6 12 0 0 Ethiopia: Ethiopia: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Ethiopia SSA facility facility Ethiopia SSA SSA = Sub-Saharan Africa average 90 | Healthy Partnerships Gabon Population: 1.5 million MDG 4 Under-5 mortality rate (per 1,000) 69 MDG 5 Maternal mortality ratio (per 100,000 live births) 260 GNI per capita (Atlas method): US$7,320 MDG 6 HIV prevalence (among ages 15–49) 5.9 Life expectancy: 60 years (% of Tuberculosis incidence 0.5 population) Malaria (notified cases) 29.5 Engagement Health Expenditure Policy and Dialogue Gabon* Gabon SSA Average 100 SSA* Health expenditure per capita in current $ 372.6 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 64.5 49.5 Public 50 Private sector share of total expenditure (%) 35.5 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 100.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Gabon SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 1,070 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 488 317 Regulation 6 13 Time to start a business (days) 58 44 Financing 3 6 Cost of business start-up 22 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 86 87 40 40 83 30 30 45 55 20 20 33 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Gabon SSA Gabon SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 91 The Gambia Population: 1.7 million MDG 4 Under-5 mortality rate (per 1,000) 103 GNI per capita (Atlas method): US$400 MDG 5 Maternal mortality ratio (per 100,000 live births) 400 MDG 6 HIV prevalence (among ages 15–49) 0.9 Life expectancy: 56 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 31.9 Engagement Health Expenditure Policy and Dialogue The Gambia* The Gambia SSA Average 100 SSA* Health expenditure per capita in current $ 21.9 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 47.9 49.5 Public 50 Private sector share of total expenditure (%) 52.1 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 48.4 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum The Gambia SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 434 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 376 317 Regulation 7 13 Time to start a business (days) 27 44 Financing 0 6 Cost of business start-up 200 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 98 96 92 40 40 30 30 67 58 20 20 34 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation The Gambia SSA The Gambia SSA SSA = Sub-Saharan Africa average 92 | Healthy Partnerships Ghana Population: 23.8 million MDG 4 Under-5 mortality rate (per 1,000) 69 MDG 5 Maternal mortality ratio (per 100,000 live births) 350 GNI per capita (Atlas method): US$1,150 MDG 6 HIV prevalence (among ages 15–49) 1.9 Life expectancy: 57 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 31.2 Engagement Health Expenditure Policy and Dialogue Ghana* Ghana SSA Average 100 SSA* Health expenditure per capita in current $ 54.1 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 51.6 49.5 Public 50 Private sector share of total expenditure (%) 48.4 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 79.3 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Ghana SSA Average Policy and dialogue 8 10 Time to enforce a contract (days) 487 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 224 317 Regulation 7 13 Time to start a business (days) 12 44 Financing 4 6 Cost of business start-up 20 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 80 80 48 70 47 70 66 60 60 50 50 14 17 40 40 82 30 60 57 15 30 59 20 38 20 36 19 10 10 13 0 Ghana: Ghana: SSA % women % births 0 Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Ghana SSA Ghana SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 93 Guinea Population: 10.1 million MDG 4 Under-5 mortality rate (per 1,000) 142 GNI per capita (Atlas method): US$340 MDG 5 Maternal mortality ratio (per 100,000 live births) 680 MDG 6 HIV prevalence (among ages 15–49) 1.6 Life expectancy: 58 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 40.6 Engagement Health Expenditure Policy and Dialogue Guinea* Guinea SSA Average 100 SSA* Health expenditure per capita in current $ 25.6 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 11.0 49.5 Public 50 Private sector share of total expenditure (%) 89.0 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 99.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Guinea SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 276 644 Information exchange 3 8 Time to prepare and pay taxes (hours per year) 416 317 Regulation 6 13 Time to start a business (days) 41 44 Financing 1 6 Cost of business start-up 147 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 80 40 80 70 47 70 69 60 60 14 50 50 17 40 40 71 30 30 8 46 20 46 20 36 10 23 26 12 10 19 0 0 Guinea: Guinea: SSA % women % births Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Guinea SSA Guinea SSA SSA = Sub-Saharan Africa average 94 | Healthy Partnerships Guinea-Bissau Population: 1.6 million MDG 4 Under-5 mortality rate (per 1,000) 193 MDG 5 Maternal mortality ratio (per 100,000 live births) 1,000 GNI per capita (Atlas method): US$460 MDG 6 HIV prevalence (among ages 15–49) 1.8 Life expectancy: 48 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 34.0 Engagement Health Expenditure Policy and Dialogue Guinea Bissau* Guinea-Bissau SSA Average 100 SSA* Health expenditure per capita in current $ 15.5 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 25.9 49.5 Public 50 Private sector share of total expenditure (%) 74.1 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 55.7 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Guinea-Bissau SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 1,140 644 Information exchange 2 8 Time to prepare and pay taxes (hours per year) 208 317 Regulation 6 13 Time to start a business (days) 216 44 Financing 0 6 Cost of business start-up 183 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 68 76 30 61 20 39 20 37 10 10 21 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Guinea-Bissau SSA Guinea-Bissau SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 95 Kenya Population: 39.8 million MDG 4 Under-5 mortality rate (per 1,000) 84 GNI per capita (Atlas method): US$730 MDG 5 Maternal mortality ratio (per 100,000 live births) 530 MDG 6 HIV prevalence (among ages 15–49) — Life expectancy: 54 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 30.3 Engagement Health Expenditure Policy and Dialogue Kenya* Kenya SSA Average 100 SSA* Health expenditure per capita in current $ 33.8 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 42.0 49.5 Public 50 Private sector share of total expenditure (%) 58.0 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 77.2 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Kenya SSA Average Policy and dialogue 9 10 Time to enforce a contract (days) 465 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 393 317 Regulation 7 13 Time to start a business (days) 33 44 Financing 2 6 Cost of business start-up 38 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 23 90 80 35 80 70 47 70 60 13 60 41 50 50 17 40 40 83 30 30 59 52 20 36 44 20 36 29 31 10 10 0 0 Kenya: Kenya: SSA % women % births Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Kenya SSA Kenya SSA SSA = Sub-Saharan Africa average 96 | Healthy Partnerships Lesotho Population: 2.1 million MDG 4 Under-5 mortality rate (per 1,000) 84 MDG 5 Maternal mortality ratio (per 100,000 live births) 530 GNI per capita (Atlas method): US$1,010 MDG 6 HIV prevalence (among ages 15–49) 23.2 Life expectancy: 45 years (% of Tuberculosis incidence 0.6 population) Malaria (notified cases) — Engagement Health Expenditure Policy and Dialogue Lesotho* Lesotho SSA Average 100 SSA* Health expenditure per capita in current $ 51.1 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 58.3 49.5 Public 50 Private sector share of total expenditure (%) 41.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 68.9 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Lesotho SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 785 644 Information exchange 3 8 Time to prepare and pay taxes (hours per year) 324 317 Regulation 6 13 Time to start a business (days) 40 44 Financing 2 6 Cost of business start-up 26 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 18 90 80 80 51 70 47 70 60 44 60 50 50 95 17 85 40 19 40 30 62 30 20 38 20 30 36 28 29 10 10 0 0 Lesotho: Lesotho: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Lesotho SSA facility facility Lesotho SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 97 Liberia Population: 4.0 million MDG 4 Under-5 mortality rate (per 1,000) 112 GNI per capita (Atlas method): US$170 MDG 5 Maternal mortality ratio (per 100,000 live births) 990 MDG 6 HIV prevalence (among ages 15–49) 1.7 Life expectancy: 58 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 30.0 Engagement Health Expenditure Policy and Dialogue Liberia* Liberia SSA Average 100 SSA* Health expenditure per capita in current $ 21.5 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 26.2 49.5 Public 50 Private sector share of total expenditure (%) 73.8 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 52.2 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Liberia SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 1,280 644 Information exchange 6 8 Time to prepare and pay taxes (hours per year) 158 317 Regulation 8 13 Time to start a business (days) 20 44 Financing 1 6 Cost of business start-up 55 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 10 90 90 80 80 53 37 70 47 70 60 60 50 50 17 40 40 19 68 30 53 30 53 46 20 20 28 36 10 19 10 17 0 0 Liberia: Liberia: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Liberia SSA facility facility Liberia SSA SSA = Sub-Saharan Africa average 98 | Healthy Partnerships Madagascar Population: 19.6 million MDG 4 Under-5 mortality rate (per 1,000) 58 MDG 5 Maternal mortality ratio (per 100,000 live births) 440 GNI per capita (Atlas method): US$420 MDG 6 HIV prevalence (among ages 15–49) 0.1 Life expectancy: 60 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 3.7 Engagement Health Expenditure Policy and Dialogue Madagascar* Madagascar SSA Average 100 SSA* Health expenditure per capita in current $ 16.3 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 66.2 49.5 Public 50 Private sector share of total expenditure (%) 33.8 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 67.9 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Madagascar SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 871 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 201 317 Regulation 8 13 Time to start a business (days) 7 44 Financing 3 6 Cost of business start-up 13 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 34 80 80 70 47 70 67 60 60 50 38 50 17 40 40 3 65 30 30 44 20 20 41 30 28 36 10 10 12 11 0 0 Madagascar: Madagascar: SSA % women % births Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Madagascar SSA Madagascar SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 99 Malawi Population: 15.3 million MDG 4 Under-5 mortality rate (per 1,000) 110 GNI per capita (Atlas method): US$260 MDG 5 Maternal mortality ratio (per 100,000 live births) 510 MDG 6 HIV prevalence (among ages 15–49) 11.9 Life expectancy: 53 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 33.8 Engagement Health Expenditure Policy and Dialogue Malawi* Malawi SSA Average 100 SSA* Health expenditure per capita in current $ 16.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 59.7 49.5 Public 50 Private sector share of total expenditure (%) 40.3 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 28.4 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Malawi SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 312 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 157 317 Regulation 9 13 Time to start a business (days) 39 44 Financing 2 6 Cost of business start-up 108 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 80 80 56 70 47 70 69 60 60 50 50 17 40 14 40 80 66 30 30 8 54 56 20 20 23 30 36 10 10 11 0 0 Malawi: Malawi: SSA % women % births attended Adult female % population % population Poorest Richest receiving all literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Malawi SSA facility facility Malawi SSA SSA = Sub-Saharan Africa average 100 | Healthy Partnerships Mali Population: 13.0 million MDG 4 Under-5 mortality rate (per 1,000) 191 MDG 5 Maternal mortality ratio (per 100,000 live births) 830 GNI per capita (Atlas method): US$610 MDG 6 HIV prevalence (among ages 15–49) 1.5 Life expectancy: 48 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 25.4 Engagement Health Expenditure Policy and Dialogue Mali* Mali SSA Average 100 SSA* Health expenditure per capita in current $ 34.3 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 51.4 49.5 Public 50 Private sector share of total expenditure (%) 48.6 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 99.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Mali SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 620 644 Information exchange 3 8 Time to prepare and pay taxes (hours per year) 270 317 Regulation 7 13 Time to start a business (days) 8 44 Financing 3 6 Cost of business start-up 80 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 30 80 80 70 47 70 73 60 60 27 50 50 17 40 40 30 30 56 4 No data 20 43 20 36 36 49 23 10 10 9 0 0 Mali: Mali: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Mali SSA facility facility Mali SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 101 Mauritania Population: 3.3 million MDG 4 Under-5 mortality rate (per 1,000) 117 GNI per capita (Atlas method): US$980 MDG 5 Maternal mortality ratio (per 100,000 live births) 550 MDG 6 HIV prevalence (among ages 15–49) 0.8 Life expectancy: 57 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 17.3 Engagement Health Expenditure Policy and Dialogue Mauritania* Mauritania SSA Average 100 SSA* Health expenditure per capita in current $ 21.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 65.3 49.5 Public 50 Private sector share of total expenditure (%) 34.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 100.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Mauritania SSA Average Policy and dialogue 2 10 Time to enforce a contract (days) 370 644 Information exchange 1 8 Time to prepare and pay taxes (hours per year) 696 317 Regulation 5 13 Time to start a business (days) 19 44 Financing 4 6 Cost of business start-up 34 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 64 59 61 30 50 49 20 20 10 26 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Mauritania SSA Mauritania SSA SSA = Sub-Saharan Africa average 102 | Healthy Partnerships Mauritius Population: 1.3 million MDG 4 Under-5 mortality rate (per 1,000) 17 MDG 5 Maternal mortality ratio (per 100,000 live births) 36 GNI per capita (Atlas method): US$6,720 MDG 6 HIV prevalence (among ages 15–49) 1.7 Life expectancy: 73 years (% of Tuberculosis incidence 0.0 population) Malaria (notified cases) — Engagement Health Expenditure Policy and Dialogue Mauritius* Mauritius SSA Average 100 SSA* Health expenditure per capita in current $ 246.9 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 49.0 49.5 Public 50 Private sector share of total expenditure (%) 51.0 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 81.