Analysing relationship between the state and non-state health care providers, with special reference to Asia and the Pacific (WP10)

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KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacic

The Nossal Institute

for Global Health

www.ni.unimelb.edu.au

HEALTH POLICY AND HEALTH FINANCEKNOWLEDGE HUB

WORKING PAPER SERIES NUMBER 10 | MARCH 2011

Analysing relationship betweenthe state and non-state health careproviders, with special reerence to

Asia and the Pacifc

Shakil AhmedNossal Institute or Global Health, University o Melbourne

Abby BloomMenzies Centre or Health Policy, University o Sydney

Rohan SweeneyNossal Institute or Global Health, University o Melbourne


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WORKING PAPER SERIES HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB

Analysing relationships between the state and non-state health care providers, NUMBER 10 | MARCH 2011with special reerence to Asia and the Pacic

ABOUT THIS SERIESThis Working Paper is produced by the Nossal Institute or Global Health at the University o Melbourne,Australia.

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Analysing relationship between the state and non-state health care providers, with special reerence

to Asia and the Pacifc

First drat March 2011Corresponding author: Shakil Ahmed

Address: Nossal Institute or Global Health, University o Melbourne

[email protected]

Other contributors: Abby Bloom, Menzies Centre or Health Policy and Rohan Sweeney, Nossal Institute or

Global Health, University o Melbourne

This Working Paper represents the views o its author/s and does not represent any ocial position o theUniversity o Melbourne, AusAID or the Australian Government.


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HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB WORKING PAPER SERIES

NUMBER 10 | MARCH 2011 Analysing relationships between the state and non-state health care providers,with special reerence to Asia and the Pacic

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SUMMARYThis paper examines rameworks, typologies and taxonomies in current use or analysing the relationshipsbetween the state and non-state (private sector) providers o health care. The paper was commissioned

as background or a project aimed at assisting selected countries in Asia and the Pacic to assess and planmore eectively the role o the private sector in health care. The paper, originally conceived as a review o theliterature, was developed urther. It contains two parts: the rst presents the methods and ndings o a review o

the literature, and considers existing taxonomies and rameworks. The second proposes a series o rameworks

developed by the authors to assess more comprehensively and plan the respective roles o the state and non-state providers.

The review was guided by the ollowing questions:

1. What types o private/non-state providers are engaged in the health sector?

2. What roles do they play? What services do they provide?

3. What are the dening elements o each relationship between the state and non-state providers, and howcan the relationships be analysed?

4. What dierent rameworks have been applied to assessing the relationships between public and private(state and non-state actors) in health care?

5. Which ramework is the most useul or country-level policy research on the role o non-state providers?

BACKGROUNDThis paper was commissioned to inorm researchers preparing to undertake long-term studies o the role and

relationships between the state and non-state providers in the Asia-Pacic region. Beore commencing in-depth

projects in several countries, it was considered valuable to review how prior research had conceptualised anddened the relationships between state and non-state providers (NSPs).

NSPs include large and small commercial companies, groups o proessionals such as doctors, nurses,

midwives, pharmacists, national and international non-government organisations (NGOs) and other individualproviders, commonly including shopkeepers. Unortunately, as explained in the paper, this straightorward

denition does not capture either the complexity or ambiguity o non-state providers in practice.

In recent years increasing attention has been paid to the respective roles and impacts on health outcomes,

cost and eciency o health service delivery and equity o publicly owned and unded health care provision onthe one hand and that o the private sector on the other. Much o this research indicates that, while the role and

unction o NSPs vary substantially rom country to country, and even within a single country, and depending

on the disease, NSPs typically play a signicant role in health care. In the case o some common healthproblemssuch as diarrhoea80% o cases sought treatment rom non-state providers (Bennett, Hanson et

al 2005). As our main interest is countries in Asia and the Pacic, examples rom this region have been selected

wherever possible.


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METHODOLOGYThe review adopted standard methods or literature reviews. The scope o the review and the issues coveredwere subject to the availability o relevant literature. The review included peer-reviewed, published and grey

literature (unpublished reports and other documents).

RESULTSThe review encountered an important limitation amiliar to scholars in the eld: despite the act that in most

low-income countries the non-ormal private sector accounts or hal or more o all health care (NationalDemographic and Health Survey 2003), there is a dearth o systematic and comprehensive inormation on

the non-ormal sector. Consequently, the research looked only at ormal non-state providers and the ormal

engagement o non-state providers in the health sector, and not at inormal NSPs.

