A Comparative Analysis of Health Markets and Private For Profit, Pro-Poor Interventions in East Africa

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1 A Comparative Analysis of Health Markets and Private For-Profit, Pr A Comparative Analysis of Health Markets and Private For Profit, Pro-Poor Interventions in East Africa Salome Wawire

2 Presentation Outline Objectives of the Study Program Background M4P approach Selection of comparative health markets Methodology Key lessons Conclusions and Lessons Learned

3 Objectives Comparing health markets in six countries of East Africa Ethiopia, Kenya, Rwanda, Somalia, Tanzania, and Uganda Comparison in terms of; macroeconomics, health financing, insurance, and supply and demand for private sector healthcare services Identifying and comparing past and current private sector, pro-poor market interventions Identifying health markets with great potential for M4P interventions Sharing experiences and lessons of PSP4H and other programs on how to work with the private sector in health using a market based approach.

4 Program Background The Private Sector Innovation Programme for Health (PSP4H) is a DFIDfunded two year research project Implemented by Cardno Emerging Markets and consortium partners. DFID/Kenya is exploring a new approach to development assistance in health. The project utilizes a market systems approach to strengthen the for-profit health sector s capacity to reach the working poor and ensure they get better value for money spent in the private health sector.

5 What is M4P? M4P is an approach to analyse the participation of the poor in market systems and to offer guidance on how to influence markets so they benefit the poor. What distinguishes the M4P framework from others is the combination of analysis with action. Facilitative Many players in M4P in health Government Sector Informal Networks Not-for-Profit Sector Infrastructure Coordination Regulations Supporting Functions Standards Informing and Communicating Standards Setting and Enforcing Rules Informal Rules and Norms Representative Bodies Laws Membership Organizations Private Sector

6 Portfolio approach Many interventions across different health markets Emphasis on the results of the whole portfolio and less on particular interventions Iterative and continuous Lessons learned from success as well as failure Key Findings of Portfolio Approach It is adaptable in programming, allowing PSP4H to shut down unsuccessful interventions or to further invest in promising ones It is flexible in budgeting, permitting PSP4H to allocate its budget according to the size and scope of each intervention and therefore manage to the bottom line of the total portfolio Fosters innovation, permitting PSP4H to take risks and experiment in new health markets with different PFP actors and new approaches while at the same time, investing in proven approaches to scale.

7 Designing an intervention

8 Selection of comparative health markets Level of Macro-Economic Development Examining gross domestic product (GDP) Poverty profile Urbanization rates GDP, combined with percent living in poverty, provides a general sense of a country s overall wealth and size of the population with the ability to purchase health services in the private sector (Source: World Bank) Country Health % of GDP Public/ Private Mix of THE % THE that is OOP % THE from external sources Hospital beds per 1000 pop. Ethiopia / (2011) Kenya / (2010) Uganda / (2010) Rwanda / No data Somalia No data No data No data No data No data Tanzania / (2010)

9 Selection. Private Sector Contribution Number and type of private health facilities levels (infrastructure) Number and type of private health professionals (HRH) Total dollar amount spent in the health sector and or drugs purchased (Source: Various, including PSAs) Country % PFP Sector % Private HRH Infrastructure A Ethiopia 49% 55% GPs (PFP only) Kenya 48% 74% MDs (PFP only) Uganda 7% 58% of all HRH (PFP & PNFP) Rwanda 45% No data Somalia No data No data Tanzania 27.4% No data

10 Selection. Health Insurance Insurance, whether public, private or mixed, is an important driver of growth for the PFP health sector (Source, Economic Intelligence Unit, 2013) Public health insurance expenditure as % of THE, 2012 (%) Availability of Public health insurance (e.g. NHIF in Kenya) Total insurance penetration (Premiums as % of GDP), 2012 Ethiopia 48% Social health insurance and community based health insurance 0.50% Kenya 38% National Hospital Insurance Fund 3.20% (NHIF) Rwanda 57% Community Based Health Insurance 0.90% Tanzania 39% National Health Insurance Fund 0.90% Uganda 24% National Health Insurance Fund 0.70% Somalia N/A N/A N/A

11 Selection. Demand for Private Health Services Measuring demand side participation through consumers health-seeking behaviour (Sources: DHS for the specific countries) Country Public/Private Family planning 1 Public/Private Maternal Delivery 1 Public/Private Malaria A,2 Ethiopia 82.0/14.7 (PFP only) 8.7/ /46.6 (MIS) Kenya 57.3/39.2 (PFP only) 32.3/ /42.5 (MIS) Uganda 46.6/45.4 (excludes FBO/NGO) 44.0/ /47.3 (ACTw) Rwanda 92.0/ / /15.7 (MIS) Somalia No data No data No data Tanzania 65.2/26.4 (PFP only) 41.0/ /30.0 (PSA)