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Mauritius SSA Average Policy and dialogue 8 10 Time to enforce a contract (days) 645 644 Information exchange 8 8 Time to prepare and pay taxes (hours per year) 161 317 Regulation 11 13 Time to start a business (days) 6 44 Financing 4 6 Cost of business start-up 4 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 99 99 99 50 99 91 40 40 85 30 30 20 20 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Mauritius SSA Mauritius SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 103 Mozambique Population: 22.9 million MDG 4 Under-5 mortality rate (per 1,000) 142 GNI per capita (Atlas method): US$380 MDG 5 Maternal mortality ratio (per 100,000 live births) 550 MDG 6 HIV prevalence (among ages 15–49) 12.5 Life expectancy: 48 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 32.6 Engagement Health Expenditure Policy and Dialogue Mozambique* Mozambique SSA Average 100 SSA* Health expenditure per capita in current $ 18.1 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 71.8 49.5 Public 50 Private sector share of total expenditure (%) 28.2 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 42.1 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Mozambique SSA Average Policy and dialogue 4 10 Time to enforce a contract (days) 730 644 Information exchange 3 8 Time to prepare and pay taxes (hours per year) 230 317 Regulation 7 13 Time to start a business (days) 13 44 Financing 0 6 Cost of business start-up 14 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 33 80 80 70 58 47 70 7 60 60 50 50 1 17 40 40 60 30 55 30 47 20 41 20 40 36 10 16 10 17 0 0 Mozambique: Mozambique: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Mozambique SSA facility facility Mozambique SSA SSA = Sub-Saharan Africa average 104 | Healthy Partnerships Namibia Population: 2.2 million MDG 4 Under-5 mortality rate (per 1,000) 48 MDG 5 Maternal mortality ratio (per 100,000 live births) 180 GNI per capita (Atlas method): US$4,260 MDG 6 HIV prevalence (among ages 15–49) 15.3 Life expectancy: 61 years (% of Tuberculosis incidence 0.8 population) Malaria (notified cases) 4.6 Engagement Health Expenditure Policy and Dialogue Namibia* Namibia SSA Average 100 SSA* Health expenditure per capita in current $ 318.5 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 42.1 49.5 Public 50 Private sector share of total expenditure (%) 57.9 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 5.8 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Namibia SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 270 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 375 317 Regulation 11 13 Time to start a business (days) 66 44 Financing 3 6 Cost of business start-up 19 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 3 100 90 90 80 40 80 70 56 47 70 60 60 7 50 50 17 88 92 40 81 40 30 53 30 53 20 20 41 36 33 10 10 0 0 Namibia: Namibia: SSA % women % births Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Namibia SSA Namibia SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 105 Niger Population: 15.3 million MDG 4 Under-5 mortality rate (per 1,000) 160 GNI per capita (Atlas method): US$330 MDG 5 Maternal mortality ratio (per 100,000 live births) 820 MDG 6 HIV prevalence (among ages 15–49) 0.8 Life expectancy: 51 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 38.0 Engagement Health Expenditure Policy and Dialogue Niger* Niger SSA Average 100 SSA* Health expenditure per capita in current $ 16.4 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 52.8 49.5 Public 50 Private sector share of total expenditure (%) 47.2 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 96.4 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Niger SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 545 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 270 317 Regulation 6 13 Time to start a business (days) 17 44 Financing 0 6 Cost of business start-up 119 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 26 80 80 70 47 70 63 60 27 60 50 50 17 40 40 30 16 30 47 No data 48 20 20 36 10 21 33 10 5 9 0 0 Niger: Niger: SSA % women % births attended Adult female % population % population Poorest Richest receiving all literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Niger SSA facility facility Niger SSA SSA = Sub-Saharan Africa average 106 | Healthy Partnerships Nigeria Population: 154.7 million MDG 4 Under-5 mortality rate (per 1,000) 138 MDG 5 Maternal mortality ratio (per 100,000 live births) 840 GNI per capita (Atlas method): US$1,170 MDG 6 HIV prevalence (among ages 15–49) 3.1 Life expectancy: 48 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 38.3 Engagement Health Expenditure Policy and Dialogue Nigeria* Nigeria SSA Average 100 SSA* Health expenditure per capita in current $ 74.2 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 25.3 49.5 Public 50 Private sector share of total expenditure (%) 74.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 95.9 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Nigeria SSA Average Policy and dialogue 8 10 Time to enforce a contract (days) 457 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 938 317 Regulation 8 13 Time to start a business (days) 31 44 Financing 2 6 Cost of business start-up 79 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 25 90 80 80 49 70 47 70 60 60 50 47 50 17 40 40 37 30 30 58 49 20 39 20 28 36 30 32 10 10 14 0 0 Nigeria: Nigeria: SSA % women % births Poorest Richest receiving all attended Adult female % population % population basic prenatal by skilled literacy rate (%) with access to with access to care services health staff improved water improved sanitation Public Private None facility facility Nigeria SSA Nigeria SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 107 Rwanda Population: 10.0 million MDG 4 Under-5 mortality rate (per 1,000) 111 GNI per capita (Atlas method): US$410 MDG 5 Maternal mortality ratio (per 100,000 live births) 540 MDG 6 HIV prevalence (among ages 15–49) 2.8 Life expectancy: 50 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 11.4 Engagement Health Expenditure Policy and Dialogue Rwanda* Rwanda SSA Average 100 SSA* Health expenditure per capita in current $ 37.2 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 47.0 49.5 Public 50 Private sector share of total expenditure (%) 53.0 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 44.4 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Rwanda SSA Average Policy and dialogue 8 10 Time to enforce a contract (days) 230 644 Information exchange 6 8 Time to prepare and pay taxes (hours per year) 148 317 Regulation 7 13 Time to start a business (days) 3 44 Financing 6 6 Cost of business start-up 9 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 33 80 80 70 47 70 57 60 60 50 34 50 17 40 40 17 30 66 65 30 54 20 33 20 36 52 26 10 10 1 0 0 Rwanda: Rwanda: SSA % women % births attended Adult female % population % population Poorest Richest receiving all literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Rwanda SSA facility facility Rwanda SSA SSA = Sub-Saharan Africa average 108 | Healthy Partnerships São Tomé and Príncipe Population: .2 million MDG 4 Under-5 mortality rate (per 1,000) 78 MDG 5 Maternal mortality ratio (per 100,000 live births) — GNI per capita (Atlas method): US$1,020 MDG 6 HIV prevalence (among ages 15–49) — Life expectancy: 66 years (% of Tuberculosis incidence 0.1 population) Malaria (notified cases) 2.0 Engagement Health Expenditure Policy and Dialogue São Tomé and São Tomé & Príncipe SSA Average Príncipe* 100 SSA* Health expenditure per capita in current $ 102.7 95.3 *normalized scores Public sector share of total expenditure (%) 47.1 49.5 (0–100) Public 50 Private sector share of total expenditure (%) 52.9 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 58.9 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum São Tomé & Príncipe SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 1,185 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 424 317 Regulation 3 13 Time to start a business (days) 144 44 Financing 0 6 Cost of business start-up 77 96 Public provision of services 0 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 82 89 40 90 40 83 98 30 30 20 20 10 26 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation São Tomé and Príncipe SSA São Tomé and Príncipe SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 109 Senegal Population: 12.5 million MDG 4 Under-5 mortality rate (per 1,000) 93 GNI per capita (Atlas method): US$980 MDG 5 Maternal mortality ratio (per 100,000 live births) 410 MDG 6 HIV prevalence (among ages 15–49) 1.0 Life expectancy: 56 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 7.1 Engagement Health Expenditure Policy and Dialogue Senegal* Senegal SSA Average 100 SSA* Health expenditure per capita in current $ 54.2 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 56.0 49.5 Public 50 Private sector share of total expenditure (%) 44.0 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 78.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Senegal SSA Average Policy and dialogue 5 10 Time to enforce a contract (days) 780 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 666 317 Regulation 7 13 Time to start a business (days) 8 44 Financing 3 6 Cost of business start-up 63 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 30 80 80 70 47 70 62 60 60 28 50 50 17 40 1 40 69 30 30 52 42 No data 51 20 37 20 36 10 20 10 0 0 Senegal: Senegal: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Senegal SSA facility facility Senegal SSA SSA = Sub-Saharan Africa average 110 | Healthy Partnerships Seychelles Population: .1 million MDG 4 Under-5 mortality rate (per 1,000) 12 MDG 5 Maternal mortality ratio (per 100,000 live births) — GNI per capita (Atlas method): US$10,530 MDG 6 HIV prevalence (among ages 15–49) — Life expectancy: 73 years (% of Tuberculosis incidence 0.0 population) Malaria (notified cases) — Engagement Health Expenditure Policy and Dialogue Seychelles* Seychelles SSA Average 100 SSA* Health expenditure per capita in current $ 564.0 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 70.2 49.5 Public 50 Private sector share of total expenditure (%) 29.8 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 62.5 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Seychelles SSA Average Policy and dialogue 5 10 Time to enforce a contract (days) 720 644 Information exchange 8 8 Time to prepare and pay taxes (hours per year) 76 317 Regulation 12 13 Time to start a business (days) 39 44 Financing 1 6 Cost of business start-up 18 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 99 50 97 92 40 40 30 30 No data 20 20 No data 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Seychelles SSA Seychelles SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 111 Sierra Leone Population: 5.7 million MDG 4 Under-5 mortality rate (per 1,000) 192 GNI per capita (Atlas method): US$320 MDG 5 Maternal mortality ratio (per 100,000 live births) 970 MDG 6 HIV prevalence (among ages 15–49) 1.7 Life expectancy: 48 years (% of Tuberculosis incidence 0.6 population) Malaria (notified cases) 36.1 Engagement Health Expenditure Policy and Dialogue Sierra Leone* Sierra Leone SSA Average 100 SSA* Health expenditure per capita in current $ 13.5 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 31.3 49.5 Public 50 Private sector share of total expenditure (%) 68.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 58.8 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Sierra Leone SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 515 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 357 317 Regulation 8 13 Time to start a business (days) 12 44 Financing 1 6 Cost of business start-up 111 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 38 80 80 70 47 70 57 60 60 50 30 50 17 40 8 40 30 30 49 20 35 42 20 32 36 29 26 10 10 13 0 0 Sierra Leone: Sierra Leone: SSA % women % births attended Adult female % population % population Poorest Richest receiving all literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Sierra Leone SSA facility facility Sierra Leone SSA SSA = Sub-Saharan Africa average 112 | Healthy Partnerships South Africa Population: 49.3 million MDG 4 Under-5 mortality rate (per 1,000) 62 MDG 5 Maternal mortality ratio (per 100,000 live births) 410 GNI per capita (Atlas method): US$5,870 MDG 6 HIV prevalence (among ages 15–49) 18.1 Life expectancy: 51 years (% of Tuberculosis incidence 1.0 population) Malaria (notified cases) 0.1 Engagement Health Expenditure Policy and Dialogue South Africa* South Africa SSA Average 100 SSA* Health expenditure per capita in current $ 497.1 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 41.4 49.5 Public 50 Private sector share of total expenditure (%) 58.6 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 29.7 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum South Africa SSA Average Policy and dialogue 9 10 Time to enforce a contract (days) 600 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 200 317 Regulation 13 13 Time to start a business (days) 22 44 Financing 3 6 Cost of business start-up 6 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 91 88 91 40 62 40 69 77 30 30 20 20 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation South Africa SSA South Africa SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 113 Sudan Population: 42.3 million MDG 4 Under-5 mortality rate (per 1,000) 108 GNI per capita (Atlas method): US$1,120 MDG 5 Maternal mortality ratio (per 100,000 live births) 750 MDG 6 HIV prevalence (among ages 15–49) 1.4 Life expectancy: 58 years (% of Tuberculosis incidence 0.1 population) Malaria (notified cases) 12.8 Engagement Health Expenditure Policy and Dialogue Sudan* Sudan SSA Average 100 SSA* Health expenditure per capita in current $ 40.5 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 36.8 49.5 Public 50 Private sector share of total expenditure (%) 63.2 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 100.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Sudan SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 810 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 180 317 Regulation 10 13 Time to start a business (days) 36 44 Financing 4 6 Cost of business start-up 34 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 84 40 40 82 30 30 60 57 49 20 20 34 10 10 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Sudan SSA Sudan SSA SSA = Sub-Saharan Africa average 114 | Healthy Partnerships Swaziland Population: 1.2 million MDG 4 Under-5 mortality rate (per 1,000) 73 MDG 5 Maternal mortality ratio (per 100,000 live births) 420 GNI per capita (Atlas method): US$2,560 MDG 6 HIV prevalence (among ages 15–49) 26.1 Life expectancy: 46 years (% of Tuberculosis incidence 1.2 population) Malaria (notified cases) 0.1 Engagement Health Expenditure Policy and Dialogue Swaziland* Swaziland SSA Average 100 SSA* Health expenditure per capita in current $ 151.1 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 62.5 49.5 Public 50 Private sector share of total expenditure (%) 37.5 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 42.3 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Swaziland SSA Average Policy and dialogue 3 10 Time to enforce a contract (days) 972 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 104 317 Regulation 7 13 Time to start a business (days) 56 44 Financing 2 6 Cost of business start-up 33 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 17 90 90 33 80 80 70 47 70 36 60 13 60 50 50 17 86 40 69 40 69 30 30 47 55 20 54 20 47 36 10 10 0 0 Swaziland: Swaziland: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Swaziland SSA facility facility Swaziland SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 115 Tanzania Population: 43.7 million MDG 4 Under-5 mortality rate (per 1,000) 108 GNI per capita (Atlas method): US$460 MDG 5 Maternal mortality ratio (per 100,000 live births) 790 MDG 6 HIV prevalence (among ages 15–49) 6.2 Life expectancy: 56 years (% of Tuberculosis incidence 0.2 population) Malaria (notified cases) 24.1 Engagement Health Expenditure Policy and Dialogue Tanzania* Tanzania SSA Average 100 SSA* Health expenditure per capita in current $ 21.7 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 65.8 49.5 Public 50 Private sector share of total expenditure (%) 34.2 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 75.