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Why non-state actors?

"Whether as a function of access, preference or economics, non-state actors play a critical role in the provision of health-care delivery in low- and middle-income countries." (1)


A Neglected Area

In 2009, the Taskforce for Innovative International Financing for Health Systems released a landmark report exploring some of the key factors that would support the achievement of the health Millennium Development Goals by 2015. It found that "improving the health of the world’s poor will often involve managing, harnessing, mobilizing and raising the performance of the non-state sector – in addition to strengthening the role of the government in governance, regulation, contracting and quality enhancement – a neglected area over the past decades". This prompted a recommendation of the Taskforce to:

"Strengthen the capacity of governments to secure better performance and investment from private, faith-based, community, NGO and other non-state actors in the health sector." [Recommendation 6]

HANSHEP was formed in 2010 as a response to this recommendation, bringing together development agencies and countries seeking to improve the performance of the non-state sector in delivering better healthcare to the poor by working together, learning from each other, and sharing this learning with others.


Non-state actors in the health sector

Although many people immediately think of for-profit or commercial providers when they think of “private”, the non-state sector also includes Non-Governmental Organizations (NGOs), Community-Based Organizations (CBOs) and Faith-Based Organizations (FBOs).  Specifically, private providers include a wide range of front-line workers: unqualified drug sellers, pharmacists, midwives, traditional healers, unqualified practitioners and qualified doctors, lab technicians, and NGO community health workers and peer educators.

The role and contribution of these NSAs in the health sector today is considerable. For example:

  • Across Africa, 52 per cent of those in the bottom income quintile receive their care from NSAs, equal to the proportion of Africans in the top income quintile. This pattern also holds true for urban and rural populations alike. (2)
  • Surveys in 42 low and middle income countries show that for children with respiratory tract infections, around 50% (95% in some countries) of those who seek medical care go to non-state actors. (3)

Given the scale and the fact that their services are used by the poor as well as the better off, NSAs must therefore be considered within any national and international health policy and planning framework. However, a key characteristic of the non-state health sector is its fragmentation and lack of regulation, compounded by a scarcity of reliable data around the quality or range of services delivered by these providers. This makes it difficult to identify and influence the factors contributing to improved health outcomes for the poor, which might include the development of public-private partnerships, the scaling up of innovative financing and delivery mechanisms, staff training programmes and/or the creation of effective regulatory frameworks. These and other challenges, accentuated by the inherent complexity, dynamism and variety of health systems around the world, have contributed to a widespread lack of knowledge about how to engage with non-state actors, be they for-profit or not-for profit.

The HANSHEP platform was created to address some of these issues (and many more), funding research to build a more comprehensive evidence base around the role and contribution of NSAs in healthcare in developing countries (including exploring innovative models of public-private collaboration); offering technical assistance to both governments and NSAs to support the development of mutually beneficial partnerships where appropriate; and providing resources to enable the piloting and scaling of successful interventions. In this way, HANSHEP members seek to better harness NSAs to provide more accessible, higher quality, more affordable and better value healthcare for the poor.

Finally, it should be noted that HANSHEP members are interested in non-state health delivery channels not for their own sake but because they believe they can, under certain circumstances, be the most appropriate channels for maximising goals of coverage and equity. Members do not have a preference for or against non-state provision, nor a preference for or against public sector provision. Increasing the non-state sector share of the health market, in either financing or provision, is not an objective for HANSHEP members.




(1) Taskforce on Innovative International Financing for Health Systems (2009) More Money for Health, and More Health for the Money. Available to download here.

(2) World Bank (2011) Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa. Available to download here.

(3) World Health Organisation (2008) Capacity building to constructively engage the private sector in providing essential health care services. Available to download here.