How Governments Can Engage the Private Sector to Improve Health in Africa

How Governments Can Engage the Private Sector to Improve Health in Africa


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Since the private health sector is an important, and often dominant, provider of health services in Sub-Saharan Africa, it is the job of governments as the stewards of the health system to engage with it. Increasing the contributions that the existing private health sector is making to public health is an important, but often neglected, element of meeting the daunting health-related challenges facing African nations. This Report presents newly collected data on how and how effectively each country in the Africa region is engaging the respective private health sectors; and how the engagement compares across the region. While the approach taken by governments varies greatly between countries, there is much room for improvement in the Africa region overall to engage more effectively and room for exchange of ideas and good practices on how to do so. Improved solutions on the policy/regulatory side should be supported by effective organization of the private sector itself and by adjustments in donor programs that take the dynamics of the private health sector better into account.



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Publié le 12 mai 2011
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EAN13 9780821384725
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Healthy Partnerships
How Governments Can Engage the Private Sector
to Improve Health in AfricaHealthy Partnerships
How Governments Can Engage the Private Sector
to Improve Health in Africa©2011 The International Bank for Reconstruction and Development / The World Bank
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Washington DC 20433
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All rights reserved
This volume is a product of the staff of the International Bank for Reconstruction and Development /
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refl ect the views of the Executive Directors of The World Bank or the governments they represent.
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ISBN: 978-0-8213-8472-5
e-ISBN: 978-0-8213-8473-2
DOI: 10/1596. 978-0-8213-8472-5
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Cover images, left to right: ©Ami Vitale/World Bank, ©Trevor Samson/World Bank; ©Glenna Gordon; ©,
©Glenna Gordon
Cover and text design: Naylor Design, Inc.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 Certifi cations 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
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 Defi cit 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 Benefi t 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 Simplifi ed 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
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 Infl uenced
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 Defi nitions 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 v | vi Healthy Partnerships |AcknowledgmentsAcknowledgments
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 Tthe International Finance Corporation (IFC). The fi ndings and conclusions con-
tained within are those of the authors and do not necessarily refl ect 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 (
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 |