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Tanzania SSA Average Policy and dialogue 8 10 Time to enforce a contract (days) 462 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 172 317 Regulation 7 13 Time to start a business (days) 29 44 Financing 2 6 Cost of business start-up 31 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 12 90 22 90 80 80 70 47 70 47 60 33 60 50 50 17 40 40 66 30 30 54 45 43 20 41 20 36 24 10 20 10 0 0 Tanzania: Tanzania: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Tanzania SSA facility facility Tanzania SSA SSA = Sub-Saharan Africa average 116 | Healthy Partnerships Togo Population: 6.6 million MDG 4 Under-5 mortality rate (per 1,000) 98 MDG 5 Maternal mortality ratio (per 100,000 live births) 350 GNI per capita (Atlas method): US$410 MDG 6 HIV prevalence (among ages 15–49) 3.3 Life expectancy: 63 years (% of Tuberculosis incidence 0.4 population) Malaria (notified cases) 30.4 Engagement Health Expenditure Policy and Dialogue Togo* Togo SSA Average 100 SSA* Health expenditure per capita in current $ 32.9 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 24.9 49.5 Public 50 Private sector share of total expenditure (%) 75.1 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 84.2 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Togo SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 588 644 Information exchange 3 8 Time to prepare and pay taxes (hours per year) 270 317 Regulation 8 13 Time to start a business (days) 75 44 Financing 1 6 Cost of business start-up 178 96 Public provision of services 1 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services Immunization coverage 100 100 90 90 80 80 70 70 60 60 50 50 89 40 84 40 30 62 30 60 54 20 20 10 10 12 0 0 DPT (% of Measles (% of % births attended Adult female % population % population children ages children ages by skilled literacy rate (%) with access to with access to 12–23 months) 12–23 months) health staff improved water improved sanitation Togo SSA Togo SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 117 Uganda Population: 32.7 million MDG 4 Under-5 mortality rate (per 1,000) 128 GNI per capita (Atlas method): US$420 MDG 5 Maternal mortality ratio (per 100,000 live births) 430 MDG 6 HIV prevalence (among ages 15–49) 5.4 Life expectancy: 53 years (% of Tuberculosis incidence 0.3 population) Malaria (notified cases) 36.2 Engagement Health Expenditure Policy and Dialogue Uganda* Uganda SSA Average 100 SSA* Health expenditure per capita in current $ 27.8 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 26.2 49.5 Public 50 Private sector share of total expenditure (%) 73.8 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 51.0 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Uganda SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 490 644 Information exchange 5 8 Time to prepare and pay taxes (hours per year) 161 317 Regulation 8 13 Time to start a business (days) 25 44 Financing 2 6 Cost of business start-up 94 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 16 13 90 90 80 80 70 47 70 60 47 60 69 50 50 17 40 40 67 67 30 30 48 20 37 42 20 36 10 18 10 4 0 0 Uganda: Uganda: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Uganda SSA facility facility Uganda SSA SSA = Sub-Saharan Africa average 118 | Healthy Partnerships Zambia Population: 12.9 million MDG 4 Under-5 mortality rate (per 1,000) 141 MDG 5 Maternal mortality ratio (per 100,000 live births) 470 GNI per capita (Atlas method): US$960 MDG 6 HIV prevalence (among ages 15–49) 15.2 Life expectancy: 45 years (% of Tuberculosis incidence 0.5 population) Malaria (notified cases) 13.5 Engagement Health Expenditure Policy and Dialogue Zambia* Zambia SSA Average 100 SSA* Health expenditure per capita in current $ 57.1 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 57.7 49.5 Public 50 Private sector share of total expenditure (%) 42.3 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 67.6 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Zambia SSA Average Policy and dialogue 7 10 Time to enforce a contract (days) 471 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 132 317 Regulation 9 13 Time to start a business (days) 18 44 Financing 3 6 Cost of business start-up 28 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 28 80 40 80 70 47 70 19 60 60 9 50 50 17 40 40 61 60 30 51 30 53 47 49 20 20 36 10 16 10 0 0 Zambia: Zambia: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Zambia SSA facility facility Zambia SSA SSA = Sub-Saharan Africa average Healthy Partnerships | 119 Zimbabwe Population: 12.5 million MDG 4 Under-5 mortality rate (per 1,000) 90 GNI per capita (Atlas method): US$ — MDG 5 Maternal mortality ratio (per 100,000 live births) 790 MDG 6 HIV prevalence (among ages 15–49) 15.3 Life expectancy: 44 years (% of Tuberculosis incidence 0.8 population) Malaria (notified cases) 7.5 Engagement Health Expenditure Policy and Dialogue Zimbabwe* Zimbabwe SSA Average 100 SSA* Health expenditure per capita in current $ 78.6 95.3 *normalized scores (0–100) Public sector share of total expenditure (%) 46.3 49.5 Public 50 Private sector share of total expenditure (%) 53.7 50.5 Provision of Information Services Exchange Out-of-pocket expenditure 50.4 72.4 0 (% of private expenditure) Financing Regulation Business Environment Score Maximum Zimbabwe SSA Average Policy and dialogue 6 10 Time to enforce a contract (days) 410 644 Information exchange 4 8 Time to prepare and pay taxes (hours per year) 242 317 Regulation 10 13 Time to start a business (days) 90 44 Financing 1 6 Cost of business start-up 183 96 Public provision of services 2 2 (% of income per capita) Intermediate Outcomes Access and Quality Supporting Services % of children with ARI taken to facility 100 100 90 90 80 41 80 70 47 70 60 60 79 50 50 26 17 89 40 40 82 60 30 33 30 20 20 44 7 36 29 10 14 10 0 0 Zimbabwe: Zimbabwe: SSA % women % births Adult female % population % population Poorest Richest receiving all attended literacy rate (%) with access to with access to basic prenatal by skilled improved water improved sanitation care services health staff Public Private None Zimbabwe SSA facility facility Zimbabwe SSA SSA = Sub-Saharan Africa average 120 | Healthy Partnerships Table A1.1 Further Details on the Indicatorsa Used in the Snapshots Derived from Third-Party Sources Indicator Year Definition Source Population (millions) 2009 Total population is based on the de facto definition of population, which World Development Indicators, counts all residents regardless of legal status or citizenship, except for World Bankb refugees not permanently settled in the country of asylum who are generally considered part of the population of their country of origin. The values shown are midyear estimates. GNI per capita, Atlas 2008 GNI (formerly GNP) is the sum of value added by all resident producers, World Development Indicators, method (current US$) plus any product taxes (less subsidies) not included in the valuation of World Bank output, plus net receipts of primary income (compensation of employees and property income) from abroad. Life expectancy (years) 2008 Life expectancy at birth indicates the number of years a newborn infant World Development Indicators, would live if prevailing patterns of mortality at the time of its birth were World Bank to stay the same throughout its life. Under-5 mortality rate 2009 Under-5 mortality rate is the probability per 1,000 that a newborn baby World Development Indicators, (per 1,000) will die before reaching age 5, if subject to current age-specific mortality World Bank rates. Maternal mortality ratio 2008 Maternal mortality ratio is the number of women who die during World Development Indicators, (modeled estimate, per pregnancy and childbirth per 100,000 live births. The data are estimated World Bank 100,000 live births) with a regression model using information on fertility, birth attendants, and HIV prevalence. Prevalence of HIV, total 2007 Prevalence of HIV refers to the percentage of people ages 15–49 who World Development Indicators, (% of population ages are infected with HIV. World Bank 15–49) Incidence of tuberculosis 2008 Incidence of tuberculosis is the estimated number of new pulmonary, World Development Indicators, (% of population) smear positive, and extrapulmonary tuberculosis cases. The standard World Bank indicator is reported per 100,000 population, but is transformed into percentages for purposes of this report. Notified cases of malaria 2008 Malaria incidence is expressed as the number of new cases reported by Millennium Development Goal (% of population) a Ministry of Health, adjusted to take into account (a) incompleteness Indicators, United Nations in reporting systems; (b) patients seeking treatment in the private sector, Statistics Division self-medicating, or not seeking treatment at all; and (c) potential over- diagnosis through the lack of laboratory confirmation of cases. For some African countries, the quality of case reporting is considered insufficient, and estimates are derived from longitudinal studies of malaria incidence recorded in the published literature, with adjustments for population distribution and public health programs. The standard indicator is reported per 100,000 population, but is transformed into percentages for purposes of this report. Health expenditure per 2007 Total health expenditure is the sum of public and private health World Development Indicators, capita (current US$) expenditures as a ratio of total population. It covers the provision of World Bank health services (preventive and curative), family planning activities, nutrition activities, and emergency aid designated for health, but it does not include provision of water and sanitation. Data are in current U.S. dollars. Public sector share of 2007 Public health expenditure consists of recurrent and capital spending from World Development Indicators, total health expenditure government (central and local) budgets, external borrowings and grants World Bank (percent) (including donations from international agencies and nongovernmental organizations), and social (or compulsory) health insurance funds. Private sector share of 2007 Private health expenditure includes direct household (out-of-pocket) World Development Indicators, total health expenditure spending, private insurance, charitable donations, and direct service World Bank (percent) payments by private corporations. Out-of-pocket health 2007 Out-of-pocket expenditure is any direct outlay by households, including World Development Indicators, expenditure (% of gratuities and in-kind payments, to health practitioners and suppliers of World Bank private expenditure pharmaceuticals, therapeutic appliances, and other goods and services on health) whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups. It is a part of private health expenditure. Time required to enforce 2010 Time required to enforce a contract is the number of calendar days from Doing Business 2011 a contract (days) the filing of the lawsuit in court until the final determination and, in appropriate cases, payment. Indicators on enforcing contracts measure the efficiency of the judicial system in resolving a commercial dispute. Healthy Partnerships | 121 Table A1.1, continued Indicator Year Definition Source Time required to 2010 Time it takes to prepare, file, and pay (or withhold) three major types of Doing Business 2011 prepare and pay taxes taxes—the corporate income tax, the value-added or sales tax, and labor (hours per year) taxes, including payroll taxes and social security contributions. Time required to start 2010 Time required to start a business is the number of calendar days needed Doing Business 2011 a business (days) to complete the procedures to legally operate a business. Cost of business start- 2010 The cost includes all official fees and fees for legal or professional services Doing Business 2011 up procedures (% of if such services are required by law. Cost to register a business is income per capita) normalized by presenting it as a percentage of GNI per capita. % children in poorest Varies by Percentage of children under age 3 at the time of survey in poorest Demographic and Health (richest) quintile with ARI country (richest) wealth quintile reporting fever/rapid breathing in the last Surveysc only taken to public facility 2 weeks taken only to a public health facility. % children in poorest Varies by Percentage of children under age 3 at the time of survey in poorest (richest) Demographic and Health (richest) quintile with ARI country wealth quintile reporting fever/rapid breathing in the last 2 weeks taken Surveys taken to private facility to any private health facility (including pharmacies). % children in poorest Varies by Percentage of children under age 3 at the time of survey in poorest Demographic and Health (richest) quintile with ARI country (richest) wealth quintile reporting fever/rapid breathing in the last 2 Surveys not taken to any facility weeks not taken to any health facility. % of women receiving Varies by Percentage of mothers giving birth in the 3 years prior to the time of Demographic and Health all 5 basic services during country survey who were checked for blood pressure, urine, and blood, and Surveys prenatal care informed about complications during prenatal care. Births attended by Varies by Births attended by skilled health staff are the percentage of deliveries World Development Indicators, skilled health staff country attended by personnel trained to give the necessary supervision, care, World Bank (% of total) and advice to women during pregnancy, labor, and the postpartum period; to conduct deliveries on their own; and to care for newborns. [Data for the latest available year between 2000 and 2009 presented for each country, average is the Sub-Saharan Africa average for 2009.] Immunization, DPT 2009 Percentage of children ages 12–23 months who received three doses of World Development Indicators, (% of children ages vaccine against diphtheria, pertussis (or whooping cough), and tetanus World Bank 12–23 months) (DPT) before 12 months or at any time before the relevant survey. Immunization, measles 2009 Percentage of children ages 12–23 months who received one dose of World Development Indicators, (% of children ages measles vaccine before 12 months or at any time before the survey. World Bank 12–23 months) Adult female literacy rate 2008 Adult female literacy rate is the percentage of women age 15 and above World Development Indicators, who can, with understanding, read and write a short, simple statement World Bank on their everyday life. % of population with 2008 Percentage of the population with reasonable access to an adequate World Development Indicators, access to improved water amount of water from an improved source, such as a household connection, World Bank public standpipe, borehole, protected well or spring, or rainwater collection. Unimproved sources include vendors, tanker trucks, and unprotected wells and springs. Reasonable access is defined as the availability of at least 20 liters per person per day from a source within 1 kilometer of the dwelling. % of population with 2008 Percentage of the population with at least adequate access to excreta World Development Indicators, access to improved disposal facilities that can effectively prevent human, animal, and insect World Bank sanitation contact with excreta. Improved facilities range from simple but protected pit latrines to flush toilets with a sewerage connection. To be effective, facilities must be correctly constructed and properly maintained. Note: GNI = gross national income, GNP = gross national product, ARI = acute respiratory infection. a. The engagement indicator is discussed in the Report; conceptual underpinnings and methodological details are presented in Appendixes 3 and 4. b. World Development Indicators is the primary World Bank collection of development indicators, compiled from officially recognized international sources. It presents the most current and accurate global development data available and includes national, regional, and global estimates. It is updated three times a year, and the indicators presented in this Report reflect the last update from December 2010. c. The Demographic and Health Survey (DHS) provides nationally representative data on maternal and child health, family planning, and other health indicators. DHS survey data presented in this appendix were obtained from the latest available Standard DHS Survey year. Additional analysis on data presented here was carried out by the RAND project team. The countries and years included in the DHS analysis are Benin 2006, Burkina Faso 2003, Cameroon 2004, Chad 2004, Democratic Republic of Congo 2007, Republic of Congo 2005, Ethiopia 2005, Ghana 2008, Guinea 2005, Kenya 2008, Lesotho 2004, Liberia 2006, Madagascar 2008, Malawi 2004, Mali 2006, Mozambique 2003, Namibia 2006, Niger 2006, Nigeria 2008, Rwanda 2005, Senegal 2005, Sierra Leone 2008, Swaziland 2006, Tanzania 2004, Uganda 2006, Zambia 2007, and Zimbabwe 2005. 