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The private sector and poverty eradication Experiences from the health sector

Minutes|Bretton Woods Project|23 April 2013|url
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Speakers:


Paul J Gertler, University of California
Jishnu Das, senior economist, development research group, World Bank
Kim Longfield, director for research and metrics, PSI

Respondents:
Gwen Hines, World Bank Executive Director for the UK
Aaltje de Roos, Ministry of Foreign Affairs, the Netherlands

Moderator:
Guy Stallworthy, Bill and Melinda Gates Foundation

Presentations:

Jishnu Das

  • Gates foundation funded work
  • Health sector and markets in low income countries
  • Private sector and results focus of presentation, in particular for IFC
  • Do we talk about private sector in terms of specifics, or in terms of policy, and how do we define results
  • Traditionally if there is no health sector in a village, we should introduce it – but story was wrong
  • A village in India had a number of health providers, eg 100 – India one of the densest providers in the world
  • On average 5 providers in a village, more than in the US
  • But the poorest places had more health providers, and used them very often
  • Very few public sector, most private sector, most with no medical qualification, some have another degree
  • Steps from access, to access with quality
  • Measuring quality – research finding that qualifications is not competence, private sector operators diagnosis better, treatment better
  • It’s not what doctors know, only partly
  • Qualifications and availability of medical equipment are very poor predictors of quality of medical advice
  • Implications for regulation and policy
  • Quality multidimensional

Kim Longfield

  • working group of 9 organisations, two funders
  • social franchising for health
  • provide a set of services, including branding, training, standards and access to commodities
  • goals including, health impacts, equity, quality, health market expansion, cost effectiveness
  • most working in family planning, also tuberculosis, malaria, etc
  • stakeholders: programme managers, agency headquarters, other stakeholders
  • Equity: improved metric – I know I reach the poor because X% of my clients are poor (rather than just work in a poor area)
  • Metric attributes: easy to collect, low cost, comparable to national context and across countries
  • Wealth index: relative measure, uses DHS data, vs PPI – chose Wealth index due to cost

Paul J Gertler

  • how we can use measures to improve performance:
  • knowing how well you are doing: enables intrinsic and extrinsic motivation
  • let consumers know - enhances competition
  • let the market know - access to finance and investment
  • examples: pay for performance
  • primary health care in Rwanda
  • pay for more higher quality, rolled in national rollout
  • result: higher quality & improved health outcomes
  • African Health Equity Markets: scale up private primary health in Kenya, Ghana and Nigeria
  • constraints: access to finance, standardising and monitoring quality and management process
  • solutions: franchising, management systems & finance, all involve performance measurement
  • measuring performance, allows knowing what you are doing
  • use of intrinsic and extrinsic incentives
  • competition, access to finance, scaling up

Respondents:

Aaltje de Roos

  • since 2007 been trying to involve private sector in health programme
  • HIV/AIDS, found large proportion of private clinics underutilised as couldn’t pay for treatment, eg in India and Nigeria, 50-60 per cent health care through private clinics
  • fund to support private companies to develop insurances for low income groups to attend private clinics – subsidised private system
  • also privately funded investment fund in Africa, attract investment to improve quality
  • small private clinics need finance, access to finance added to insurance
  • need quality standards, too, trying to standardise quality, also to improve quality
  • working with health in Africa initiatives, including IFC

Gwen Hines

  • use results measurement key messages
  • board of WB group, including looking at investments if they are good enough – often look at results matrix
  • this is where evidence comes in, are we maximising impact
  • UK this year 0.7 goal on ODA, need to ensure we do the right thing, have to justify for tax payers
  • Challenges:
  • Results measurements, can you tell the difference between input, impact, output, etc
  • Language is a challenge
  • Quality of care important
  • How to distinguish who is poor
  • Women – how do we specifically target girls and women, including whether it is targeting the elite
  • What to do when targets aren’t achieved, how to check the results, eg self reporting and are people telling you the truth
  • Like the idea of mystery shoppers, I generally go for triangulation
  • Technology, teachers sub contracting their jobs
  • What do we do with all of this
  • Focus on mid course evaluation
  • Have to be prepared to learn from failure
  • Need to prepare incentives for people
  • Have do we really make WB a knowledge bank

Q&A

Q:

  • broad brushed baskets where things are going, but not why they are going there
  • micro based, are our assumptions correct
  • but how do we empower businesses that partner with us to get strategic clarity

Q:

  • to what extent are you ready to tolerate failure in Africa

Q:

  • effectiveness, how to implement on how to collect data
  • skills to collect the information
  • challenge to attract quality staff, how to deal with
  • what data is needed, who need it, etc, India situation is not unique

Kim Longfield

  • try not to measure too much
  • by getting people involved, get them incentivised
  • challenge people to think beyond outputs to outcomes
  • so far doing toolkits, building up capacity of staff

Jishnu Das

  • access to finance for private sector important
  • are the private sector responding to people’s demand
  • informal providers already biggest health system, lot of thinking about how to deal with these – decentralised providers in a competitive market
  • IFC role: specific investments in particular firms or bodies, can pick a winner who can be a winner only with IFC support – need to find a way of picking out about a million of these guys

Paul Gertler

  • as money start to pour into private health sector especially health insurance, will see expansion
  • seeing some novel technologies and opportunities
  • will this be better than going to the bank for a loan
  • other technology, digitalising patient information through phone, eg in Africa

Aaltje de Roos

  • should allow failure as quite a new area and field of working, not everything goes right from the first moment
  • under scrutiny of public scrutiny
  • in Nigeria, progressing very well, but some challenges, which might result in an interesting business model

Gwen Hines

  • yes, have to tolerate failure, and do have to be innovative
  • have to balance your portfolio, have to show enough results, but retain a small percentage of high risk
  • debate need to be up front what percentage this is – what is the minimum level of result you can have to justify
  • eg P4R forces you to think up front
  • behaviour change the most difficult
  • need to learn from what is already out there
  • need to think about incentive structure
  • also need to know when to quit

Published: 23 April 2013 , last edited: 16 September 2013

Viewings since posted: 864

Articles: 3465

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