The review considered typologies and models o NSP-state relationships with global application. The our main

types o NSPs identied are:

1. ormal or prot2. inormal or prot

3. ormal not or prot

4. inormal not or prot.

There is a scarcity o material on, and analysis o, rameworks used to examine the relationship between the

state and non-state providers o health care, especially in Asia and the Pacic, even taking into consideration

the grey literature. In particular, inormation on providers and services in the important category o inormalor-prot providers is scant and tends to be ound in the grey literature in studies o health-seeking behaviour,

including the anthropological literature.

Nevertheless, the authors did nd some relevant rameworks, although none was adequate or the breadth o

state-NSP relationships uncovered.


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CONCLUSIONS AND RECOMMENDATIONSAmong the available rameworks, the most useul is the classication put orward by Waters, Hatt et al (2003)and Peters, Mirchandani et al (2004). However, these rameworks, which drew on experience mainly in

reproductive health projects, can be useully expanded by incorporating experience rom the health sectormore broadly dened. We have sought to do this, and in doing so have generated what we believe to be a morecomprehensive and useul strategic ramework.

Our recommended ramework, like that o Waters, Hatt et al (2003) and Peters, Mirchandani et al (2004),

is pragmatically based and aimed at decision makers responsible or appraising and implementing theseinitiatives. Comment and discussion on our proposed ramework is encouraged.

A comprehensive ramework should enable users to:

1. determine the desired health, economic, political and other outcomes resulting rom a relationship with non-

state providers;

2. dene relationships that are likely to produce those outcomes;

3. assess the states capacity to meet the undamental requirements to engage benecially with non-stateproviders (e.g. regulatory, procedural, contractual, legal) and identiy the steps needed so that the state can

eectively manage each type o relationship; and

4. provide a structure or cross-country comparisons.

Our proposed ramework is an initial step or analysing both existing and new relationships between the stateand non-state providers, and answering these undamental questions. Future work will be required to answer

all o these basic questions, especially on the capacity o states to manage dierent relationships. These must

ultimately be done on a case-by-case basis.


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INTRODUCTIONIn recent years, much research has ocused on the role and impact o the state and non-state health careproviders (Bloom, Champion et al 2009; Balabanova, Oliveira-Cruz et al 2008). In many low and middle income

countries, NSPs provide hal or more o all health care services. For some common health problems, includingdiarrhoea, NSPs can even be the sole provider (Aljunid 1995).

Poorer people, in particular, are more likely to seek health care rom inormal or-prot providers, both or-

prot physicians and hospitals providing modern care (Berman and Hanson 1993). In a study conducted in

Indonesia o children aged less than ve years who used services or an episode o illness (n=2478), 44.5% oamilies used ormal NSPs and 16.8% used inormal NSPs (Thind 2005). NSPs account or care sought in 60%

o all illness episodes and 60% o all health care expenditure in Vietnam. A sizeable proportion o patients rom

low and moderate income groups attend private clinics in Papua New Guinea (Mulou 1992). The most common

reason or choosing a private clinic was that treatment was easier and aster rom private providers.

NSPs were the major sources o primary health care in Bangladesh, India and Pakistan. In Bangladesh, 88%

o households that sought health care went to NSPs (CIET 2003). The village doctor provided care to 43%

o households seeking care. The greater part o health care in rural areas o Bangladesh is inormal or prot(Claquin 1981; FHS Research Brie 2008). NSPs provided 79% o all outpatient care or those below the poverty

line in India during 1995-96 (Peters, Yazbeck et al 2002).

Protecting health and well-being, and ensuring sae and eective health care, are part o the stewardshiprole o the state (Lagomarsino, Nachuk et al 2009). The states stewardship role, some maintain, does not

necessarily require it to own or provideor even completely nancehealth services, but to ensure that its

health and equity goals and objectives are achieved (Lagomarsino, Nachuk et al 2009).. Within this paradigm,

NSPs are seen to have potential to contribute to the states health and health care objectives, and are lookedupon as potentially useul complements o or adjuncts to state owned, nanced and operated health care

services (Bennett, McPake et al 1997).