122 | Healthy Partnerships APPENDIX 2—Data tables Healthy Partnerships | 123 Table A2.1: Selected Sub-Saharan African Indicators Banner information Millennium Development Goals Engagement Maternal mortality ratio (modeled estimate, Information Exchange Score: Max 8 (2010) Policy and Dialogue Score: Max 10 (2010) Under-5 mortality rate (per 1,000) Regulation Score: Max 13 (2010) population ages 15–49) (2007) per 100,000 live births) (2008) Financing Score: Max 6 (2010) Prevalence of HIV, total (% of GNI per capita, Atlas method Life expectancy, years (2008) Population (in ‘000s) (2009) (as % of population) (2008) (as % of population) (2008) Notified cases of malaria Incidence of tuberculosis (current US$) (2008) (2009) Country Angola 18,498 3,330 47 161 610 2.1 0.3 21.6 6 4 5 3 Benin 8,935 700 61 118 410 1.2 0.1 35.6 7 4 8 2 Botswana 1,950 6,550 54 57 190 23.9 0.7 0.6 7 6 6 3 Burkina Faso 15,757 480 53 166 560 1.6 0.2 45.3 8 6 8 2 Burundi 8,303 140 50 166 970 2.0 0.4 48.5 3 2 5 4 Cameroon 19,522 1,140 51 154 600 5.1 0.2 27.8 4 4 6 1 Cape Verde 506 2,830 71 28 94 — 0.2 0.0 4 5 8 6 Central African Republic 4,422 410 47 171 850 6.3 0.3 35.8 4 2 6 1 Chad 11,206 540 49 209 1,200 3.5 0.3 39.5 3 2 4 0 Comoros 659 750 65 104 340 0.1 0.0 24.6 4 2 6 1 Congo, Dem. Rep. 66,020 150 48 199 670 — 0.4 37.4 2 2 5 1 Congo, Rep. 3,683 1,980 54 128 580 3.5 0.4 34.3 6 2 6 1 Côte d’Ivoire 21,075 980 57 119 470 3.9 0.4 36.5 5 5 6 2 Equatorial Guinea 676 14,980 50 145 280 3.4 0.1 27.7 3 2 7 4 Ethiopia 82,825 280 55 104 470 2.1 0.4 11.5 7 6 7 2 Gabon 1,475 7,320 60 69 260 5.9 0.5 29.5 3 2 6 3 Gambia, The 1,705 400 56 103 400 0.9 0.3 31.9 4 2 7 0 Ghana 23,837 1,150 57 69 350 1.9 0.2 31.2 8 5 7 4 Guinea 10,069 340 58 142 680 1.6 0.3 40.6 3 3 6 1 Guinea–Bissau 1,611 460 48 193 1,000 1.8 0.2 34.0 3 2 6 0 Kenya 39,802 730 54 84 530 — 0.3 30.3 9 5 7 2 Lesotho 2,067 1,010 45 84 530 23.2 0.6 — 4 3 6 2 Liberia 3,955 170 58 112 990 1.7 0.3 30.0 6 6 8 1 Madagascar 19,625 420 60 58 440 0.1 0.3 3.7 6 5 8 3 Malawi 15,263 260 53 110 510 11.9 0.3 33.8 7 4 9 2 Mali 13,010 610 48 191 830 1.5 0.3 25.4 7 3 7 3 Mauritania 3,291 980 57 117 550 0.8 0.3 17.3 2 1 5 4 Mauritius 1,275 6,720 73 17 36 1.7 0.0 — 8 8 11 4 Mozambique 22,894 380 48 142 550 12.5 0.4 32.6 4 3 7 0 Namibia 2,171 4,260 61 48 180 15.3 0.8 4.6 6 5 11 3 Niger 15,290 330 51 160 820 0.8 0.2 38.0 7 5 6 0 Nigeria 154,729 1,170 48 138 840 3.1 0.3 38.3 8 5 8 2 Rwanda 9,998 410 50 111 540 2.8 0.4 11.4 8 6 7 6 São Tomé and Príncipe 163 1,020 66 78 — — 0.1 2.0 3 4 3 0 Senegal 12,534 980 56 93 410 1.0 0.3 7.1 5 5 7 3 Seychelles 88 10,530 73 12 — — 0.0 — 5 8 12 1 Sierra Leone 5,696 320 48 192 970 1.7 0.6 36.1 6 4 8 1 South Africa 49,320 5,870 51 62 410 18.1 1.0 0.1 9 5 13 3 Sudan 42,272 1,120 58 108 750 1.4 0.1 12.8 6 5 10 4 Swaziland 1,185 2,560 46 73 420 26.1 1.2 0.1 3 4 7 2 Tanzania 43,739 460 56 108 790 6.2 0.2 24.1 8 5 7 2 Togo 6,619 410 63 98 350 3.3 0.4 30.4 6 3 8 1 Uganda 32,710 420 53 128 430 5.4 0.3 36.2 7 5 8 2 Zambia 12,935 960 45 141 470 15.2 0.5 13.5 7 4 9 3 Zimbabwe 12,523 — 44 90 790 15.3 0.8 7.5 6 4 10 1 Average 18,353 1,934 55 115 536 6.0 0.4 24.5 5 4 7 2 124 | Healthy Partnerships Public sector Health expenditure Business environment Supporting services gover- nance (% of private expenditure on health) (2007) Cost of business start-up procedures (% of % of population with access to improved % of population with access to improved Public Provision of Services Score: max 2 Time required to prepare and pay taxes Time required to start a business (days) CPIA quality of public administration Time required to enforce a contract rating (1 = low to 6 = high) (2009) Private sector share of total health Public sector share of total health Out-of-pocket health expenditure Adult female literacy rate (2008) Health expenditure per capita income per capita) (2010) expenditure (%) (2007) expenditure (%) (2007) (hours per year) (2010) (current US$) (2007) sanitation (2008) (days) (2010) water (2008) (2010) (2010) 2 2.5 85.7 80.3 19.7 100.0 1,011 282 68 163 57.0 50 57 2 3 31.9 51.8 48.2 94.9 825 270 31 152.6 28.1 75 12 2 — 372.0 74.6 25.4 27.3 625 152 61 2.2 83.5 95 60 1 3.5 29.3 56.1 43.9 91.3 446 270 14 49.8 — 76 11 1 2.5 17.3 37.7 62.3 60.5 832 211 32 129.3 59.9 72 46 2 3 54.3 25.9 74.1 94.5 800 654 19 51.2 67.8 74 47 2 4 132.3 74.6 25.4 99.7 425 186 11 18.5 79.3 84 54 1 2.5 16.5 34.7 65.3 95.0 660 504 22 228.4 41.1 67 34 1 2.5 31.7 56.3 43.7 96.2 743 732 75 226.9 21.9 50 9 0 2.5 23.5 57.2 42.8 100.0 506 100 24 176.5 67.8 95 36 1 2 9.2 20.8 79.2 51.7 625 336 84 735.1 56.1 46 23 2 2.5 51.8 70.4 29.6 100.0 560 606 160 111.4 — 71 30 1 2 40.7 24.0 76.0 88.7 770 270 40 133 44.3 80 23 1 — 347.5 80.4 19.6 75.6 553 492 136 104.3 89.1 — — 2 3.5 9.2 58.1 41.9 80.6 620 198 9 14.1 22.8 38 12 1 — 372.6 64.5 35.5 100.0 1,070 488 58 21.9 83.2 87 33 2 3 21.9 47.9 52.1 48.4 434 376 27 199.6 34.3 92 67 2 3.5 54.1 51.6 48.4 79.3 487 224 12 20.3 59.3 82 13 1 3 25.6 11.0 89.0 99.5 276 416 41 146.6 26.4 71 19 2 2.5 15.5 25.9 74.1 55.7 1,140 208 216 183.3 36.5 61 21 2 3.5 33.8 42.0 58.0 77.2 465 393 33 38.3 82.8 59 31 2 3 51.1 58.3 41.7 68.9 785 324 40 26 95.1 85 29 2 2.5 21.5 26.2 73.8 52.2 1,280 158 20 54.6 53.0 68 17 2 3.5 16.3 66.2 33.8 67.9 871 201 7 12.9 65.3 41 11 2 3.5 16.7 59.7 40.3 28.4 312 157 39 108.4 65.8 80 56 2 3 34.3 51.4 48.6 99.5 620 270 8 79.7 — 56 36 1 3 21.7 65.3 34.7 100.0 370 696 19 33.6 49.5 49 26 1 — 246.9 49.0 51.0 81.5 645 161 6 3.8 84.8 99 91 1 3 18.1 71.8 28.2 42.1 730 230 13 13.9 40.1 47 17 2 — 318.5 42.1 57.9 5.8 270 375 66 18.5 87.7 92 33 1 3 16.4 52.8 47.2 96.4 545 270 17 118.6 — 48 9 2 3 74.2 25.3 74.7 95.9 457 938 31 78.9 48.8 58 32 2 3.5 37.2 47.0 53.0 44.4 230 148 3 8.8 66.1 65 54 0 3 102.7 47.1 52.9 58.9 1,185 424 144 77.3 83.3 89 26 2 3.5 54.2 56.0 44.0 78.5 780 666 8 63.1 — 69 51 1 — 564.0 70.2 29.8 62.5 720 76 39 17.5 92.3 — — 2 3 13.5 31.3 68.7 58.8 515 357 12 110.7 28.9 49 13 2 — 497.1 41.4 58.6 29.7 600 200 22 6 88.1 91 77 2 2.5 40.5 36.8 63.2 100.0 810 180 36 33.6 59.6 57 34 2 — 151.1 62.5 37.5 42.3 972 104 56 33 85.6 69 55 2 3.5 21.7 65.8 34.2 75.0 462 172 29 30.9 66.3 54 24 1 2 32.9 24.9 75.1 84.2 588 270 75 178.1 53.7 60 12 2 3 27.8 26.2 73.8 51.0 490 161 25 94.4 66.8 67 48 2 3 57.1 57.7 42.3 67.6 471 132 18 27.9 61.0 60 49 2 1.5 78.6 46.3 53.7 50.4 410 242 90 182.8 88.8 82 44 2 2.9 95.3 49.5 50.5 72.4 644 317 44 96 61.8 69 34 continued Healthy Partnerships | 125 Table A2.1, (continued) Health care access and quality with ARI taken to private facility (2003–2008)* with ARI taken to private facility (2003–2008)* NONE—% of children in poorest quintile with NONE—% of children in richest quintile with PUBLIC—children in richest quintile with ARI PUBLIC—% of children in poorest quintile ARI not taken to any facility (2003–2008)* % of women receiving all 5 basic services ARI not taken to any facility (2003–2008)* only taken to public facility (2003–2008)* PRIVATE—% of children in poorest quintile PRIVATE—% of children in richest quintile Measles Immunization (% of children Births attended by skilled health staff with ARI only taken to public facility during prenatal care (2003–2008)* DPT Immunization (% of children ages 12–23 months) (2009) ages 12–23 months) (2009) (% of total) (2000–2009)* Country Angola 73 77 — — — — — — — 47.3 Benin 83 72 22 9 69 26 39 35 16.0 74 Botswana 96 94 — 94.6 Burkina Faso 82 75 27 2 71 61 16 23 5.8 53.5 Burundi 92 91 — 33.6 Cameroon 80 74 25 6 69 31 40 29 25.7 63 Cape Verde 99 96 — — — — — — — 77.5 Central African Republic 54 62 — — — — — — — 43.7 Chad 23 23 2 8 90 21 3 76 3.3 14.4 Comoros 83 79 — 61.8 Congo, Dem. Rep. 77 76 24 29 47 13 62 25 18.2 74 Congo, Rep. 91 76 30 4 66 56 27 17 32.0 83.4 Côte d’Ivoire 81 67 — — — — — — — 56.8 Equatorial Guinea 33 51 — — — — — — — 64.6 Ethiopia 79 75 19 3 78 22 14 64 2.8 5.7 Gabon 45 55 — — — — — — — 85.5 Gambia, The 98 96 — — — — — — — 56.8 Ghana 94 93 38 14 48 66 15 19 60.0 57.1 Guinea 57 51 23 8 69 46 14 40 12.4 46.1 Guinea–Bissau 68 76 — — — — — — — 38.8 Kenya 75 74 52 13 35 36 41 23 28.8 43.8 Lesotho 83 85 30 19 51 38 44 18 28.4 61.5 Liberia 64 64 28 19 53 53 37 10 18.7 46.3 Madagascar 78 64 30 3 67 28 38 34 12.4 43.9 Malawi 93 92 23 8 69 30 14 56 11.2 53.6 Mali 74 71 23 4 73 43 27 30 9.1 49 Mauritania 64 59 — — — — — — — 60.9 Mauritius 99 99 — — — — — — — 99.2 Mozambique 76 77 41 1 58 60 7 33 16.0 55.3 Namibia 83 76 53 7 40 41 56 3 53.1 81.4 Niger 70 73 21 16 63 47 27 26 5.1 32.9 Nigeria 42 41 14 37 49 28 47 25 29.6 38.9 Rwanda 97 92 26 17 57 33 34 33 0.8 52.1 São Tomé and Príncipe 98 90 — — — — — — — 81.7 Senegal 86 79 37 1 62 42 28 30 20.1 51.9 Seychelles 99 97 — — — — — — — — Sierra Leone 75 71 35 8 57 32 30 38 25.5 42.4 South Africa 69 62 — — — — — — — 91.2 Sudan 84 82 — — — — — — — 49.2 Swaziland 95 95 54 13 33 47 36 17 46.6 69 Tanzania 85 91 45 33 22 41 47 12 20.2 43.4 Togo 89 84 — — — — — — — 62 Uganda 64 68 37 47 16 18 69 13 4.2 41.9 Zambia 81 85 53 19 28 51 9 40 15.5 46.5 Zimbabwe 73 76 14 7 79 33 26 41 29.1 60.2 Average 77.4 75.69 30 13 57 39 31 30 20.39 44.4 Note: — = data not available. * data refer to the most recent year available during the period specified in the column heading. 126 | Healthy Partnerships The data tables restate the data from the snapshots and expand the indicator set with additional measures. The additional measures are from the Demographic and Health Survey (DHS) and from the World Bank’s Country Policy and Institutional Assess- ment (CPIA). To provide a more comprehensive and more complete picture of the contributions of the private health sector, we offer additional DHS measures in table A2.2. The details regarding the additional DHS measures are discussed in table A2.3. Healthy Partnerships | 127 Table A2.2: Selected Indicators from Demographic and Health Survey Data Knowledge of modern Use of modern health Barriers to Overall private sector health care services care services access market share facility as % of total taken to any facility tion from private medical sector source, % women reporting distance to health Women obtaining modern contracep- % women reporting cost as problem respiratory infection taken to private % mothers with knowledge of ORS knowledge of modern contraception % children with ARI taken to health Births taking place in private health facility as % of births in any facility Children under 3 years with acute % of births taking place in health % currently married women with % currently married women with unmet need for contraception facility as problem for access as % total users for access facility facility Country Benin 90.1 70.7 29.9 80.1 41.7 — — 34.7 17.9 36.4 Burkina Faso 90.4 66.7 28.8 38.9 39.4 46.4 63.0 13.8 1.8 11.8 Cameroon 88.5 54.9 20.2 60.0 50.3 38.7 65.6 25.0 30.6 41.0 Chad 48.6 64.5 19.1 13.6 8.7 — — 12.8 13.9 28.5 Congo, Dem. Rep. 76.7 78.0 24.4 72.0 59.0 40.4 75.6 58.4 29.4 59.8 Congo, Rep. 96.3 54.3 16.2 82.6 57.0 — — 26.4 9.8 24.1 Ethiopia 87.4 45.8 33.8 5.8 22.4 67.7 75.6 16.9 8.4 25.3 Ghana 97.8 89.6 35.3 58.0 63.8 25.9 45.1 47.1 17.0 27.7 Guinea 92.6 88.9 21.2 31.3 47.1 55.0 73.3 19.3 5.2 19.1 Kenya 96.2 78.7 25.6 43.4 66.4 — — 35.9 25.5 34.7 Lesotho 98.1 88.1 31.0 52.4 61.6 27.5 39.1 15.4 25.6 38.9 Liberia 86.7 91.0 35.6 39.9 68.6 48.6 53.6 30.5 26.3 40.6 Madagascar 95.0 40.5 18.9 34.8 45.4 20.6 27.0 19.6 7.7 32.4 Malawi 98.6 93.9 27.6 56.8 36.7 59.9 61.5 3.3 27.2 23.8 Mali 75.0 65.3 31.2 47.3 40.2 38.4 52.5 36.9 5.6 16.8 Mozambique 90.4 86.9 18.4 49.1 58.4 51.6 57.1 10.7 0.4 3.2 Namibia 99.0 90.3 20.6 81.4 68.3 41.5 38.9 10.1 5.5 17.7 Niger 68.3 78.4 15.8 18.6 48.5 51.1 64.9 24.1 2.3 42.3 Nigeria 76.2 65.0 16.9 35.4 61.3 24.4 30.4 56.7 42.9 65.1 Rwanda 97.5 86.4 37.9 29.3 47.9 40.0 70.8 14.1 4.9 42.8 Senegal 93.1 64.4 31.6 63.6 53.9 36.2 53.3 21.9 6.5 23.9 Sierra Leone 66.2 90.8 27.6 24.8 51.6 52.9 80.0 38.9 10.9 25.8 Swaziland 99.9 98.0 23.8 75.1 77.1 24.5 25.2 30.5 41.0 32.8 Tanzania 97.4 95.5 21.8 47.5 87.5 37.6 39.9 15.5 20.5 45.6 Uganda 96.9 86.1 40.6 42.4 81.9 54.5 65.2 51.7 28.2 66.4 Zambia 98.7 94.3 26.5 47.7 68.0 40.8 33.6 16.5 10.2 18.2 Zimbabwe 99.2 — 12.0 66.7 27.5 41.3 57.8 22.1 18.2 24.0 Average 89.1 76.3 25.9 48.1 52.4 42.0 54.3 25.8 16.1 31.6 128 | Healthy Partnerships Disparities in access to private health care Quality of care Women obtaining modern Births in private facility as Children under 3 years with acute contraception from private % of total births in facility respiratory infection taken to private current method as % of contraceptive users % of women receiving all 5 basic services medical sector source as facility as % of total taken to % of women informed of side effects of % of total users any facility Neonatal mortality rate in facilities Neonatal mortality rate in facilities (% of births): Private during prenatal care (% of births): Public Poorest Poorest Poorest Richest Richest Richest Urban Urban Urban Rural Rural Rural 45.6 16.5 16.7 52.0 25.1 13.5 12.7 30.9 50.0 28.1 30.3 59.6 49.0 16.0 2.2 2.1 20.3 4.7 2.1 20.1 5.1 0.5 0.0 4.8 22.7 8.6 6.2 20.7 63.0 5.8 2.0 0.0 26.8 18.4 14.7 28.7 31.5 29.2 29.1 28.8 51.5 26.5 19.4 56.7 44.0 25.7 2.0 2.0 14.5 6.4 0.0 14.5 7.6 25.8 47.6 6.5 15.4 42.3 83.4 11.4 — 3.3 1.6 2.4 60.4 54.4 43.0 69.4 46.0 13.8 9.5 56.9 72.6 50.0 54.7 82.4 40.0 18.2 2.4 2.2 31.7 15.4 7.2 37.1 13.1 6.1 6.6 9.2 22.1 27.4 10.9 32.3 — 32.0 3.1 1.9 24.0 13.1 0.1 21.6 5.9 11.9 15.3 5.8 42.4 23.2 14.3 39.5 34.0 2.8 5.1 0.0 53.9 40.3 30.2 52.6 20.8 12.4 7.4 24.4 22.4 31.4 27.1 18.9 49.0 60.0 2.8 0.6 21.2 15.3 6.8 19.9 9.5 1.2 0.0 13.2 14.8 20.7 26.6 23.2 51.0 12.4 3.4 4.3 45.8 31.7 16.2 47.0 31.1 22.7 11.6 36.9 45.8 32.2 20.4 53.0 45.0 28.8 3.8 5.1 16.4 14.9 3.4 19.8 20.6 27.1 20.9 26.1 45.9 37.9 38.6 54.0 — 28.4 2.4 2.9 33.3 25.3 17.4 43.3 30.2 21.8 17.3 39.2 39.4 41.0 40.5 41.0 — 18.7 1.8 2.8 41.2 14.4 5.4 42.0 19.5 5.0 0.9 19.3 63.7 24.6 9.9 57.5 45.0 12.4 2.3 1.1 3.3 3.4 2.9 3.3 21.8 28.5 21.0 30.6 15.8 24.7 24.8 31.0 69.0 11.2 1.7 1.7 49.0 17.1 18.2 48.2 5.3 5.7 8.6 6.3 35.2 6.0 13.6 38.6 42.0 9.1 2.7 3.7 13.9 3.9 4.2 15.5 0.5 0.4 0.5 0.8 6.8 0.8 1.4 10.1 58.0 16.0 2.3 0.0 15.2 2.9 0.0 26.6 9.3 2.1 0.3 21.2 30.8 10.7 11.8 58.2 45.0 53.1 2.0 0.4 32.7 13.6 8.2 30.9 3.5 0.5 2.7 3.5 35.7 44.0 44.1 36.6 36.0 5.1 2.3 0.0 56.3 57.3 51.8 55.6 48.4 37.2 35.4 53.2 68.5 63.6 72.4 62.7 42.0 29.6 3.3 3.7 29.9 7.6 4.4 23.2 10.9 2.7 4.2 8.6 55.0 39.4 40.0 50.9 53.0 0.8 2.9 0.0 25.4 12.4 5.2 32.0 9.0 3.8 0.9 17.1 33.0 13.9 3.6 40.4 49.0 20.1 2.0 2.8 45.7 22.9 18.9 45.2 20.7 3.7 4.6 31.5 46.9 20.8 18.2 48.6 — 25.5 2.8 5.0 41.2 25.4 19.8 43.4 50.6 37.4 39.1 47.2 47.1 30.8 18.9 43.4 49.0 46.6 2.0 0.5 25.3 7.2 6.9 26.1 12.2 24.7 21.8 16.3 46.6 45.4 42.1 53.6 64.0 20.2 2.4 3.5 56.8 49.4 37.7 58.3 26.3 28.7 22.6 31.6 71.4 65.9 56.4 79.4 50.0 4.2 2.1 1.6 23.6 8.6 4.5 27.6 5.2 15.5 17.4 7.9 9.6 22.3 26.1 14.5 67.0 15.5 2.9 3.2 40.2 9.2 4.7 44.5 13.2 21.5 23.4 21.2 47.2 13.8 33.9 43.9 45.0 29.1 2.1 0.6 32.7 18.4 13.0 35.1 18.6 14.5 14.1 22.2 38.9 28.7 29.2 43.0 47.3 20.4 2.6 2.0 Note: — = data not available. Healthy Partnerships | 129 