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 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
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 fi ndings, interpretations, and conclusions expressed in this volume do not necessarily
refl ect 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. The boundaries, colors,
denominations, and other information shown on any map in this work do not imply any judgement on the
part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of
such boundaries.
Rights and Permissions
The material in this publication is copyrighted. Copying and/or transmitting portions or all of this work
without permission may be a violation of applicable law. The International Bank for Reconstruction and
Development / The World Bank encourages dissemination of its work and will normally grant permission
to reproduce portions of the work promptly.
For permission to photocopy or reprint any part of this work, please send a request with complete
information to the Copyright Clearance Center Inc., 222 Rosewood Drive, Danvers, MA 01923, USA;
telephone: 978-750-8400; fax: 978-750-4470; Internet: www.copyright.com.
All other queries on rights and licenses, including subsidiary rights, should be addressed to the Offi ce of
the Publisher, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2422;
e-mail: pubrights@worldbank.org.
ISBN: 978-0-8213-8472-5
e-ISBN: 978-0-8213-8473-2
DOI: 10/1596. 978-0-8213-8472-5
Library of Congress Cataloging-in-Publication data has been requested.
Cover images, left to right: ©Ami Vitale/World Bank, ©Trevor Samson/World Bank; ©Glenna Gordon; ©iStockimages.com,
©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
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 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
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-Financ