Given the extent o non-state involvement in health services in many settings, there is now a heightened

interest in assessing the relationships between the state and non-state providers (Lagomarsino, Nachuk et al2009; International Finance Corporation 2008). States and policy analysts have recently ocused on identiying

mechanisms that improve the means to achieve health care objectives. A major ocus is on harnessing orleveraging NSPs, including both or prot and not or prot (Bennett, McPake et al 1997; Mills, Brugha et al

2002).

The relationships between the state and non-state providers have been analysed in dozens o countries, andregions within countries have been compared. However, there are ew comparative studies involving more than

two countries or states. For this complex task, a clear ramework is essential.

This paper examines typologies/taxonomies and rameworks currently used, rst to understand the roles o

non-state providers o health care and secondly to analyse the relationships between the government (thestate) and non-state providers (the private sector and civil society) in relation to health care services.

The ramework, typologies and taxonomies used to describe and categorise the relationships between

the state and NSPs are important or several reasons. At a undamental level, Willis, Daly et al (2007) note,Theories provide structured interpretations or models or investigating and understanding a problem. The

authors explain the infuence o underlying theories as ollows:

Theory provides a ramework or structuring a study and plays a central role in data collection and analysis.This use o theory in a study provides the essential link to the theoretical literature and, in turn, this allows

researchers to assess the extent to which the results can be extended to other settings and contexts.

Frameworks and typologies help organise the natural world. In the analysis o the relationship between thestate and non-state providers o health care, rameworks and typologies assist policy makers and program

designers to understand better the current situation and to design a more eective uture system. Frameworks

are useul in uncovering the logicor lack o itin both the analysis o health care systems and their redesign.


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It is important to keep in mind that rameworks, their implicit assumptions and their categories all undamentally

infuence and guide the users interpretation o real-world phenomena. As Willis, Daly et al (2007) highlight,

rameworks are likely to infuence the importance a researcher places on some data relative to other data,and the extrapolation o this data to hypotheses and generalisations. Thus, while rameworks may appear

objective, even explicitly articulated rameworks act subjectively to colour our perception and interpretation o

phenomenain this case, the role and interplay between public and private in health care.

The rameworks, models, typologies and taxonomies we use infuence our interpretation o, and responses

to, health systems. Moreover, the ramework we apply thus aects not only our perception o the relationship

between the state and non-state providers, but also the strategies and actions we use to develop thatrelationship.

The purpose o this paper is to develop urther the theoretical rigour underpinning an understanding o the

relationships between the state and non-state providers, and to assist in the cross-country comparison o

relationships between the state and non-state providers. While noting the potential biases that rameworks canintroduce to an analysis, we believe this descriptive analysis o current ways o understanding and analysing the

roles o and relationships between the state and non-state health care providers is important or policy makers

and researchers. An additional ocus o the literature review and subsequent discussion was the application oidentied rameworks to Asia and the Pacic, where much o the authors work is directed.

DEFINITIONSA ramework is a model used or identiying elements and relationships among the elements that need to

be considered or theory generation; a typology is a system or the study o dividing a group o things into

smaller groups according to the similar qualities they have (Walt, Shiman et al 2008; Ostrom 2007; Longman2009).

For the purpose o this review, we used relationships as a broad term to capture the range o mechanisms by

which the private sector and civil society (non-state) engage with the public sector to und or provide health

care. The private sector includes both or-prot entities, such as corporations, as well as not-or-prot or civilsociety entities, which includes NGOs, a category that has long been involved in the unding and provision o

health care. Civil society is:

the arena o uncoerced collective action around shared interests, purposes and values in practice, the

boundaries between state, civil society, amily and market are oten complex, blurred and negotiated Civil

societies are oten populated by organizations such as registered charities, development non-Governmental

organizations, community groups, womens organizations, aith-based organizations, proessionalassociations, trade unions, sel-help groups, social movements, business associations, coalitions and

advocacy groups (Centre or Civil Society 2004).

State providers describes health care workers and acilities employed, owned and controlled by national,provincial, state or local governments (USAID 2009). Non-state providers are those who work outside the direct

employment, ownership or control o the state (Bennett 1992; Smith 2001). Unortunately, this straightorwarddenition captures neither the complexity nor the ambiguity o actual non-state providers (Ferrinho, Lerbergheet al 2004). In particular, private non-prot unders and providers are in most contexts (a notable exception

being the USA) distinct rom private or-prot unders and providers (Swan and Zwi 1997).