12 Selection. Based on the above selection criteria, the study selected Uganda and Tanzania as comparator health markets to Kenya in terms of readiness for M4P approach

13 Method For the three comparison countries selected: Literature review peer review journals, grey literature (reports) Key Informant Interviews with people in selected countries Four projects similar to PSP4H market interventions selected as below: Market Market Intervention PSP4H Other examples Drug Retail PHARMNET Network Tanzania - Accredited Drug Dispensing Outlets (ADDOs) Network Pooled Procurement Tunza Family Health Network Kenya - Kenya Association of Physician (TB) Low-cost, high quality maternal service Low-cost, high quality maternal service Private Community Midwives Network (PCMN) (Bungoma County) Jacaranda Health (Maternal, Newborn and Child Health market research and strategic marketing planning) Tanzania - PRINMAT Network of Nurse Midwives (no comparator) Micro-insurance for health Jawabu Uganda - Microcare

14 Key Lesson: Intervene with established health providers and institutions Cases: ADDO case in Tanzania and Pharmnet (PSP4H) case in Kenya Similarities : i) target drugs shops and/or pharmacies located in poor communities, ii) bring them under a common name or brand, iii) work with a lower-level pharmacy health cadre, iv) provide clinical and business training, and v) offer supportive supervision and continuous professional development. Differences ADDO uses informal providers and trains them while Pharmnet uses Pharm Techs Management: Pharmnet uses existing structures at KPA and Nairobi Pharm Tech to run a sustainable business model ADDO dependent on donor funds, and management transferred to Tanzania regulatory body Lesson: 1. Working with recognized formal providers has created savings in time and costs 2. Working with recognized formal institutions enhances programme sustainability

15 Key Lesson: A market intervention has to be easy or else it will not be adopted Cases: Kenya Association for the Prevention of Tuberculosis and Lung Disease (KAPTLD) and the Tunza Family Health Network of providers Similarities: Providing access to quality products Pooled procurement Differences Pooled procurement simplified for KAPTLD Pooled procurement deemed complicated for Tunza providers. Only 22% participate in the MEDS pooled procurement model Lesson: Simplified processes are easier to implement and easier to to be adopted

16 Key Lesson: Plan early for network management to be financially sustainable Cases: The Tunza Network, KAPTLD, Pharmnet (Kenya) and The Private Nurses and Midwives Association Tanzania (PRINMAT), Tanzania Similarities: Network Certain benefits to members Differences: Organized system of management ensuring sustainability and scale up for Pharmnet and KAPTLD and unsure model of sustainability for Tunza and PRINMAT Lessons: Managing provider networks, whether it is a chain of retail pharmacies or a group of private providers, is a complex task requiring a formal organizational structure. This needs to be part of the framework from the initial stages of the program

17 Key Lesson: A successful business model is as important as a high-quality service Case: Jacaranda Health (Kenya) Providing a comprehensive set of maternal and newborn child services supporting non-complicated deliveries at a secondary level facility Referral of complicated pregnancies to a tertiary hospital Innovations to keep costs low and affordable include: clinical task-shifting, standardization of operating procedures, and focus on cost-effectiveness Yet: There is low uptake of services and the facility is unable to convert its prenatal maternal health services into facility deliveries Lessons: Although the clinical delivery model is sound, the business model requires significant improvements. PSP4H is working with Jacaranda to address business side of operations

18 Key Lesson: Market interventions with potential scale may require more time and several attempts Cases: Afya Poa (PSP4H) and Microcare (Uganda) Similarities: Leveraging community groups and and microfinance (MFI) institutions Inpatient and outpatient insurance outpatient through Medical Savings Accounts (MSAs) Difficulties in engaging partners Underwriter for Afya Poa; MFIs for Microcare Spent long periods of time nurturing partnerships Differences: Afya Poa eventually got an underwriter and the project is ongoing Microcare closed down, albeit due to solvency issues Lesson: Time, patience and relationship management is required for success of interventions with potential scale

19 Conclusions and recommendations The goal of this report is to share lessons learned on how to work with the private sector in health using a market based approach. M4P approach works to analyse and shape health markets but with important differences between sectors, health markets Implementing M4P differs from traditional donor programming facilitative PSP4H has developed analytical approaches that can jumpstart future M4P programmes scan of private sector, consumer profiling, health seeking behaviour Using a portfolio approach helps minimize risk when facilitating change in health markets Adaptability, flexibility, innovation Field-based learning can guide design and implementation of market interventions PFPs serving the poor may have to partner with the government to achieve scale Consider Tanzania and Uganda as target countries for expansion of M4P in Health in the region

20 Thank You!

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