When Single Sector Solutions are not
Enough: Addressing Health Systems
Gaps with Public-Private Partnerships
Barbara O’Hanlon, Senior Policy Adviser, SHOPS
Susan Mitchell, Project Director, SHOPS
October 8, 2010
Presentation overview
 Growing interest in working with the private sector
 Different levels of private sector engagement
 Benefits of partnering with the private sector
 Strategies for addressing health systems gaps through
public-private partnerships
 Examples of successful private sector programs
Growing interest in PPPs
Context
 Growing recognition among donors and developing countries of the
need to work with all actors in the health sector
 Many in global health community are promoting public private
partnerships
 Lots of confusion exists on
 When is appropriate to engage the private sector to address public health
objectives
 What are PPPs
Benefits of engaging the private
sector
Why work with the private sector?
Partnering with the private sector can strengthen the health
system by …..
 Building sector-wide capacity to deliver high quality services and
products
 Increase number and distribution of health personnel
 Improve the generation, dissemination and use of health information
 Enhance government’s ability to ensure availability of quality,
affordable medicines
 Mobilize resources and expertise
 Strengthen government oversight through dialogue and greater
interactions
Different levels of private sector engagement
P1
P3
P1
Public private dialogue
Coordination between the sectors
to exchange information and to
dialogue on issues related to health
P2
P2 Public private interaction
P3
Public private partnerships
Formal partnerships improving
access to health services and
products
Cooperation between the public
and private sectors to produce
policy reforms creating favorable
environment in PPPs in health
Working definition of PPPs (P3 )
A PPP in health is any formal
collaboration between the public
sector at any level (international
donor agencies, bilateral government
donors, national and local
governments,) and the non-public
health sector (commercial, non-profit
and tradition) to jointly regulate,
finance or implement the delivery of
health information and
communication; services; products
and equipment; and research.
Types of PPPs (P3 )
 Market Model – commercially viable
activity
 Charity Model – CSR/Philanthropic
activities
 Mixed Model – Combination of market and
charity activities
PPPs (P3 )
When to partner with the private
sector
When to use P3
P3 should be used selectively
 Requires considerable time and money to negotiate
 Requires new stewardship skills on gov’t side
 Often requires outside “honest broker” to connect
 Rationale for govt to decide to enter into a P3
 Are there persistent gaps in the health system not being
addressed by single sector approaches? If no, then do not
need P3
 If yes, explore P3 to bridge health system gaps to choose P3
models known to address common gaps
Algorithm to decide when to use P3
Are there persistent
gaps in the health
system not being
addressed by single
sector approaches?
IF NO
No need for PPP’s.
Continue to use single
sector approaches.
IF NO
Consider different
approach and/or
invest in single sector
approach.
IF YES
Will PPPs address
equity, access and
efficiency?
IF YES
Broker PPPs with
appropriate partners and
formalize agreements for
implementation
Health system gaps
Human
Resources
Governance
Information
Demand
Generation
Affordability
Access
Health system gaps and possible
solutions
Strategies to strengthen health systems
with the private sector
Private sector participation in policy reform,
strategic planning
PPP dialogue process
Consumer Advocacy Groups
Market Research
Task-shifting Para-skilling
Consumer Research
Share ManageriaLExpertise
Contract Private Medical
and Nursing Schools
Training and Continuing
Medical Education
Social Marketing of
Services and Products
Demand-side Subsidies
and Vouchers
GOVERNANCE
GAP
HUMAN
RESOURCES
GAP
IMPROVED
HEALTH
OUTCOMES
Market Segmentation
Private sector sends data to MOH
Strategic Planning
INFORMATION
GAP
AFFORDABILITY
GAP
DEMAND GAP
ACCESS GAP
Risk-pooling Mechanisms
Community Based Health Insurance
Contracting-out of Services
Performance-based Financing
Social Marketing of Services and
Products
Access to Finance for Private
Providers
Leveraging of Private Sector Infrastructure
Concessionary Leasing
Subsidized Drugs Donated to Certified Providers
Demand-side Subsidies and Vouchers
Health system gaps
Governance gap
Legal and regulatory reform to permit private providers to
perform key public health tasks in a private settings