NSPs dier by type o services, legal status, training and institutional organisation. NSPs include individualproviders (doctors, nurses, midwives, quacks) and groups o providers and acilities (clinics, nursing and

maternity homes, hospitals, pharmacies, diagnostic acilities, NGO-run medical clinics). Some non-state

providers do not have ormal training and practice illegally (Bennett 1992). The denition o non-state providers

does not always dierentiate precisely between state and non-state (Berman 1996). For instance, some stateproviders may be considered NSPs when they practise in both state and NSP acilities (dual practice). They

may even practise privately within public sector acilities.


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METHODOLOGYWe used established methods or a literature review (Arksey and OMalley 2005; Glasziou, Irwig et al 2001;WHO 2005). The search strategy used broad search terms (Table 1) in order to identiy literature that presented

rameworks and typologies or describing and assessing relationships between the state and non-stateproviders.

Search StrategyThe literature search was conducted in July 2009. The strategy explored three data sources: electronic

bibliographic databases, an internet search engine and reerence lists o identied papers. Details o the search

strategy are included in the appendices.

Electronic bibliographic databases

Pubmed and Scopus were searched or literature published between July 1989 and June 2009 controlled bymedical subject headings and ree text key terms. The broad key terms are non-state providers or private sector

in combinations with other terms using the Boolean operators AND and OR.

These key terms were also combined with the special types o NSPs (traditional practitioners and healers, drugsellers, pharmacists, traditional birth attendants and indigenous systems medical providers). The complete

search strings used are available in Appendix 1.

Internet search engine

Websites o the dierent organisations, research institutes and research networks were searched using the key

terms in Table 1 to nd technical reports. In addition, a Google general internet search was conducted.

Search o reerence lists

The reerence lists o selected journal articles and technical reports were checked to nd additional articles and

reports or documents particularly relevant to the relationship between the state and non-state providers.

Selection Criteria and Review ProcessTitles, abstracts and executive summaries o the journal articles, technical reports and documents were readater completing the search strategies. Final selection o articles, technical reports and documents was basedon the content criteria below.

Papers and reports were included i their ocus was primarily on the ollowing issues:

1. Types, roles and mechanisms: the types, roles and services o non-state providers elements or mechanisms

o the relationship (regulation, incentives, contracting out, policy dialogue, collaboration, nancing andinormation).

2. Geographic: Asia-Pacic countries; developing countries; low-income countries; middle income countries.

3. Linguistic: English.

4. Publication period: 07/1989 to 06/2009.

Given the nature o the review topic and subsequently the somewhat ethereal quality o rameworks andtypologies identied, we did not exclude papers on the grounds o methodological quality.

Table 1. Key Terms

Non-state providers Public private partnerships Regulation

Private sector* Health seeking behavior Legislation

Non-state relations Utilization Contracting

Health care sector Service provision Incentive

Private providers Delivery o health care Training

Collaboration

* Medical subject headings and ree text


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RESULTSThe search strategy resulted in 471 reerences. Only 66 o these met selection criteria and were chosen ornal review. Few o the 66 discussed the elements o relationship between the state and NSPs. The excluded

reerences described experiences o public-private partnership. Many papers examining the impact o elements(or example evaluating, contracting out) were not included or review. The specic ndings are presentedbelow.

Typology o Non-State ProvidersWhile in most low-income countries the non-ormal private sector accounts or hal or more o all health care

provision (National Demographic and Health Survey 2003), there is a dearth o systematic and comprehensiveinormation on the non-ormal sector. The search strategy was guided by review questions, and consequently

we ound only papers looking at ormal non-state providers or the ormal engagement o non-state providers in

the health sector, and not at inormal NSPs.

Using the commercial orientation and the organisational orm classications, NSPs can be divided into our

types (see Table 2):1. ormal or prot

2. inormal or prot

3. ormal not or prot

4. inormal not or prot.

These our broad types cover the range o individuals and organisations providing allopathic, traditional andindigenous health services through ormal or inormal structures or through voluntary organisations (Bhat

1993). But they may still not capture the diversity o NSPs, especially in low-income countries, where political

and economic actors and the historical eatures o health systems have led to a wide variety o organisationaltypes, or example the dual practice described earlier; dual practice is not always either legal or sanctioned,

although it is perectly legitimate in some countries.

Contributing urther to the blurry lines between state and non-state providers is the act that in some countries,NGOs or privately owned mission health acilities receive subsidies rom both the state and non-state actors,

including international donors. Thus their ownership status is private (not or prot), but their unding is a mix o

private and state unding. Their patients may include both public and private, ee-paying patients.

