Implementation Challenges to Engaging the Private Health Sector

1. Implementation Challenges to Engaging the Private Health Sector Asia Network Private Health Sector Policy April Harding World Bank/ IFC Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010

2. Teaching points Distrust, lack of dialogue, lack of cooperation undermine effective implement of private sector engagement strategies Strategies for overcoming constraints include • mechanisms for on-going communication • formalizing participation of private sector representatives in the policy making and implementing process • support to implementing officials to shift to new approach.

3. Outline of Session • The Challenge • Six Steps of Implementation • Strategies to help ensure implementation success

4. Moving from identifying or designing policies to engage the private sector to implementation The Challenge

5. Policy Design

6. Policy Implementation

7. Why so hard? • Inherently political • Conflicting views & objectives of stakeholders • Cultural & institutional context • Typically more attention paid to policy content or design than to implementation

8. Administration Monitoring Impact Politics Legitimation Mobilizing Actions Organizational Design Ensuring Resources Six Steps of Implementation Constituency Building

9. Six Steps of Implementation Administration Monitoring Impact Politics Legitimation Mobilizing Actions Constituency Building Organizational Design Ensuring Resources

10. Legitimation Is getting policy accepted as important, desirable and feasible • Depends directly on consultation and communication with the regulated entities (Consultative mechanism)

11. Public- private consultative mechanism Any forum or mechanism where public and private actors meet to exchange information; discuss policy issues; agree on coordinated or partnership activities.

12. Six Steps of Implementation Administration Monitoring Impact Politics Legitimation Mobilizing Actions Constituency Building Organizational Design Ensuring Resources

13. Constituency Building • Assessment • Gaining support of allies/ beneficiaries (must be able to make good arguments) • Reducing opposition (or impact of…)

14. Constituency Building • Having a strategic plan for dealing with stakeholders • Having a strategic communication plan

15. Be proactive, not reactive Explain your initiative and what it means for people…… Or someone else will.

16. Constituency Building • Who are key public actors? Likely positions? • Who are key private actors? Likely positions? (CM) • How strong are they?

17. Constituency Building • For allies/ beneficiaries • How can you bring about collaboration/ coordination? • How can you strengthen their influence? • For potential opponents • What are their biggest concerns? • Can you address some of their concerns?

18. Vouchers for delivery attendance for poor women • Who may be your allies? - How can you strengthen their influence? • Who may be opposed? • What are their biggest concerns? • Can you address some of their concerns?

19. Methods to Assess Obstacles • Stakeholder Analysis • Political Mapping/Analysis (www.polimap.com) • Policy Workshops

20. Stakeholder Analysis • A stakeholder is any individual, community, group or organization with an interest in the outcome of a policy • Three types: • Key: can significantly influence success of activity • Primary: ultimately affected by an activity (either positively or negatively) • Secondary: all other individuals/institutions with a stake, interest or intermediary role in activity

21. Stakeholder Analysis * 1=strongly support; 2=support; 3=neutral; 4=oppose; 5=strongly oppose

22. More strict quality standards in hospitals

23. Stakeholder Analysis - Strategies Low resources High resources Support Oppose

24. Six Steps of Implementation Administration Monitoring Impact Politics Legitimation Mobilizing Actions Constituency Building Organizational Design Ensuring Resources

25. Ensuring Resources/ Capacity Financial resources Do implementation plans ensure predictable flow of funds to support implementation? Often private sector engagement is pursued without funding (as a result of financial constraints)

26. Six Steps of Implementation Administration Monitoring Impact Politics Legitimation Mobilizing Actions Constituency Building Organizational Design Ensuring Resources

27. Organizational Design • Establishing procedures, objectives, systems and structures to carry out policy implementation. • Entails creating new organizations and relationships - formal or informal • Bodies with appropriate authority • Clear allocations of responsibility and accountability

28. Organizational Design: Check List • Adequate planning for review & revision of needed laws? • Implementing bodies: • clearly understand their roles & responsibilities? • have adequate authority? (Does authority need to be assigned or redistributed?) • Are plans based on realistic assumptions about private actors?

29. Organizational Design/ Structure Role of private representative bodies • What are their capacities? Interests? • What are they willing to do? • How will gov’t ensure they are behaving appropriately? • How will gov’t step in if they fail?

30. Organizational Design/ Structure A consultative mechanism can play an important role in implementation of private health sector engagement.

31. Why would you consider establishing a public- private consultative mechanism? Many initiatives to work with the private sector fail due to lack of understanding, or due to lack of their engagement in policy design and implementation

32. Public Private Consultation Mechanisms • Formalizing consultation of most relevant private actors (or representative bodies) in consideration of policies directly related to their activities • EX: Australia private hospital legislation reviews – private hospital association participates at every stage.

33. Australian Health Ministers Advisory Council Representatives of different government actors payers (HIC, State Gov’ts); public and private providers; technical experts. Temporary Working Groups are established to support intensive engagement toward addressing specific policy issues (health workforce; patient information; health technology assessment; consumer protection/ patient rights; medical education)

34. Public Private Consultation Mechanisms Physician reimbursement consultative mechanisms Formal bodies that meet to work out adjustments to physician fees – usually exist on a continuous basis Members are physician reps (medical assns); payer reps (gov’t/ independent/ private); technical experts.

35. Public Private Consultation Mechanisms France: Standing Commission on Physician Reimbursement Germany: Concerted Action Commission Canada: (Provinces): Schedule of Benefits Working Group (Ontario)

36. Public Private Consultation Can Lead to: • Improved information for decision-making • Greater consensus about and ownership of new policies • Greater accountability of public decision-makers • More resources for agreed actions • Building of trust….leading to better relations in the longer-term

37. Consultation Requires Listening as Well as Talking

38. Public Private Consultation Requires: • Participation of • truly representative actors/ bodies • authoritative actors (highly knowledgeable; speaking for other actors) • Clear agendas for meetings • Resources to prepare for, facilitate meetings and follow-up on meetings • Transparency about how agenda is set

39. Public Private Consultation – Getting Started • Establish government commitment • Establish clear objectives • What can the private actors gain through participation?? • Establish and share goals and agenda • What will they discuss • What outputs can be expected? • Figure out who to invite (consult with) • Logistics (where to meet, staffing) • Identify resources/ responsibility for follow-up

40. Public Private Consultative Mechanisms Can be structured, or at least initiated around an analytical piece of interest to the private actors (e.g. Quality Regulation Review; Private health sector assessment; Improving Child Health; Fighting TB or HIV/ AIDs)

41. Six Steps of Implementation Administration Monitoring Impact Politics Legitimation Mobilizing Actions Constituency Building Organizational Design Ensuring Resources

42. Mobilizing Action

43. Mobilizing Actions Ensuring implementing actors and individuals are going forward Implementing officials – • Who are the key ones? • How can you motivate or “incentivize” or persuade them? • How can they be monitored? • Getting feedback from private actors (CM)

44. Six Steps of Implementation Administration Monitoring Impact Politics Legitimation Mobilizing Actions Constituency Building Organizational Design Ensuring Resources

45. Monitoring Impact Critical to check to see if actions • are being implemented • are having desired impact Review results together (CM)

46. Checking the Map

47. M&E is not academic . Malaria medicine regulation in Uganda (REDUCED access to front-line drug) • Licensing regulations can reduce access to needed services • Quality standard rules can increase informality

48. Questions: • How can policymakers engage the private sector in implementation without allowing some private actors to “capture” the process? • In your country, do public and private collaborate in implementation of any initiatives? • What problems have emerged? • How can such problems be overcome?