Table A2.3 Definitions for Country Policy and Institutional Assessmenta and Demographic and Health Survey Indicatorsb Presented in Table A2.2 Indicator Definition CPIA quality of public administration rating Extent to which civilian central government staff is structured to design and implement (1=low to 6=high) government policy and deliver services effectively % currently married women with knowledge Percentage of currently married women at time of survey who report knowing any modern of modern contraception method of contraception % mothers with knowledge of ORS Percentage of mothers of children under age 3 at the time of survey who report knowing about ORS as a treatment for diarrhea % currently married women with unmet need Percentage of currently married women at time of survey who are assumed to be fecund but are for contraception not using contraception and (a) have unmet need for spacing (want to wait >2 years for next birth, unsure if or when to have next birth, or are experiencing/have recently had mistimed pregnancy) or (b) have unmet need for limiting (do not want more children and are experiencing or have recently had unwanted pregnancy) % of births taking place in health facility Percentage of deliveries up to 3 years prior to the time of survey taking place in any health facility % children with ARI taken to health facility Percentage of children under age 3 at the time of survey in poorest wealth quintile reporting fever/rapid breathing in the last 2 weeks and taken to any health facility (including pharmacies) % women reporting distance to health Percentage of women of reproductive age reporting “distance to a health facility” as a problem facility as problem for access when obtaining care for self % women reporting cost as problem for access Percentage of women of reproductive age reporting “cost” as a problem when obtaining care for self Women obtaining modern contraception from Percentage of women of reproductive age reporting currently using modern contraceptive private medical sector source as % total users methods (including pills, IUD, injectables, female sterilization, or implants) who obtain their method from private medical sector (including pharmacies) Women obtaining modern contraception from Percentage of women of reproductive age reporting currently using modern contraceptive private medical sector source as % total users methods who obtain their method from private medical sector (including pharmacies); expressed (urban, rural, poorest, richest) by location of residence and wealth quintile Births taking place in private health facility Number of deliveries up to 3 years prior to the time of survey taking place in any private as % of births in any facility health facility as a percentage of the total number of deliveries up to 3 years prior to the time of survey taking place in any health facility Births in private facility as % of total births in Number of deliveries up to 3 years prior to the time of survey taking place in any private facility (urban, rural, poorest, richest) health facility as a percentage of the total number of deliveries up to 3 years prior to the time of survey taking place in any health facility; expressed by location of residence and wealth quintile Children under age 3 with acute respiratory Number of children under age 3 at the time of survey reporting fever/rapid breathing in the infection taken to private facility as % of total last 2 weeks taken to any private health facility (including pharmacies) as a percentage of the taken to any facility number of children under age 3 at the time of survey reporting fever/rapid breathing in the last 2 weeks taken to any facility Children under age 3 with acute respiratory Number of children under age 3 at the time of survey reporting fever/rapid breathing in the infection taken to private facility as % of total last 2 weeks taken to any private health facility (including pharmacies) as a percentage of the taken to any facility (urban, rural, poorest, number of children under age 3 at the time of survey reporting fever/rapid breathing in the last richest) 2 weeks taken to any facility; expressed by location of residence and wealth quintile % women informed of side effects of current Percentage of women of reproductive age reporting currently using modern contraceptive method as % of contraceptive users methods who report being informed about side effects % of women receiving all 5 basic services Table A1.1 during prenatal care Neonatal mortality rate in facilities (% births); Number of deliveries in any public facility with reported deaths under 1 week from birth as a public percentage of total deliveries in any public facility Neonatal mortality rate in facilities (% births); Number of deliveries in any private facility with reported deaths under 1 week from birth as a private percentage of total deliveries in any private facility Note: ARI = acute respiratory infection, IUD = intrauterine device, ORS = oral rehydration salts. a. The World Bank’s Country Policy and Institutional Assessment (CPIA) rates countries against a set of 16 criteria grouped in 4 clusters: economic management; structural policies; policies for social inclusion and equity; and public sector management and institutions. The rating ranges from 1 = low to 6 = high. We include the ratings for the quality of public administration criteria from the 2009 CPIA as an additional measure of the operating environment for private health providers. b. The Demographic and Health Survey (DHS) provides nationally representative data on maternal and child health, family planning, and other health indicators. DHS survey data presented in this appendix were obtained from the latest available Standard DHS Survey year. Additional analysis on data presented here was carried out by the RAND project team. The countries and years included in the DHS analysis are Angola 2006, Benin 2006, Burkina Faso 2003, Cameroon 2004, Chad 2004, Democratic Republic of Congo 2007, Republic of Congo 2005, Ethiopia 2005, Ghana 2008, Guinea 2005, Kenya 2008, Lesotho 2004, Liberia 2006, Madagascar 2008, Malawi 2004, Mali 2006, Mozambique 2003, Namibia 2006, Niger 2006, Nigeria 2008, Rwanda 2005, Senegal 2005, Sierra Leone 2008, Swaziland 2006, Tanzania 2004, Uganda 2006, Zambia 2007, and Zimbabwe 2005. 130 | Healthy Partnerships background APPENDIX 3—Conceptual on engagement framework This appendix provides further detail and the international partners to the operating environ- conceptual background on the engagement ment of the private health sector.108 framework introduced in the Report. The frame- The fact that a constraint (the operating envi- work grew out of an extensive consultative devel- ronment) to better contributions by the private opment process of more than two years. Please health sector was identified matters, because if refer to the background paper available at www. such contributions could be improved, health sys- wbginvestmentclimate.org/health for a discussion tems performance would improve as well, which of the development process itself, and of the in turn would improve the ultimate outcomes alternative frameworks that were considered but (for example, people’s health). This logical frame- ultimately discarded in favor of the one present- work was discussed in the Report, but is consid- ed here. ered here in slightly more detail and is presented The starting point for both the Report and the schematically in figure A3.1. framework is the understanding that the operat- This Report’s focus on public-private engage- ing environment is a constraint to greater contri- ment, therefore, is based on the understanding butions of the private health sector to health that it is through engagement that major elements systems performance. This understanding grew of the inappropriate operating environment for out of the findings of the earlier International private providers can be identified and improved. Financial Corporation report, “The Business of Such improvements in the operating environ- Health in Africa,” and was confirmed by the ment, in turn, will relieve one of the key con- increased attention of national governments and straints to enhancing the contributions of the Figure A3.1 Simplified Logic Model for Private Health Sector Contributions to Health Outcomes Influences Operating Contributions by (Intermediate) Engagement environment the private sector outcomes Influences and Influences is part of Healthy Partnerships | 131 private health sector and to improving health sys- government responsibility for the health sector. tems overall. The World Health Organization’s World Health This model is a crude simplification and adap- Report 2000 describes stewardship as involving tation of the more comprehensive logical model oversight of “the entire health system” (p. 123), that is typically used for the health sector, such as private as well as public. Key elements of this gov- the one depicted in figure A3.2. The essence of it, ernment responsibility—usually through a health however, is the same. ministry—include strategic planning, regulating, Figure A3.2 is also a schematic representation monitoring and evaluating, and setting and enforc- of the underlying theory: engagement can impact ing the rules and incentives that define the envi- health sector characteristics and, therefore, the ronment and guide the behavior of health system private health sector’s contribution to the health players. system overall. This, in turn, will impact those This Report’s focus on government engage- things we really care about—health outcomes and ment with the private health sector does not sug- protection from financial risk. gest that other stewardship functions are less important in reaching health targets. Rather, the focus on engagement is motivated by the fact that Setting the context—Engagement as relatively little attention has been paid to how a part of stewardship governments are engaging the private sector at Engagement with the private health sector is part the systems level. Given the poor performance of of the broader concept of stewardship, or overall many health systems in Africa, and the large size Figure A3.2 Logic Model for Private Health Sector Contributions to Health Outcomes Social, Political, Policy, Regulatory, Economic & Contexts Physical contexts, Population characteristics Material Human resources Inputs Fiscal resources resources for health engagement research Focus of Policy and governance-level activities and decisions Activities (processes that enable Healthcare management-level activities and decisions PHS service delivery) Clinical-level activities and decisions Outputs Private Health Sector products and services: type and quality of care available (products & services) (curative, diagnostic, maternity, disease prevention, etc.) Maintain or Reduced risk and Reduced risk and Intermediate improve worklife effect of chronic duration of acute (direct outcomes) of PHS workforce health problems health problems Healthcare Access— Healthcare Intermediate appropriateness of system system (indirect outcomes) place and provider efficiency equity Contexts and external factors Sustainable Improve and/or Improved level and Final outcomes healthcare maintain health distribution of system for individuals population health Source: Adapted from Watson, Broemeling, and Wong 2009. Note: PHS = private health sector. 132 | Healthy Partnerships of the private health sector, a closer look at how It is in this context of the evolving roles in the engagement is currently carried out, and how it ministries, or in observations that their neighbor- might be improved, is especially important. ing country ministries are evolving, that policy makers are asking for support. A central challenge for them and, therefore, for this Report is that pri- The shifting stewardship role in Africa vate health sector engagement requires not only In recent years, the way in which governments the point of view of health and health systems, have been carrying out their stewardship func- but also the point of view of private sector devel- tions has been shifting significantly. As the capac- opment and a careful consideration of the busi- ity of nonstate oversight mechanisms within the ness environment. private health delivery system grows, the mechan- ics of transactions between public and private sec- Building the analytic framework for tors become institutionalized and the role of engagement government increasingly emphasizes strategy and the ongoing review and adjustment of rules to The project team set out to create a conceptual ensure efficient and fair functioning of the mar- framework capable of measuring and enabling ket, equitable distribution, and acceptable levels comparison of how governments are engaging the of quality. Two important trends are underway in private health sector in each country. Engagement different countries in the Africa region: was defined as the deliberate, systematic collabo- ration of the government and the private health • The separation of stewardship functions such sector according to national health priorities, as policy and strategy from the management of beyond individual interventions and programs. publicly provided services The engagement framework is based on the clas- • The separation of stewardship functions from sic role of the state and the policy instruments the financing functions such as revenue genera- that governments can use to influence the private tion, risk pooling, and purchasing. health sector, as adapted by Harding and Preker In Organisation for Economic Co-Operation and (2003). Engagement, therefore, is broken down Development countries, the experience has been into five domains, each of which is bidirectional to an evolution from the direct provision of care to a and from the private health sector, and each inter- more nuanced balance. In Africa, the same evolu- acts with the others: tion has also been happening, at different speeds • Policy and dialogue in different countries. But the continental trend is • Information exchange unmistakable. Ghana provides the clearest exam- • Regulation ple of this evolution: in 1997, the country created • Financing the Ghana Health Services (GHS), separating the • Public provision of services. provision of care (now under GHS) from the pol- icy functions of the Ministry of Health. In 2004, Each of the domains represents a key aspect of Ghana went further and separated the bulk of government engagement with the private health financing and risk pooling from policy, creating sector. Although it is not a specific policy instru- the Ghana National Health Insurance Scheme ment, the policy and dialogue domain measures and giving it a degree of autonomy from both gov- the underlying policy framework for, and dialogue ernmental delivery, in the form of the GHS, and with, the private health sector. The other domains governmental policy, in the form of the Ministry cover the range of policy instruments that govern- of Health. Similar changes are occurring in other ments can use to engage the private health sec- countries across Africa, such as Namibia, Nigeria, tor—information exchange, regulation, financing, Rwanda, and Uganda. and public provision of services. Healthy Partnerships | 133 Defining the constructs to be measured What follows is a brief discussion of each of the The operating environment for private health domains. Background is provided for the key con- providers is best understood as consisting of three structs in each domain, as is an explanation of interrelated elements: how they link to the measures discussed in Sec- tion 2 of the Report. • The health side, affecting all operators in the health sector Policy and Dialogue • The private sector side, to which all private Policy and dialogue is the starting point for mea- companies in any sector are subject suring government engagement with the private • Elements of the