Building Public/Private Partnership for Health System Strengthening

1. Building Public/Private Partnership for Health System Strengthening The Private Sector for Health Services Delivery in South Asia, Southeast Asia, and the Pacific Dominic Montagu 0 Bali Hyatt Hotel, Sanur, Bali 21-25 June 2010

2. Asia Network countries can be divided into three categories Groups have differences in: • types of private sector provision of healthcare • experiences of government-private interaction Useful information can be shared within each group of countries

3. Out-of-pocket spending on healthas a percentage of national Total Health Expenditure Group 1 (plus China) Group 2 (plus Mongolia) Group 3 Source: WHO, 2006 National Health Accounts Data: http://www.who.int/nha/country/en/index.html

4. Total Health Expenditure (THE) by source Group 1 countries: • Private payment funds most healthcare • Government stewardship of the private sector is especially important Group 2 countries: • Governments are major funding source for healthcare; often with donor money • Government coordinationwith private sector is important Group 3 countries: • Governments are the only funding source for healthcare Source: WHO, 2006 National Health Accounts Data: http://www.who.int/nha/country/en/index.html

5. Source of care • Who pays for healthcare can be misleading: in many countries private spending occurs in public facilities • A better measure of “the private sector” in providing healthcare for children is “where people go for basic medical services” • The following data, disaggregated for rich and poor, provides some answers…..

6. Population-weighted DHS data from Bangladesh, India, Nepal, Pakistan

7. Population-weighted DHS data from Philippines, Indonesia, Cambodia

8. Country Profiles

9. Source of healthcare for rich and poor: Cambodia Other Non-Formal Other Non-Formal Traditional Practitioner Informal Shop Shop Comm. Health Workers Other Formal Pharmacies Comm. Health Worker Hospitals Pharmacies Formal Hospitals Public Private Public Private Poorest Poorer Middle Richer Richest

10. Cambodia - Current Situation • High disease burden • Private Out of Pocket (OOP) is main source of financing • 80% of population treated in private facilities • Good examples of government & private collaboration to increase access & quality for priority health services

11. Source of healthcare for rich and poor: India Other Non-Formal Friend’s Relatives Friend’s Relatives Other Formal Traditional Practitioner Informal Religious Hospital Shop Other Formal Private Doctors Private Doctors Pharmacies Hospitals Pharmacies Formal Hospitals Public Private Public Private Poorest Poorer Middle Richer Richest

12. India • Over 75% of health is privately provided; both rich and poor • Large, well-organized, professional organizations • Government active support for NGOs • State-initiated innovations in collaboration with private sector • Common usage of ‘doctori’ to refer to provider of any type

13. Source of healthcare for rich and poor: Indonesia Other Non-Formal Shop Informal Other Non-Formal Other Formal Shop Private Doctors Other Formal Pharmacies Private Doctors Pharmacies Formal Hospitals Hospitals Public Private Public Private Poorest Poorer Middle Richer Richest

14. The Growth of Hospital in Indonesia The geographic distribution The growth of the number of beds

15. In the last decade, non-state beds increased by 30% while state beds increased by only 10% • Mostly urban, mostly in Java • Mostly small and mid-size hospitals, mostly Foundation-owned • Government: • Different views over the private sector • Face challenging stewardship role e.g. develop and monitor regulations on investment, quality standards, employment, mandatory reporting and treatment requirements, etc

16. Source of Healthcare by Income - Bangladesh Other Non-Formal Other Non-Formal Informal Traditional Practitioner Other Formal Traditional Practitioner Private Doctors Shop Other Formal Private Doctors Pharmacies Pharmacies Formal Hospitals Public Private Public Private Poorest Poorer Middle Richer Richest

17. HNPSP: Nature and Dynamics • Total Health Expenditure in 2000/01 = $12 • Public Sector Finance was only 34.5% • Private Sector Finance (primarily out-of-pocket) was about 63.8 % • GOB financing actually declined from 24% of the THE in 1996/97 to 18.5% in 2001/02 • Donor financing increased from 10.5% of the THE in 1996/97 to 13.3% in 2001/02 • Donor financing increasing further for the MDGs

18. Health System Structure: Other Actors • Drugs account for 70% of out-of-pocket health expenditure • 838 Diagnostic centers registered with MOHFW in 2000/01 • 682 private sector Clinics and Hospitals registered with MOHFW in 2001/02. 15% annual growth rate. About 30% of all beds are in this sector • Health insurance only about BDT 20 million in 2001/02. Growing slowly

19. Source of healthcare for rich and poor: Pakistan Other Non-Formal Traditional Practitioner Shop Shop Informal Other Formal Other Formal Private Doctors Private Doctors Hospitals Hospitals Formal Public Private Public Private Poorest Poorer Middle Richer Richest

20. Private Health Sector • per-capita health expenditure is Rs. 750 to 800 ($10). 25% is contributed by the public sector and 75% through private out-of-pocket fee-based funding • Majority of healthcare is financed out-of-pocket. • The private sector has developed considerably by capitalizing on demand. • people prefer private services for quality reasons but prefer public hospitals for inpatient care • Health care is provided by stand-alone clinics operated by individual providers with highest profits for investment • No coordination between public and private sector

21. Distribution of Health Workforce/facilities by Public and Private Sector • annual output of 5,000 medical graduates • 1 doctor/1400 persons (1:1000 WHO recom) Proportion of Workforce in Public : Pvt • Physicians----35:65 • Nurses--------70:30 • Midwives----35:65 No of Facilities • Hospitals---1000 &700 • Beds---------100,00 & 20,000 • Clinics------75000---all Pvt • Trust hospitals---580

22. Summary For countries in Asia • The private sector is an important source of healthcare across all wealth levels • Improving the health and wellbeing of citizens in most Asian countries therefore mustinclude engagement with private providers of varying types • A range of public-private-partnership models are feasible, but… • depend on each country’s capacity, situation, & experience

23. Next Steps • Analyze private service provision where this information is not available • Create a working group to consider a. opportunities and b. priorities for private sector partnerships and interventions • Strengthen technical capacity in this field within stakeholder institutions in each country (MOH, MOF, ADB, WB, UN agencies, bilateral donors, etc.)