Reflections on the iHEA Private Sector in Health Symposium 2013
Back in 2009, when the first Private Sector in Health Symposium was held in Beijing, the focus was squarely on stimulating research interest in non-state actors and building the foundations for understanding their role and contribution to modern mixed health systems models. Four years later, following a second successful Symposium in Toronto, it is encouraging to see the momentum that has grown around this topic, with over 120 delegates and 50 presentations on offer at the 2013 Private Sector in Health Symposium in Sydney, Australia.
As a first time attendee of these biannual events I was keen to take in as much as possible, and the rich diversity of papers the organising committee had assembled for the programme enabled me to explore the complexity of private sector health interventions from the perspective of government, provider, patient and donor.
Many governmental Ministries of Health were represented among the Symposium delegates, and the challenges they were facing with regard to the design and enforcement of appropriate private sector regulation frameworks were a hot topic of discussion. Many of these were captured in the research conducted by Jane Doherty at the University of Witwatersrand School of Public Health, which analysed legislative frameworks in 16 countries in East and Southern Africa. With the rapid and uncontrolled expansion of non-state facilities and providers across these regions in recent years, governments have struggled to develop adequate regulatory measures to capture the entry of health professionals and organisations into the market, let alone monitor their behaviour and quality of their services. Without detailed comprehensive census data (the focus of another presentation by Douglas Johnson of Abt Associates), these providers are effectively invisible to government in many instances, and in the absence of a culture of accountability are further fragmenting and distorting the quality, distribution and price of health services in an already complex market. Strengthening regulatory instruments in advance of efforts to expand private sector involvement was seen to be key – and yet, as delegates later pointed out in one of the plenary discussion sessions scattered throughout the day, regulation must also be kept in check itself if it is to avoid smothering the capacity of these very same providers to innovate.
Research conducted in Malawi by Abt Associates through the USAID-funded SHOPS programme provided a different perspective on this issue, this time from the viewpoint of health workers themselves. Surveys conducted with over 600 public and private workers suggested that it was regulatory measures at the facility level (especially performance management systems and access to a mentor/supervisor support) that were the most powerful predictor of private health workers’ motivation – more so than the financial compensation that approaches such as performance-based pay prioritise. Interestingly, this could also be another factor contributing to the growing popularity of healthcare franchising models across Africa, by virtue of their bringing fragmented private sector health workers together within clearly structured and mutually supportive networks. Either way, this research has interesting implications for the relationship between national and facility-level approaches to non-state health sector regulation, and suggests that such frameworks would do well to devote more attention to the non-financial incentives of performance management.
The experiences of patients themselves were also presented in a number of sessions, including Chen Gao's research from China using multi-year panel data from the Urban Resident Basic Medical Insurance Household Survey to examine whether patient satisfaction levels differed depending on whether they were being treated by a public or private provider. Although the study ultimately found little statistically significant difference between the two, it did find that the higher the percentage of private providers in a city, the higher the satisfaction levels became for patients – regardless of whether they were visiting a public or a private provider. In fact, the research pointed to a strong ‘spill-over’ effect on patient satisfaction from the private providers, and concluded with a call to subsequently reduce the range of prohibitive policy measures that currently hinder the development of private providers in China, such as heavier taxes and inequitable regulation.
Finally, it was encouraging to see a number of presentations of work being undertaken to improve the credibility, comprehensiveness and comparability of private provider reporting – something that those in the donor community heavily rely on to understand where to target their resources effectively in an increasingly crowded marketplace. Prominent among these was the work of a team from the University of Toronto commissioned by the Center for Health Market Innovations to enhance the integrity and scope of indicators used in their Reported Results framework. A variety of approaches to measure provider performance and impact were evaluated to eventually form a new framework of indicators more effectively balancing the timely and inexpensive collection of quality, meaningful data with the capacity and resource limitations of the provider. By then applying this framework to over 100 programmes in the CHMI database, the areas where performance reporting was lacking became clearer, enabling programme managers to focus their data collection efforts more effectively.
Similarly, the Global Health Group at the University of California, San Francisco, has been working to enhance the way social franchise providers measure and report against their equity targets (i.e. the extent to which their services are effective in reaching the poor). Following a rigorous evaluation of several potential metrics available, two of the most promising measures – the Progress out of Poverty Index (PPI) and the Wealth Index (WI) – were piloted across a number of country platforms and clients. The team then compared these criteria using a range of criteria (including cost-effectiveness and feasibility) before concluding that the strongest and most appropriate measure for measuring the equity impact of private sector interventions was the Wealth Index, which they will now look to integrate into the reporting of their social franchise networks going forward.
This blog is a just a taster of the many presentations on offer throughout the day, which concluded with a lively networking reception sponsored by HANSHEP and co-hosted with the Center for Health Market Innovations. Of course, as with every forum of this nature there are lessons that will help to strengthen the content and format of these Symposia going forward.Some of the suggestions raised by delegates at the end of the day were around increasing the coherency of presentations within a session to facilitate the easier extraction of collective insights and meta-analysis; others wanted more time for deeper audience discussion and Q&A (e.g. by narrowing the focus of the Symposia, reducing the number of presentations within each session, and/or clustering papers by country to provide for multi-dimensional analysis of a key issue). By building on these suggestions, the organisers of the next Symposium in 2015 will ensure the energy, interest and status of this important gathering continue to grow.
To download the agenda, abstracts and presentations from the 2009, 2011 and 2013 Symposia CLICK HERE.