operating environment that health sector; it underlines and summarizes gov- are unique to the private health sector, that is, ernment intentions for the use of the other poli- specific issues in the operating environment cy instruments. Given the frequent mistrust and that affect private businesses engaging in health suspicion between the government and private service delivery. providers in many countries, establishing an Table A3.1 delineates areas specific to the private underlying policy framework for the private health sector, and the more general areas from health sector can help lay the foundation for the private sector and health system perspectives. practical engagement by framing the intention The dark green areas are the areas of focus for for the relationship as one of collaboration rather the framework, and those shaded in light green than competition. The existence of a functioning are secondary areas of focus, given their overall dialogue mechanism with the private providers importance to public-private collaboration. shows that the government is aware of their presence, takes them into account, and views Table A3.1 Domain Matrix for Indicator Development Private sector Private health sector Health Policy and Overall policy, inclusion, and Specific policy and private health sector Degree of government dialogue attitude of government toward dialogue ownership of its role as steward private sector of the whole health system Information Less applicable to private sector; Specific information Full inclusion of the Quality of overall exchange information related to registration exchange for private private sector in the health information and accreditation under “regulation” health sector information system management system Regulation Regulatory burden on Applicability of general Regulatory Equal treatment Capacity of the private sector (e.g., regulatory burden for framework in terms of quality government to ease of entry) private health service specific for private restrictions, exercise oversight providers health sector inspections, etc. role generally for the public sector Financing Use of private providers for the Public money flowing to the private health Government capacity in delivery of public services in other sector for the delivery of services decentralized financing and sectors (education, infrastructure, availability or strength of risk- water, etc.) pooling mechanisms Public provision Provision of basic services for Public provision of services Full inclusion of the Coverage and quality of services private sector operations, such to crowd out private private sector in the of services provided as electricity, water, education providers (e.g. due to distribution of public through the public perceived lack of quality) goods (e.g., vaccina- health system tion programs) Source: “Healthy Partnerships” data, 2010. Primary areas of focus Secondary areas of focus 134 | Healthy Partnerships them as a partner to improve overall health sys- operations or delivery of care. In such cases, the tems performance. Taken together, policy and critical factor is not the creation of systems spe- dialogue presents the overall context for the pri- cific to the private health sector that parallel those vate health sector across the region. in the public sector; rather, the critical factor is In light of the fact that the government’s stew- that the government is fully including the private ardship role toward public and private health sec- health sector in the various information functions tor providers can be significantly different, the it has under its jurisdiction. domain focuses on policy and dialogue specific to The key construct for the information exchange the private health sector. The key construct here, domain, therefore, is whether the private health therefore, is finding out the intention and action sector is included in the governments’ informa- of the government toward the private health sec- tion systems. This includes whether there is a flow tor. The policy and dialogue domain captures both of basic information between the government and overall intentions toward, and current level of private providers both in terms general informa- government engagement with, the private health tion on the operating environment and for the sector by measuring two things: health information management system. Private sector participation in national disease surveil- • The existence of a private health sector policy lance programs, a critical function of a Ministry of framework and its implementation Health, is also measured. Information collection, • The presence of a dialogue mechanism between dissemination, and management, with the full the government and the private health sector, as inclusion of the private providers, should be part well as actual levels of dialogue. of the government’s overall strategy for the health sector as a key element of ensuring the outcomes Information Exchange intended. A key ingredient of engagement is the govern- ment having accurate information on the private Regulation health sector. In practical terms, this requires the Most governments in the region view their role development of an information exchange between vis-à-vis the private health sector primarily as that the government and the private health sector so of regulators. Thus, their penchant for turning to that important data about the scale and scope of regulation—setting rules to direct, prescribe, or private providers can be collected by the govern- otherwise influence the actions of private provid- ment and then used in a strategic manner to ers—to solve problems is often strong. The use of ensure private health care is used as efficiently as regulation, among other public interventions, is possible to further overall health goals. Indeed, usually justified, in economic terms, by the intent having more systematic information about health to correct a market failure. Evidence from other markets is a key first step in any reform. This is country contexts suggests, however, that engage- especially pertinent if the private health sector is ment of the private health sector is almost always providing a large amount of care in a country, as it designed with an overemphasis on regulation. does in much of the Africa region. Often these regulations prescribe unrealistic Unlike the other domains, however, informa- requirements for registration, licensing, use of tion exchange is not something that needs to be medical equipment, or the type of professional done specifically for the private health sector. The who can provide particular services. These inap- government, as the steward of the entire health propriate rules are often mitigated by almost uni- system, needs to have basic information on all the versally poor enforcement, which is considered health service facilities, regardless of whether they one of the primary reasons for the poor quality of are public or private, for appropriate planning and services offered by private providers.109 action. Moreover, government must inform pri- Part of the trouble with delivering effective vate practitioners and facilities of changing regula- regulation is the lack of consensus on what consti- tions, infectious disease outbreaks, new treatment tutes “good” regulation outside of a particular con- protocols, and other information relevant to their text. Very little has been published about the Healthy Partnerships | 135 successes and failures of government attempts to But without any coherence in the approach to implement regulatory frameworks to ensure that quality regulation, the engagement with the pri- the private sector is delivering what it is supposed vate health sector cannot be deemed to be com- to. What has been examined mostly concerns plete. An important subconstruct here is the scope evaluations of government efforts to regulate pri- of the regulatory framework and whether a given vate pharmacies and does not specifically address country’s regulatory framework includes the most service delivery.110 Indeed, the criteria for good important providers of health services. The impor- regulation are quite general. A regulatory frame- tance of traditional medicine in most countries in work is considered good if it is targeted, propor- the Africa region suggests that their inclusion in tional, coherent, consistent, and transparent111—in the regulatory framework may be a useful proxy. other words, if the rules are understandable, if The third construct is the effective enforce- they address the problem they are meant to cor- ment of regulation. Enforcing basic regulations, as rect, if they do not contradict other rules, if they mentioned, is a key component of government establish a clear framework for what happens if engagement. This not only includes carrying out they are not followed, and if the severity of the frequent inspections of private facilities, but also rules’ intervention matches the severity of the ensuring that enabling services are there to follow problem. The challenge in measuring regulation, regulations, such as allowing private sector par- therefore, is to define constructs that unequivo- ticipation in continuing medical education oppor- cally (that is, independent of the country context) tunities. The level of enforcement capacity varies have a positive impact on the functioning of the widely from country to country, so any potential health system. regulations must be aligned with the ability to The key constructs for the regulation domain enforce them. are three simple, but core, aspects of the regula- tory function that should be carried out by the Financing government. Financial incentives are a main motivator of the The first construct is the proper registration private sector and are central to effective public- and recording of new entrants into the market. private engagement. Strategic government financ- While the team collected data on the registration ing of private providers can create mutually process itself (in terms of steps and time), such a beneficial arrangements that improve the efficien- construct does not lend itself for inclusion in a cy of available public funds while taking advan- measure of engagement. It is not clear whether tage of capacities in the private health sector. lower entry barriers increase access (positive) or However, government financing of the private lower the quality standards for new entrants into health sector is contentious in terms of the overall the market (negative). Irrespective of the barrier benefit to the health system. This is especially the to entry, however, new entrants into the market case in countries where the public system pro- should be officially registered. Hence, the cross- vides much of the care and where the private country comparison focused on attainment of this health sector is small. Where the private sector threshold, not on the process of registration, by provides a substantial proportion of care, howev- looking at the quality of private-provider registry er, the assessment of financing as an instrument in each country. provides some measure of how the governments The second construct is the existence of a qual- are taking advantage of the capacities of the pri- ity regulatory framework. This is measured by the vate sector. existence of rules covering the very basic regula- The key construct in the financing domain is tory functions—for opening a private facility, simi- whether public funds are being channeled to the lar rules for public and private clinics, and rules in private health sector. This can take the form of place for inspecting a private clinic. Of course, government contracting of private providers to such rules should be defined according to a local perform particular services. Strategic purchasing context, taking enforcement capacity into account. allows governments to use limited resources on 136 | Healthy Partnerships the most needed services, without due regard for production of health care inputs and services to who is providing those services. It also refers to promote and encourage collaboration between the financial incentives for capital investments or public and private sector. The key construct is operating costs (for example, tax exemptions) whether the private sector is explicitly included in that can lower the operating costs for private facil- government programs that can and should be open ities. to all qualified providers, regardless of what sector An important area of financing is the role of they come from. An example of this is private sec- government in promoting a mechanism for risk tor participation in government or government- pooling and sustainable financing for the health sanctioned vaccine programs. This measure also system. Engagement with the private health sector considers private sector involvement in govern- is, then, also about fostering the expansion of cov- ment health system processes, such as the referral erage and depth of health insurance and making system in place for transferring patients from the the private health sector accessible to enrollees. private to the public sector and vice-versa. Public Provision of Services Challenges in defining an optimal level Direct government production of health care of engagement inputs and health services has an impact on the operating environment for the private health sec- The goal of the Report is to promote an optimal tor. The intentional inclusion of the private health level of engagement, not only in terms of more or sector in the use of public resources enhances the less engagement, but also in terms of quality ability of the for-profit providers to operate, and engagement. Defining good engagement would contributes to better health performance overall. enable direct assessment of country performance Through strategic allocation of resources, govern- by measuring the distance between the observed ments can use public production to complement, level of engagement and the optimal level. How- crowd out, or build a supporting environment for ever, the empirical basis for defining what consti- private health care markets. tutes an optimal level of engagement does not For example, even though it is not directed at currently exist. Accordingly, the focus of the the private health sector, reliable and affordable domains discussed is on those elements of engage- infrastructure services are critical for private sec- ment where some consensus exists that they are tor development and economic growth. For necessary. Since effective engagement is very low health services businesses, access to electricity, in many African health systems, the elements are water, and sewerage facilities are core technical defined to cover only the basics of engagement. In inputs. Efficient government production of these other words, without most of these elements in services has a tangible benefit in terms of the place, it will be difficult for governments to engage operating environment for private providers. In with the private health sector in a way that fosters other areas, government services may have less of improved access, quality, and efficiency in health a benefit to the private health sector, but a great- service delivery. The challenge moving forward er overall health benefit. will be to continually refine the engagement Measuring public production, therefore, focus- framework and to make further progress in defin- es on whether the government is using its own ing the optimal level of engagement. Healthy Partnerships | 137 APPENDIX 4—Methodology for data collection Data collection, analysis, and validation The minimum number of interviews was des- ignated at 8 per country; the team completed Data were collected for 45 countries between interviews with over 750 respondents for an aver- February and July 2010. The only countries in the age of 16 respondents per country. African region of the World Bank not covered in In-country data