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1 Jeffrey L. Moe, Ph.D. Director, Private Sector Task Force Executive in Residence and Adjunct Associate Professor, Fuqua School of Business, Duke University

2 Disclaimer & Limitations Views expressed are those of the authors Jeffrey Moe, Caroline Hope Griffith and Michael Merson; not necessarily those of the Global Health Workforce Alliance Report limited self-report data v. objective (independently verified) descriptive v. normative or prescriptive health workforce innovation is also occurring in the public sector report focused only on private sector activity

3 IN HEALTH, THE PRIVATE SECTOR PLAYS A SIGNIFICANT ROLE IN LOW INCOME MARKETS Public E.G. SUB-SAHARAN AFRICA Private Health care expenditure by financing agent Percent $16.7B 100% Health care expenditure by provider ownership Percent* $16.7B 100% Public ~40 Public ~50 For-profit ~65 Out-ofpocket Other private Private prepaid ~50 ~5 ~5 Private ~50 Social enterprise Nonprofit Traditional healer ~15 ~10 ~10 Financing agent Providers Private sector providers When measured on a usage basis: Private sector providers likely comprise larger share of market due to under-reporting of non-profit and informal segments Social enterprises, non-profit and informal segments comprise larger share of private sector due to smaller user fees and under-reporting Source: IFC 2008 *52% of expenditure is on private providers when extrapolated for SSA (excluding South Africa) from most recent year available between from NHA reports for Ethiopia, Kenya, Malawi, Namibia, Nigeria, Rwanda, Tanzania, Uganda, Zambia, Zimbabwe; 41% when other sources for an additional 13 countries are included (at average exchange rate) Source: NHA, MoH, WHR 2006, team analysis 3

4 Private Health Sector Context Low Income Countries Private = non-government (NGO), faith-based (FBO), not for profit, for-profit; all non-state Blurry lines between public and private health resources Mistrust Government often describes private health sector as 1) providing services targeting the middle class; 2) provides low quality, unregulated services which exploit the poor Private sector has accused government of 1) under-investment in HC, 2) investment in broken systems, 3) malfeasance and/or corruption Private health sector growth is potentiated AND constrained by its enabling environment Legal, business, policy, HC market, technology, civil society = enabling environment Weak institutional frameworks impede private health sector growth HC innovators often lack business acumen, management expertise Aid programs can create a donor mentality ; reduce search for sustainability

5 Health workforce innovators: workforce innovation is often a by-product of mission Supply Increase effectiveness and efficiency Health Workforce Increase retention Innovator s Primary Mission Enabling Environment or Innovation Eco-system

6 31 Health Workforce Innovators (identified in 2008; MANY others not included in this report) Increase Supply Increase Efficiency and Effectiveness of Existing Workers Increase Retention Rural Technology Business Incubator First Care Health Enterprise, Medical Knowledge Institute (MKI), African Medical Research Foundation (AMREF_ - Maridi), Touch Foundation, Healthstore Foundation/CFWShops, Accredited Drug Dispensing Outlets (ADDOs), Health Careers of America, Aga Khan School of Nursing, AMREF E- Learning Program - Kenya. Tulane University Technical Assistance Program Ethiopia, HIV/AIDS Coordination, Human Resources, and Health Systems Zambia, The Council for Health Service Accreditation of Southern Africa (COHSASA), Bidan Delima Quality Recognition of Private-Sector Midwives, RAISE Service Delivery Training Centers, MSH Technical Assistance to COMBASE, Karuna Trust, FriendlyCare Foundation, Inc., Rwanda: Community Health Insurance Plan (CBHI), Hygeia, Janani, The AIDS Support Organization (TASO) - Uganda Uganda Private Midwives Association, JHPIEGO, JTA International, JHPIEGO Ethiopia, BD Global Health Department, Health Careers of America (HCOA), Rwanda: Performance Based Financing, SDSH (Santé pour le Développement et la Stabilité d'haiti Pwojè Djanm) (MSH), Inter- Religious Council of Uganda, Abt Associates-led Private Sector Partnerships (PSP-One) Ethiopia

7 Private Sector Task Force action research with 3 of the innovators Nurse distance Learning in Kenya replications in Uganda and 2 new countries - active engagement re: replication challenges Placed 200 bush doctors 1 st Dr. placed epidemiological baseline of Sikasso region Replication of ADDO rural pharmacy program in Tanzania - subsidized initial training for shop owners

8 Enabling Environment for Health Workforce Innovators Health Workforce Innovators Business & Capital Civil Society Technology Education & Training Local Ownership Professional Health Worker Advocacy Organizations Political will Government

9 Health Workforce Incubators: Stimulate private health sector markets for ideas, talent and capital Innovator/Needs Matching What are local health needs? Which local initiatives can be scaled or global models replicated? <label> Match Funders to Plans Foundation, government, individual, private equity and banks fund plans they choose Baselines set which allow assessments of health outcomes, quality, access HWI Health Workforce Incubators <label> <label> NOTE: Incubator = event, process or location Leadership, Knowledge, Skills and Abilities (KSA) Gaps ID local and international talent to lead Training to close KSA gaps & build business plans

10 Private Health Sector and HRH Crisis: Recommendations Promote public/private dialogue Advocate whole market approach with active and coordinated private & public roles in HRH responses Country Coord. & Facilitation Public Private Partnerships Develop enabling environment Amplify patient perspective and overhaul regulation to balance patient safety with innovation Bring patient voice into regulation of professionals Patients supported to make informed decisions Build right-touch regulation Curate global health workforce innovations e.g. Center for Health Market Innovations, International Partnership for Innovative HC Delivery Leverage productivity through use of technology Base staffing models around telemedicine Assume and telephone consultations Match training and staffing to actual systems of care Train for care outside hospitals, clinical leadership, continuous improvement, research Increase vocational training and apprenticeships for specific processes within care pathway Increase evidence, accountability, training and access to funding Funders support or require independent evidence gathering Private sector: internal accountability Incubators: scale local activities OR replicate global innovation, training for innovator managers, funding

11 Thank you