Building Public/Private Partnership for Health System Strengthening Some Other Issues:

1. Building Public/Private Partnership for Health System Strengthening Some Other Issues: Defining and Measuring the Private Sector in Health Value debates about public and private roles Peter Berman The World Bank Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010

2. Defining “Private” • Non-government • Ownership? • Control?

3. What do we mean by “private sector”?

4. A Conceptual View of Public and Private Sectors “PUBLIC” SECTOR “PRIVATE” SECTOR A 2x2 matrix showing the potential mix of public and private financing and provision Public financing PUBLIC PROVISION PRIVATE PROVISION PUBLIC PROVISION Private financing PUBLIC FINANCING Public financing PRIVATE FINANCING PRIVATE PROVISION Private financing

5. Financing and Provision • Private financing • Private health insurance: FP and NFP • Direct payments by firms and employers • NGOs • Out of pocket payments • Private provision (services) • Hospitals, clinics, individual MDs and paramedics • Providers of ancillary services • Traditional practitioners • “LTFQ” practitioners • Private provision (inputs and resources) • Medical education and training • Equipment and supplies • Pharmaceuticals • Management services

6. Measurement of the Private Sector in Health • Financing • Private share of total health expenditure • Distribution of that share across relevant institutional categories • Policy-relevant attributes of institutions • Provision • Numbers and share of different types of providers who are “private” • Policy relevant attributes of provider-types

7. Provision “below the radar” • What qualifies as a “health service” and who actually delivers these services? • Technical definition • Based on technology • Based on outcome? • Definition based on purpose or intent • “Informal” providers • “LTFQ” • Pharmacies and drug shops • “Traditional” providers • Formal systems • Other systems • Mixed provision

8. Provider Mix Highly Variable Across Countries • Public provision is surprisingly similar across countries, but private provision is not • Historical conditions • LTFQs in S. Asia • Mission/church providers in E and W Africa • Role of pharmacies in Anglophone and Francophone countries • Restriction of private provision in socialist countries and changes with transition to market • Expanding role of “scientific” medicine

9. What should be the role of private sector in health system? • Normative question – ethics, values, goals? • Strongly different views reflect differences in underlying values • Economists: “market failures” argument • Public health advocates: focus on equity and population health outcomes • Others?: “Rights” perspective, Role of the State, etc. • Pragmatist view: Feasibility and Consequences • Short term and longer term view

10. Economists’ View: Public, Quasi-public and Private Goods “Pure public good” Clean air Disease eradication Water Disease control “Quasi-public good” Immunization ANC Safe delivery Well baby care Acute illness care “Pure private good” Symptomatic treatment Elective surgery Hospitalization for acute or chronic illness Privately provided/ financed goods Publicly provided/ financed goods

11. Economists’ View: Additional Criteria

12. Public health specialists’ view: Equity and Social Service • Health is a right, should not be affected by ability to pay • Government should be proactive in determining what health outcomes should be assured for all, not rely on individual preferences • Private sector is market-driven • Profit motive, reduces equity for both health and financial protection • More responsive to consumer preferences, less to objective health needs • Non-profit private sector may be OK

13. A Pragmatist’s Approach • Identify problems in terms of core performance goals, national values, political feasibility • Traces the causes of problems back to intermediary criteria and their causes • Be agnostic about whether government or private sector: “Who cares if the cat is black or white as long as it catches mice!”