collection was reinforced by the Report are Eritrea and Somalia. desk research performed before and during the in- country visit, particularly in terms of collecting Data source and collection and verifying the de jure indicators. The primary method of data collection was confi- A standardized set of in-depth interview guide- dential face-to-face interviews with key respon- lines covering each of the domains was used to col- dents during a one week in-country visit. An “ideal” lect the data. During the two rounds of pilot testing, key respondent list was created. The respondent less-relevant questions were dropped in order to list (box A4.1) covers a cross-section of the key keep the guidelines as concise as possible. The ques- stakeholders in the public and private sector, tions in the guidelines took on different forms; the including from the Ministry of Health, regulators, de jure indicators asked whether a particular policy for-profit and not-for profit private providers, and or regulation exists as a matter of fact; de facto independent experts. The purpose of the list was questions asked respondents to evaluate, on a cate- to ensure as much standardization as possible gorical scale, a particular aspect of engagement in across countries and to serve as a guide for plan- practice. ning the schedule for in-country interviews. The scores across the domains and the assess- ment of engagement more generally apply primar- BOX A4.1 ily to the urban centers, since that is where the data collection and interviews took place (capital city Respondent List and largest economic center, where applicable). The degree and nature of the engagement in rural In each country, key respondents include: areas was not separately assessed. The indicators • Two to four independent experts: donor representatives, former across the domains likely represent an upper bound officials, academia on the quality and intensity of engagement that is • Two to five officials from the Ministry of Health, Director of Planning, seen throughout the country. The same urban bias Health Information Management Unit, Inspectorate, Office of Stan- is found in other policy measures, such as the Doing dards and Regulation, and the Public-Private Partnership unit Business indicators. It should be noted that the • One to four officials from regulatory boards measures for Nigeria and Sudan represent a special • One state- or district-level Health Officer case of this limitation, due to the fact that in both • Two to six representatives of the private health sector, which in- countries most governmental authority toward the cludes representatives of the appropriate professional or private private health sector is exercised at the state level. facility associations and owners of prominent private facilities, Therefore, for several measures in Nigeria and not the for-profit sector. Sudan the assessment had to be made at the level Source: “Healthy Partnerships” data, 2010. of Lagos and Khartoum State, respectively, rather than at the national level. 138 | Healthy Partnerships Data coding First, the team completed an initial verification Once the data collection was finalized, the team by reviewing the coded data by comparing the coded a subset of the collected data into quantita- coding with the raw data file containing the inter- tive form. The data were primarily coded in bina- views conducted in each country. ry form (1 or 0). Five de facto indicators were Second, two country experts (usually indepen- coded on a categorical scale (1 to 4) to allow for dent experts) analyzed the team’s assessment by more nuanced answers across countries, and for filling out a document containing the coded data assigning a higher score to engagement in practice. for the country and the coding principles. Any A set of coding principles was developed for each inconsistencies were clarified by e-mail and tele- of the indicators to guide assessor coding. phone with experts from the relevant country. Data validation Coding principles To ensure accuracy of the coded data, the Health in Africa team engaged in two major rounds of Table A4.1 lists the principle behind the coding data validation. for each element. Table A4.1 The Principle Behind the Coding of Each Element Domain Indicator Coding principle (unless otherwise noted, coding is binary [1/0]) Policy and dialogue A policy exists for engaging with The government has a stand-alone policy toward the private health sector or the the private health sector on paper. private health sector is included in the Ministry of Health’s main and current health sector policy or strategic plan. The policy or plan must make more than a passing mention of the private health sector; it should include, at a minimum, a definition of the role of the private health sector and identify possible areas of collaboration. There is de facto implementation The government is implementing, in practice, the engagement policy with the of the engagement policy with private health sector; scored on a 1–4 scale as follows: the private health sector. 4 – comprehensive implementation of the policy 3 – solid implementation of engagement components with significant room for improvement 2 – low day-to-day engagement, or engagement limited to subsectors or individual disease programs 1 – very little, if any, implementation of an engagement policy. Note: Day-to-day implementation of engagement is also possible in the absence of an explicit engagement policy. Selective engagement with key players is sufficient only in cases where further engagement is not currently feasible (e.g., conflict-afflicted countries). There is a formal dialogue There is a formal or official mechanism for dialogue between the Ministry of Health mechanism with the private and the private health sector. This can include a specialized forum, regularly sector (de jure). scheduled meetings, joint committees, or other forums where the private health sector is deliberately invited to participate. The existence of a dialogue mechanism that is limited to a disease-specific program, such as Global Fund-mandated dialogues for HIV/AIDS, does not count. There is dialogue with the private There is an active dialogue taking place between the Ministry of Health and the health sector, in practice (de facto). private health sector through one of the forums mentioned above or through an alternative forum outside of disease-specific dialogue arrangements. Aggregated responses from key informants were scored on a 1–4 scale as follows: 4 – strong, comprehensive, and ongoing dialogue with the full private health sector 3 – ongoing dialogue with the private health sector with significant room for improvement 2 – ongoing dialogue restricted to subsectors or disease areas 1 – Very low level of dialogue or no ongoing dialogue. Note that the coding does NOT refer to the quality of the dialogue or to the outcomes it produces (such aspects would be found under implementation of engagement) but, rather, to whether it is currently taking place. continued Healthy Partnerships | 139 Table A4.1, (continued) Domain Indicator Coding principle (unless otherwise noted, coding is binary [1/0]) Information There is a functioning exchange of There are information flows, in practice, between the Ministry of Health and the exchange health-specific information between private health sector. This includes vital statistics and other service statistics (which the Ministry of Health and the flow both ways) and other relevant information from the government to the private health sector. private health sector (e.g., updated treatment guidelines and changes in regulation, and so forth). Aggregated responses from key informants were scored on a 1–4 scale as follows: 4 – strong, comprehensive information exchange with the full private health sector 3 – ongoing information exchange with the private health sector, with significant room for improvement 2 – information exchange restricted to subsectors or disease areas 1 – very low or no ongoing exchange of information. The private health sector is The Ministry of Health requires that private health sector clinics provide health required to provide health-related status vital statistics (e.g., births and deaths) or health services utilization data information to the Ministry of information on a regular basis. The requirement is explicitly mandated by law or Health. regulation and is beyond (a) information reported as part of the national disease surveillance program and (b) requirements arising from participation in disease-specif- ic programs such as HIV or TB programs. Information from the private Private health sector clinics are sending the required information to the Ministry health sector is reaching the of Health on a regular and timely basis and the Ministry of Health is receiving this Ministry of Health as intended. information, coded as a “1” or “yes”’ if at least two-thirds of the private health sector respondents indicate that they (and/or others like them) are providing information with positive corroboration from the Ministry of Health. The private health sector is included The Ministry of Health (or a designated body) includes the private health sector in in the Ministry of Health’s disease the country’s national disease surveillance program, as defined by the government. surveillance program. Not all of the private health sector needs to be involved as long as the government does not exclude private health sector facilities from the surveillance program. The private health sector receives The Ministry of Health sends prompt disease surveillance updates to the private disease surveillance updates from health sector, at the very least, in cases of emergency. The private health sector the Ministry of Health. receives such updates in a timely manner. Regulation Quality of private health sector An assessment of the regulator’s knowledge about private health sector providers providers’ registry is taken. Aggregated responses on the quality of the registry (i.e., the list of private health sector providers) coded on a 1–4 scale are as follows: 4 – There is an updated, comprehensive registry of private health sector providers currently operating. A positive assessment is reserved only for countries where the quality of the registry implies good implementation of registration and maintenance of the registry; where there are few informal providers. 3 – A registry of private health sector providers exists and is being used (i.e., updated at least once a year). Despite being used, the registry is not complete or fully representative of the private health sector. 2 – A registry of private sector providers exists, but it is not being used or updated in any practical way. 1 – A registry of private sector providers could not be readily produced by the registrar or designated body. The quality of regulation is good. The laws and regulations that govern the private health sector are deemed to be of good quality. Coding is based on respondent answers to the question, and a positive assessment is restricted to countries where there is a consensus among respondents that the laws and regulations are appropriate and reasonable. It does not explicitly take into account whether such laws and regulations are actively enforced. Regulation is enforced as intended. The Ministry of Health (or a designated body) generally enforces laws and regulations toward private health sector clinics. Coding is based on respondent answers to the question, and a positive assessment is restricted to countries where there is a con- sensus among respondents that the laws and regulations are enforced as written. There are standardized rules to There is a clear set of rules that outline the requirements and steps necessary to open a private health sector clinic. open and officially register a private health sector clinic. continued 140 | Healthy Partnerships Table A4.1, (continued) Domain Indicator Coding principle (unless otherwise noted, coding is binary [1/0]) Regulation, There is an inspection regime on The Ministry of Health (or a designated body) has procedures for inspecting private continued paper for private health sector health sector clinics on paper. Coding is independent of whether the inspections clinics. are actually carried out. The inspection regime is carried out, The Ministry of Health (or designated body) carries out the inspection as intended. in practice, for private health sector No judgment is made regarding the level of detail or quality of the inspection. clinics. Coding is based on a consensus among respondents. The quality control process or There is no institutionalized difference in terms of the way the private and public inspection regime, on paper, is the health sectors are inspected, coded as a 1 by default except when there is an same for private and public health undue distinction in the inspection process and in the requirements for the public sector providers. and private providers based on ownership. Specific rule or cited evidence for such a distinction, and appropriate corroboration among respondents, is needed for a 0 coding. There are continuing medical Medical doctors have to fulfill a CME requirement to maintain their professional education (CME) requirements license. Evidence of enforcement of this requirement is needed. The existence of for professional license renewal. a CME requirement that is not linked to the renewal of professional license does not count. Ministry of Health trainings or Ministry of Health trainings, workshops, or other CME opportunities for public other CME opportunities are open sector health professionals are open to private professionals. This also includes to private health sector professionals. where they have to pay to participate. This is determined by respondent answers; evidence of participation is necessary. There is a policy on, and There is a policy, unit, or program in the Ministry of Health (or a designated, engagement of, traditional health-specific body) responsible for engaging with traditional medicine medicine practitioners. practitioners or their representatives. The existence of any of these is sufficient. Financing The government uses contracts The government is purchasing specific clinical services from the private health with the private health sector. sector. This includes contracts with individual medical practitioners. Price agreements between the private health sector and government health insurance organizations do not count. Subcontracting by public hospitals to private hospitals to provide services for which they are responsible and remunerated with public funds count as contracts. There are financial incentives The government offers financial incentives to the private health sector, including available to private health sector but not limited to tax breaks, tax credits, import duty reductions, and value-added operators. tax exemptions. The incentives have to be specific to the private health sector; in other words, incentives that are available to all private sector businesses do not count. Evidence of implementation of the incentive scheme is required. If the incentive exists in theory, but it is never accessed by the private health sector, it does not count. Overall population covered by The approximate percentage of citizens covered by either public or private health health insurance. insurance, including community health insurance schemes, that would reimburse for treatment received in a private facility, is indicated by respondent answers: 4 – more than 50% 3 – more than 20% 2 – more than 10% 1 – less than 10% 0 – no insurance. Public provision The private health sector receives The government provides vaccines or medicines to the private health sector for of services vaccines, medicines, or similar items distribution to the general population. The private health sector may or may not from the Ministry of Health or be permitted to charge a consulting/service fee. from