(Ethiopia, Kenya, Zambia)
PPP dialogue mechanisms in Kenya, Ghana, Mali and
Uganda
Creation of PPP Units in Ghana, Kenya, Nigeria, Mali
Uganda and South Africa
Human resource
gap
MOUs and contracting with private medical training
institutions (Kenya)
Contracting private management firms and/or private health
providers to manage private hospitals (Kenya, Lesotho,
Zambia)
Health system gaps
Affordability gap
A pilot insurance project covering informal workers with basic
healthcare in private sector (Okambilimbili Project,
PharmAccess, Namibia)
THT, a HMO/PPO, delivering affordable family wellness services
under the NHIS (PSP-One, Nigeria)
Innovations in insurance – micro insurance, micro-finance – to
cover informal workers (Uganda, Kenya)
Demand gap
Vouchers for ITNs (AED, multiple countries)
Vouchers for maternal health and RH services (KfW, Uganda and
Kenya)
Health system gaps
Access gap
Indian generic mfg. (FAMICARE) distributing generic OC thru
NGO distributor (SFH) (LOCAN-PSP-One-Nigeria)
Network of legal (private) drug outlets in rural areas to supply
essential OTCs (MSH-SEAM, DLDBs in Tanzania)
Private provider network -PrimeCure- delivering affordable
services and medicines (South Africa)
Private provider network -NewStart- delivering VCT services
(PSI- multiple countries)
PPPs with local health authorities and extractive industries to
expand services to remote communities (Namibia, South
Africa)
Concessionary / leasing of MOH hospital infrastructure to
private providers (Lesotho)
P1 and P2 – Kenya Example
P1
Dialogue – multi-sectoral body formed
and lead with equal representation
between sectors
P2 Interactions – active engagement on key
policy reforms underway
 Update of Health Policy framework
 Review of 17 health acts
 Development of PPP Framework
A PPP to introduce Zinc in Nepal
Sustained provision and use of pediatric Zinc in addition to
ORS/ORT as the first line treatment for uncomplicated diarrhea
for children under 5
 Sustainable supply of pediatric Zinc tablets created
 Increase access to pediatric Zinc for caregivers of under-5
children
 Improve caregiver knowledge and treatment so that
caregivers provide ORS/ORT together with Zinc for
uncomplicated diarrhea regardless of source
 Improve private provider knowledge and treatment practices
Why a PPP? Use by source of supply
DHS 2006
Sustainable commercial supply
Challenge: Government preference for local supply
 Three Nepalese pharmaceutical manufacturers assisted in bringing
to market quality pediatric Zinc products
 Affordable pricing
 ($0.19 – 0.52)
 National commercial distribution
Improving access
Challenge: Coordinating with the phased government approach (at program
inception public sector had introduced Zinc in 5 of 75 districts and planned a
three year phase-in)
 Launch in a phased manner
 Phase 1: Fund public sector introduction in priority private sector
geographic focus (capital region)
 Phase 2: Program extension to all 27 Community-Based Integrated
Management of Childhood Illness (CB-IMCI) districts from February
through September 2008
Improving provider knowledge
Challenge: Ensuring private practitioners and pharmacists had access to the
same training as public sector staff
 Developed private providers’ training materials to be consistent with
Government protocols
 Trained: 5810 private doctors/chemists
 Trained manufacturer's detailers for message reinforcement
 Job aids and informational materials delivered to over 8000 trainees
Improving caregiver knowledge
Challenge: Creating a common communications message
 Built consensus on messaging and logos through an official body:
Zinc task force
 Created a national umbrella campaign logo used on wall charts,
posters, and billboards
 Produced and aired radio generic spots and one television
advertisement that promoted Zinc use in general
Nepal conclusion
 Lesson: Building a “true” public-private partnership
takes time, flexibility and willingness to compromise but
yields sustainable results
Take home messages
 Health system strengthening efforts focusing solely on the public
sector over look available important private sector resources
 It is critical for governments to determine if a sole sector or
partnership approach is needed given the considerable time and
effort to engage the private sector
 Private sector can make important contributions to address a wide
range of health system gaps
 Different levels of private sector engagement – the first two are
necessary conditions to reach PPPs (P3)
 Public-private dialogue (P1)
 Public-private interaction (P2)
 Public-private partnerships (P3)
Thank you!