Encouraging Ministries of Health to look at total health sector
Question:
Ministries of Health usually focus their efforts in health data and services on the poor. This is partly due to donors' policies in considering only the government as their partner in public health services. How could donors best encourage Ministries to look at the full spectrum of clients for public health issues?Answers
Rita's question is about donors, but I think this is too narrow, and begs a bigger question about what drives the plans and strategies of Ministries of Health.
After all, the large-scale contracting of private doctors to deliver safe motherhood to the poor in Gujarat has not involved any donors.
It is a brave MOH official who can tell his service-delivery colleagues 'I know you do not have enough medicines and I know a third of nursing posts are vacant and I know your clinics need refurbishment, but since only 30% of the population come to MOH facilities, our new plan recommends spending scarce government money on contracting private clinics...'.
On a long day-time flight in July I read right through the most recent health sector plans of two African countries, and gave each paragraph a score as to how well or badly it dealt with the reality of the private health market. They got an A if they fully incorporated this reality; B if they acknowledged it; C if they at least referred to it; and a D if they ignored it. (For one plan I also created a special grade of E for 'wilful denial' but that is not for sharing in polite company!).
The results were not very 'scientific' but they did show sharp differences between the two countries' plans - and there was no obvious reason for this (e.g. it was not that one country had had European consultants with their usual pro-government bias, and one had had consultants from PSP!).
With colleagues here at HLSP I am now doing a more systematic review of the plans of a bigger sample of countries. We have identified 13 topics (for example 'health-seeking behaviour', 'quality of drugs' etc) which we have grouped under 3 headings - demand, supply, and stewardship. For each topic we will record whether and how comprehensively the private market is addressed; whether any data is presented or analysed; and how far (if at all) the strategies proposed include the private market.
We aim to produce an initial briefing paper before March, and will circulate it widely.
Bruce Mackay
www.hlsp.org
Answers
In my opinion, donors should work jointly with the private/NGO sector prior to approach Ministries. An essential preparatory task is to gather and produce hard evidence coming from research that proves the importance of the private sector to meet public health goals. The next step is to engage in a policy dialogue process that could lead to some policy decisions or prompt the need for more research. This dialogue can also induce the need to explore public policy options, like the use of private-provider networks and health franchises. Policy dialogue among donors, private providers, and Ministries about these options could be initiated even though the existing evidence base on franchises is limited and characterized as being at a proof-of-concept stage.
Answers
Dear Dr. Leavell
You ask a provocative question. You assume that donors already acknowledge and agree that the private health sector has a positive role and contribution in addressing public health objectives such as delivering basic health services to a wide range of clients, including the poor. Many donors continue to concentrate their technical assistance and funds almost exclusively in support of the public and NGO sectors. So a first step would be to inform and educate the international community about the wide range of clients - including the poor - who access and use the private health sector for their health needs. Secondly, we need a paradigm shift in how we view the health systems and the health sector towards a whole market approach that recognizes the range of actors –public, NGO and private – who all work on different aspects of public health so that those of us who work in the international health field do not continue to focus our research and technical assistance on the Ministries of Health and NGOs only. Finally, we need to dedicate more resources to better understand what the private health sector is doing to address public health issues - both the good and bad - so we can offer Ministries of Health the evidence they need to be persuaded to work with the full spectrum of providers.