a government-sanctioned donor program. There is a public-private referral There is a process in place to refer patients from the private sector to the public process. sector (or vice versa) for further treatment when required. It does not have to be a strictly formal process, as long as there is a method to facilitate the movement of patients. Patients moving from private to public or vice versa through self-referral do not count as part of the referral process. Healthy Partnerships | 141 APPENDIX 5—Scoping the private health care market The size and growth of a country’s economy large- how the overall size and the relative public/ ly determines the size of the health sector. It also private share could possibly develop in the com- influences the relative share of public and private ing years (figure A5.1). While these calculations spending on health services. A large share of the remain incomplete, they do indicate where gener- population of low-income countries often lives in ally observed trends will lead African health care the rural areas and works in the informal sector. markets. This limits the effective taxation capacity of their These projections have significant implications governments. In middle- and upper-income coun- for public sector engagement with the private sec- tries, larger segments of the population work in tor and for private sector development during the urban settings and the formal employment sec- next decade or two. For example, there will be tors. This makes it relatively easy to tax workers at more money spent on the health care sector and a the source and to design a health care system steady shift in relative spending from out-of- financed by government or payroll taxes. In most pocket private spending to collective, publicly low-income countries, the formal urban employ- mandated spending. Additional public spending, ment sector is small relative to the population in however, does not have to be spent only in the rural areas and in informal employment. public sector. Governments often have little con- Based on data from official National Health trol over how the current funding envelope is Accounts, total health spending on health care in spent because of pressures from the wage bill and Sub-Saharan Africa was US$68 billion in 2008, of existing public service delivery obligations. But which 45 percent was spent in the public sector with good planning, future growth in public and 55 percent was spent in the private sector. spending could (and should) be spent on services During 2001–06, Africa experienced remarkable provided by public or private providers, which- economic growth (approximately 5 percent), and ever is most effective at delivery. A shift away the relative share of public spending on health from out-of-pocket spending to more risk pool- care increased annually by 1 percent, while the ing, for example, through public financing, is like- relative share of private spending on health care ly and a welcome prospect. Adept governments decreased annually by 1 percent. These trends are will take best possible advantage of the public and consistent with historical trends observed in other private capacities currently in the system that can regions going through rapid growth. We use some best contribute to public health goals. basic back-of-the-envelope calculations to project 142 | Healthy Partnerships Figure A5.1 Africa: Spending on Health, by Source 120 100 Billions of US dollars 80 60 40 20 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 Donor aid with growth 2020 Total health expenditure with donor growth Private health expenditure with growth Donor aid without growth Total health expenditure without donor growth Public health expenditure with growth Source: “Healthy Partnerships” analysis and projection based on WDI data, 2010. Healthy Partnerships | 143 Notes 1. WHO 2010a; IFC 2008; Lagomarsino, Nachuk, and 27. World Bank, World Development Indicators, Kundra 2009. December 2010. 2. Data obtained from Demographic and Health Surveys 28. Data obtained from DHS surveys; latest available year (DHS); latest available year included. RAND analysis. included. RAND analysis. For a complete list of countries and years included in 29. Ibid. the RAND DHS analysis, see Appendix 2. 30. World Bank, World Development Indicators database, 3. Data obtained from DHS; latest available year December 2010. included. RAND analysis. 31. Data obtained from DHS surveys; latest available year 4. IFC 2008. included. RAND analysis. 5. Data obtained from sum of all Population-Weighted 32. Ibid Sub-Saharan Africa Demographic and Health Surveys 33. Ibid conducted after 2000. Analysis by Dominic Montagu, 34. World Bank, World Development Indicators database, 2010. For a complete list of countries and years December 2010. included in the DHS analysis, see www.ps4h.org/ 35. Data obtained from DHS surveys; latest available year globalhealthdata. included. RAND analysis. 6. See Section 1 for details on use of health care services 36. Ibid by wealth quintiles. 37. Ibid 7. Davoodi, Tiongson, and Asawanuchit 2010. 38. Ibid 8. See literature review in Section 1, under Observation 39. Ibid 3, of main report. 40. Ibid 9. World Bank, World Development Indicators database, 41. Ibid December 2010; WHO, Global Health Observatory 42. World Bank, World Development Indicators database, Database, February 2011. December 2010. 10. IFC 2008. 43. IFC 2008. 11. Reinikka and Svensson 2010. 44. Data obtained from DHS surveys; latest available year 12. WHO 2010b. included. RAND analysis. 13. IFC 2008. 45. Marek et al. 2005. 14. This analysis borrows from other health systems 46. Data obtained from DHS surveys; latest available year measures that have been developed; for instance, the included. RAND analysis. WHO framework for health systems performance 47. Klemick, Leonard and Masatu 2008. assessment, and the World Bank control knobs 48. Klemick, Leonard and Masatu 2008; Leonard 2007. framework. 49. Leonard 2007. 15. WHO 2010a. 50. Leonard 2004. 16. Lagomarsino, Nachuk, and Kundra 2009. 51. “Healthy Partnerships” data, 2010. 17. WHO 2008a. 52. WHO 2002. 18. IFC 2008; Jütting 2002; Hozumi et al. 2009. 53. IFC 2008. 19. WHO 2007a. 54. Kadiri, Arije and Salako 1999; Isnard et al. 2004. 20. WHO 2005. 55. Wall, et al. 2004. 21. WHO, various years, World Health Statistics. 56. Barnes et al. 2010. 22. WHO 2010d. 57. Results for Development, no date. 23. UNICEF 2010. 58. IFC 2008. 24. World Bank, World Development Indicators database, 59. Hongoro and Kumaranayake 2000. December 2010. 60. IFC 2008. 25. World Bank, World Development Indicators database, 61. Brugha and Zwi 1998; Sauerborn 2001; Zwi, Brugha, December 2010. and Smith 2001; Chakraborty and Frick 2002; Kamat 26. WHO, various years, World Health Statistics. 2001; Gilson et al. 2007. 62. Das, Hammer, and Leonard 2008. 144 | Healthy Partnerships 63. Yoong et al. 2010. 90. Rosenthal 2000. 64. Mills et al. 2002; Dahlgren and Whitehead 2007; 91. Ensor and Weinzierl 2007; Hanson and Berman 1998; Oxfam International 2009. Hanson et al. 2008. 65. WHO 2010b. 92. Hozumi et al. 2009. 66. WHO 2008c. 93. Das and Teng 2004. 67. Results for Development Institute, no date. 94. Fousekis and Shortle 1995. 68. Berman 1998; Harding and Preker 2003. 95. “Healthy Partnerships” data, 2010. 69. Patouillard, Goodman, and Hanson 2007. 96. Bennett et al. 2005; Bowles 2008. 70. Davoodi, Tiongson, and Asawanuchit 2010. 97. Ferrinho et al. 2004; Jan et al. 2005. 71. Castro-Leal et al. 2000. 98. Batley 2006. 72. “Healthy Partnerships” data, 2010. 99. Batley 2006. 73. Harding, forthcoming. 100. Transparency International 2006. 74. McLaughlin, van Olst, and Whelan 2010. 101. Reinikka and Svensson 2010. 75. Stover and Ross 2010; Antarsh 2004; Winikoff and 102. Logie, Rowson, and Ndagije 2008; Peters et al. 2009. Sullivan 1997; Daniel and Rivera 2003. 103. World Bank 2010. 76. Van Dalen and Reijer 2006. 104. “Health in Africa” initiative support of policy reforms 77. Stanback, Mbonye and Bekiita 2007. in several countries, including Burkina Faso, Congo, 78. WHO 2007b. Ghana, Kenya, Mali, and Uganda. 79. Prata et al. 2005; Prata et al. 2009; Pagel et al. 2009. 105. WHO 2007a. 80. Pagel et al. 2009; Sutherland et al. 2010. 106. Mathers et al. 2005. 81. Bradley et al. 2007; Prata et al. 2009; Sutherland and 107. United Nations Statistics Division, Millennium Bishai 2009; Sutherland et al. 2010. Development Goals Indicators database, January 82. Koblinsky 2003. 2011. 83. Madhvan et al. 2010. 108. WHO 2010a; IFC 2008; Lagomarsino, Nachuk, and 84. For instance, Loevinsohn 2008. Kundra 2009. 85. Loevinsohn and Harding 2005. 109. Yazbeck and Peters 2003. 86. Basinga et al. 2010. 110. Goodman et al. 2007; Smith 2009; Wijesinghe, 87. “Healthy Partnerships” data, 2010. Jayakody, and De A Seneviratne 2007. 88. 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Geneva: WHO. 150 | Healthy Partnerships Index Note: b indicates boxes, f indicates figures, and t indicates tables. accreditation faith-based organizations, 2, 55–58, 65 third-party, 26, 47, 48b financing domain, 5, 31t, 33t, 47–52 action plan, 68–70 faith-based organizations, 56 for future research, 71–72 key conclusions, 67 Angola, 35, 41, 45, 49, 53, 55, 60 five domains of engagement, 1, 5, 7, 31t, 32, 33t. see also assessing engagement, 25, 26b. see also five domains of specific domains engagement alignment between domains and health systems building comparative analysis, 31–32 blocks, 65 data collection and framework, 32–33 Rwanda domain scores example, 63 results from data collection, 33-55 Football Association World Cup information exchange collaboration example, 39, 39b Benin, 11, 13, 41, 44 for-profit operators, 1, 2 Botswana, 26b, 37, 47, 50, 54 framework for assessing engagement, 25, 26b Burkina Faso, 33, 34, 37, 38b franchising Burundi, 39, 40, 40t, 47 to expand quality improvements, 26, 27b business environment measures, 6, 6b, 20, 21, 21f future policy discussions, 7, 63–70 Cameroon, 38, 44, 53 Gabon, 43 Cape Verde, 12, 41, 41b, 42, 47 Gambia, The, 28, 35 Central African Republic, 41 geographic scope of analysis, 3–4 Chad, 12, 14, 44, 46b, Ghana, 18, 18f, 19, 23b, 29, 33, 34b, 35, 36, 40, 40t, 46, 46t, Christian Health Association of Lesotho, 56, 57b 47, 50, 52, 54b, 59, 61b, 68 Comoros, 25, 49, governments conclusions, 63–65 action plan, 68–69 key conclusions by domain, 65–68 engagement, 31–32 Congo, Democratic Republic of, 25, 39, 44, 47t, 52, 52b, 56, minimal level of engagement, 20 58 oversight, 26 Congo, Republic of, 35, 36, 60t role in shaping private health’s operating environment, contracting or purchasing, 25, 49 20–22 Côte d’Ivoire, 47t, 60 Guinea, 46 Guinea-Bissau, 49, 54, 55t delivery and financing, 2 donors, 2 health system crisis action plan, 70 overview, 1 urgent need for improvement, 11–14 engagement. see also assessing engagement health systems strengthening, 65 definition, 1, 9–11 “Healthy Partnerships” Report excessive, 25, 26b conclusions, 63–68 framework for analysis and reform, 7, 9–11. see also context of, 9, 10b assessing engagement geographic scope of analysis, 3–4 incentive programs, 49, 50b impact on outcomes, 22 informal providers, 2 international and regional agreement, 6–7 information exchange domain, 5, 31t, 33t, 37–41 in low-resource environment, 58–59 collaboration example, 39, 39b minimum level, 20 communication example, 41, 41b obstacles, 27–28 faith-based organizations, 56 purpose of measuring, 5–6 good practice example, 37, 38b toolkit for improving, 72 key conclusions, 66 trust and predictability requirements, 28–29 intermediaries, 2. see also third-party organizations types of providers considered, 3 International Standards Organization (ISO) Certification, 47, Equatorial Guinea, 44, 45, 47 48b Ethiopia, 11, 13, 35, 37, 45, 47t, 48b, 50, 52, 53, 54 Healthy Partnerships | 151 Joint Commission International (JCI), 47, 48b public provision of services domain, 5, 31t, 33t, 53–55 Kenya, 17, 18, 18f, 20, 23b, 29, 33, 36, 40, 40t, 46, 46t, 48b, faith-based organizations, 56–57 52, 54, 59, 61b high-level subsidy example, 53, 54b key conclusions, 67–68 Lesotho, 17, 36, 44, 45, 47, 49t, 50, 56, 57, 57b, 58, 60 public-private collaboration, 59–60, 61b level of organization, 59–60 toolkit for improving, 72 Liberia, 37, 41, 47, 55, 56, 59 public-private dialogue mechanism, 36–37 public-private partnership, 1, 34, 36, 49t Madagascar, 37, 41, 46, 49t, 50, malaria drugs reforms public provision of services example, 53, 54b as political process at country level, 64–65 Malawi, 54 role of business environment measures in, 6, 6b Mali, 29, 35, 36, 53, 55, trust and predictability requirements, 28–29 maternal and child health regulation domain, 31t, 33t, 41–47 program evaluation evidence from literature, 22–24 example, 43, 45b as proxy, 5 faith-based organizations, 56 Mauritania, 25, 47 good practice example, 41, 43b Mauritius, 13, 26b, 29, 33, 34, 36, 37, 38, 41, 43, 44, 45b, 47, key conclusions, 66–67 50 opening a clinic, 46b Mozambique, 51 Rwanda, 63, 6b, 12, 13, 13f, 25, 33, 34, 35, 36, 37, 46b, 47, 49, 50, 52, 56, 57, 63, 64 Namibia, 12, 13, 13f, 14, 41, 44, 50, 55t Niger, 12, 14, 28, 35, 37, 41, 42, 46, São Tomé and Principe, 44 Nigeria,15,16, 33, 40, 49, 49t, 52, 59 self-financing, 1, 2. see also for-profit operators nongovernmental organization (NGOs), 59, 59b self-financing providers, 31–32, 32b nonprofit operators, 2 self-regulation, 26 Senegal, 45, 50 outcomes Seychelles, 12, 36, 37, 38, 41, 42, 55 impact of engagement, 22 Sierra Leone, 28 oversight, 26 social franchising to expand quality improvements, 26, 27b South Africa, 14, 17, 26b, 33, 34, 35, 38, 39b, 41, 43b, 44, policy and dialogue domain, 5, 31t, 33–38, 33t 49t, 50, 55t, 59 faith-based organizations, 56 South Sudan, 59, 59b good practice example, 33, 34b stability requirements, 28–29 key conclusions, 65–66 stakeholders, 7 public-private dialogue mechanism, 36–37 action plan by group, 68–70 political process, 64, 65 Sub-Saharan African countries predictability requirements, 28–29 geographic scope of analysis, 3–4 private health sector subsidies action plan, 69–70 public provision of services example, 53, 54b available resources, making best use of, 19–20 Sudan, 35, 39, 47, 49t, 50, 59b consumer choice and, 14–15 Swaziland, 16, 45 contracting versus purchasing issue, 25 systems level obstacles, 27–28 definition, 1–2 effects of ignoring, 24, 24b Tanzania, 12, 13, 13f, 14, 16, 19, 24b, 33, 35, 40, 40t, 50, 52b, full spectrum of quality of care, 18–19 53, 60t geographic scope of analysis, 3–4 third-party accreditation, 26 government role in shaping operating environment, 20–22 voluntary certifications by third-party organizations, 47, integration into health system, 14 48b level of organization, 59–60, 61b third-party organizations, 2 maternal and child health as proxy, 5 action plan, 70 participation in public schemes, 49, 50b Togo, 44, 45, 60t, population served by, 14 toolkit information, 72 role of, 2–3 trade associations Taiwo Road example, 15, 16 engaging with private sector, 60, 61b type of providers analyzed, 3 traditional practitioners, 2, 16, 45 wide range of providers, 16–18 trust and predictability requirements, 28–29 program evaluation evidence from maternal and child health literature, 22–24 Uganda, 12, 13, 13f, 14, 16, 35, 36, 39, 46b, 47t, 52, 53, 56 public health activities in the private health sector, 22, 23b public health spending, 19–20 voluntary certifications by third-party organizations, 47, 48b Zambia, 16, 34, 40, 55t, 58 Zimbabwe, 39, 55t, 56 152 | Healthy Partnerships Photo credits: p. i: same credits as front cover (see page ii) pp. vi: ©Glenna Gordon p. viii: ©Dana Smillie/World Bank p. x: ©iStockphoto.com p. xii: ©Glenna Gordon p. xviii: ©Glenna Gordon p. xx: ©iStockphoto.com p. 3: ©Glenna Gordon p. 8: ©iStockphoto.com p. 28: ©Glenna Gordon p. 30: ©Shutterstock.com p. 58: ©iStockphoto.com p. 62: ©Ami Vitale/World Bank ISBN 978-0-8213-8472-5 SKU 18472