In 2008, the Rockefeller Foundation asked the Results for Development Institute (R4D) to lead an effort to better understand the role of the private sector in health systems in developing countries. In partnership with the International Health Policy Program of the Thai Ministry of Public Health and other health policy research organizations, R4D worked to identify opportunities to strengthen public/private health systems through the collection, analysis, and dissemination of information and evidence on non-state health care providers and funders, and on public stewardship mechanisms designed to better harness these private actors. This effort, drawing on the work of a wide range of academic, think tank, and consulting partners, resulted in 14 research papers and produced a wealth of information. This body of work has significantly informed and shaped the thinking behind the Center for Health Market Innovations. All associated publications are available for download below:
Public stewardship of private providers in mixed health systems: Synthesis report
Results for Development (R4D)
Drawing extensively on the findings of a 2008 review sponsored by the Rockefeller Foundation and on the vast other literature on the private health sector and health systems, this report by authors from the Results for Development Institute and the Rockefeller Foundation, outlines the large and complex private markets for healthcare and emphasizes the importance of effective stewardship by governments of their country’s health system, especially given the reality that the private (non-state) part of the system is large and complex, with major challenges and significant opportunities.
Innovative Pro-Poor Healthcare Financing and Delivery Models
Results for Development (R4D)
The report describes 33 innovative pro-poor healthcare financing and delivery programs in South Asia and Sub-Saharan Africa that are led by or engage the private heath sector. The programs were selected based on their relevance to broader health systems and potential to achieve positive impact for poor people. While these programs range from donor-driven initiatives to large-scale government-subsidized efforts to for-profit businesses, they all involve the private health sector. These programs complement key elements of countries’ healthcare financing and delivery platforms, and national governments, donors, and development agencies may consider these or similar programs as stepping stones toward longer term health system reform.
Overcoming the Challenges of Scaling Voluntary Risk Pools in Low-Income Settings
Results for Development (R4D)
The report discusses the challenges of introducing and scaling smaller, voluntary riskpooling programs in an attempt to constructively consider how to overcome these challenges. It presents six major hurdles that risk-pooling programs are faced with and highlights various mechanisms that program implementers are currently experimenting with to overcome them. It concludes with lessons from successful cases of small programs being scaled up to the national level.
Private-public mix in woman and child health in low-income countries: an analysis of demographic and health surveys
International Health Policy Program, Thailand
The paper presents a comparative analysis of the two most recent waves of Demographic and Health Survey data, with a focus on private provision of care to women in reproductive ages and children. Overall findings reveal a wide variation in the role of informal private, formal private, and public sector actors.
Private Sector Role in Health Supply Chains: Review of the Role and Potential for Private Sector Engagement in Developing Country Health Supply Chains
Dalberg and MIT-Zaragoza
The report sets a baseline understanding of healthcare supply chains and characterizes the current private sector role in supply chains in lower middle income countries. It is informed by in-depth case studies of Ghana and Zambia, as well as interviews of over 40 supply chain and health experts in 12 countries about private sector initiatives in those countries. The major findings characterize supply chains, analyze the potential to invest in private sector initiatives, and make recommendations for key stakeholders.
Provider Purchasing and Contracting for Health Services: The Case of Zambia
University of Zambia
The study identifies and characterizes a number of contracting models that exist in the Zambian health sector and their impact on access to health. It reveals that the contracting mechanism is prevalent in Zambia, as evidenced by several contracting-in examples (such as different levels of the referral system within the public health sector contracting each other for services) and contracting out arrangements (such as FBOs and NGOs providing care on behalf of the government). It finds that the impact of these programs on the quality of services has remained mixed.
Provider Purchasing and Contracting Mechanisms Institute
The paper reviews various purchasing models and the advantages each offers for purchasing from the private sector. It then identifies the key challenges to successful implementation of these models, and discusses improvements needed in the contracting mechanism itself. It determines that the purchasing mechanism can create new incentives for providers, payers, and consumers on a national scale, but it may require that changes be made in the health sector as a whole for new programs to be successful.
Performance Incentives in Provider Purchasing and Contracting Arrangements: Rationale and Experiences
Center for Global Development & University of California, Berkeley
The paper describes performance-based incentive contracting schemes that have been implemented to improve results for a range of interventions from time-limited immunizations to chronic conditions that require significant lifestyle changes, such as diabetes. It finds that limited interventions with results or actions that can be measured and that require minimal changes in lifestyle seem to be well suited for performance-based incentives. It argues that performance incentives are a viable and potentially more powerful solution than typical inputoriented approaches to dealing with underutilization, poor quality, and low efficiency.
Health Sector Governance and Implications for the Private Sector
London School of Hygiene and Tropical Medicine
The paper develops an analytical framework applied to India, Uganda, and Afghanistan— for conceptualizing the governance/stewardship function within health systems and the role of government in the context of an expanded role for private service provision and financing. The paper begins by reviewing the approaches to conceptualizing and operationalizing stewardship, drawing on recent literature, and then explores typologies of governance, with a focus on working models of engagement and collaboration between major public and private sector actors in achieving public health goals.
Regulation of Health Service Delivery in the Private Sector: Challenges and Opportunities International Health Policy Program, Thailand
Based on reviews of international peer-review papers and an analysis of Demographic and Health Surveys (DHS), this paper seeks to better understand the role of the private health sector in low-income and lower middle-income countries and its relationship with governments' capacity to regulate and to act as stewards pf the health system. The findings from a global, self-administered, questionnaire survey in 15 LIC and 15 MIC-L reveal wide variations in political, administrative, and information constraints; policy concerns and priorities; and institutional capacities in health systems regulation.
Andhra Pradesh Health Sector Reform: A Narrative Case Study
Access Health Initiative
The State of Andhra Pradesh in India has recently taken several innovative approaches to improve access to healthcare. This report presents the major initiatives, including health insurance and contracting arrangements for health services, and describes underlying motives, challenges, and opportunities associated with the reform.
Innovative Health Service Delivery Models for Low and Middle Income Countries
University of Toronto
The report reviewed the literature on a number of innovative service delivery models, isolating business processes that could be applied more broadly, including marketing strategies (communications, customer orientation, franchising), financing strategies (reduced operating costs, high volume/low cost, cross-subsidization, capital funding, revenue generation), and operating strategies (human resource management, knowledge-development, telemedicine). The authors find that successful organizations tend to innovate across several of these business processes.
Making Health Markets Work for the Poor: Improving Provider Performance
Institute of Development Studies (IDS)
The paper develops a framework for designing and implementing healthcare delivery innovations aimed at making markets work better for poor people. Focusing on the social contract between providers and users, it reviews several arrangements that have emerged, with a particular focus on the providers largely used by the poor.
Toward a New Paradigm for Health Sector Development
Brookings Institution, Amsterdam Institute for International Development
The paper seeks to explain the very large differences in per capita spending on healthcare across countries and determines that almost all (more than 90%) of these differences can be explained by variation in per capita income (gross national product). It looks at potential mechanisms to increase healthcare spending to above the level predicted by per capita income and investigates whether a larger public share of overall spending “buys” better health outcomes.
The role of the private sector in health: a landscape analysis of global players’ attitudes toward the private sector in health systems and policy levers that influence these attitudes
PATH and Harvard School of Public Health
Employing qualitative and quantitative research methodologies, the report assesses the attitudes of global and national stakeholders toward the private health sector in developing countries.