For all these reasons, precise descriptions and quantication o the extent o non-state provider involvement inhealth services are challenging. Comparisons across countries are dicult because o dierences in nature,

size, participation and types o services. No current model adequately captures the complexity and variations

o public-private ownership, unding and legal regulation (Lagomarsino, Nachuk et al 2009).

Table 2. Types of Non-State Providers Engaged in the Health Sector

Provider Inormal FormalFor prot A wide range o individuals and enterprises

including traditional healers, birth attendants,drug sellers, indigenous systems medicalproviders as well as drug shops and stalls. Theyoperate on a or-prot basis oering mainlycurative services largely in rural and semi-urbanareas.

Small or large hospitals, clinics, diagnostic acilities, pharmacies andqualied individuals providing health services or prot or gain. Theseproviders can earn revenue in excess o their expenses and have widediscretion on how to spend prots.

Not or prot Local unpaid midwie, volunteer village healthworker are only some examples. They operate asvolunteers and do not receive any cash benet.

NGOs, community and aith-based organisations, charities and socialenterprises oering a wide range o health services. Their aim is to achievesocial goals rather than a prot. Some not-or-prot providers have costrecovery strategies while others are heavily dependent upon externaland internal assistance. Still others do make a prot, which they re-investin their activities; they are still not or prot in that their char ter does not

require them to make a prot.Source: Adapted rom Lagomarsino, Nachuk et al (2009),[13] and Oxam International (2009)


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Several authors recommend a more detailed categorisation ramework to capture some o this diversity. Using

a common set o more detailed variables or categorising providers also enables comparison among countries.

The most common set o broad categories was:

A. Commercial orientation: or prot or not-or-prot.B. Therapeutic system: ormal or inormal, modern or traditional/alternative.

C. Financing and taxation: public nancing, private nancing and donor unding.

D. Organisational orm: individual providers to tertiary hospitals. (Green 1987; Berman and Hanson 1993; Belly,

Lonnroth et al 2001; Oxam International 2009)

Illustrative o the literature, Belly, Lonnroth et al (2001) describe these our categories in the ollowing way:

A. Commercial orientation

Commercial orientation is used to distinguish or-prot rom not-or-prot entities (USAID 2005). For-prot

entities include hospitals, individual qualied providers and the large numbers o inormal providers typicallyound in low and middle-income countries (Palmer 2006). They are owned by a clinician or corporation. Not-or-

prot entities can be NGOs (local/national, international), trusts, cooperatives, industry or others.

B. Therapeutic system

Therapeutic systems can be separated into modern or traditional/alternative systems. The modern system

includes:

clinics(individualandnetworks),company-ownedhealthclinics,hospitals;

ancillaryservices(forexamplelaboratories,diagnostics);

doctors,nurses,midwives,paramedicalstaff,pharmacists,chemists,patentmedicinevendors.

The traditional/alternative system includes:

traditionalpractitionersandhealers;

marketdrugsellers;

traditionalbirthattendants; indigenoussystemsmedicalproviders.

C. Financing and taxation status

The nancing and taxation status can be examined under the ollowing sub-groups:

Proportion o nancing by source:

publicnancing

privatenancing(privateinsuranceandout-of-pocketnancing)

fundingbyinternationalsource

Contractual arrangements by type:

publichealthcaresector insurancecompany

otherprivateproviders

Payment mechanisms (clinic and individual sta):

prepayment

capitation

fee-for-service

Taxation: Type and level o taxation o services


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D. Organisational orm

An analysis o organisational orm considers the ollowing practice characteristics and unctions o a

non-state provider:

authorisedorunauthorised(formalorinformal) sizeofcompany/organisation(numberofhealthfacilitiesbytype,turnoveretc)

numberofstaffinclinicbyprofession

proportionofthestaffalsoemployedinpublicsector

xedormobilelocation

openinghours

generalorientation:preventive,generalpractice,specialist

linkedto/memberofprofessionalassociation

inpatientserviceprovidedornot

numberofbeds

drugdispensing:sellingdrugs,yes/no interactionwithpublichealthcareandreferralroutines:establishedformalreferralroutines

gatekeepingfunction.

Systematic Approaches to Assessing the RelationshipSeveral authors encouraged a return to undamental questions about the rationale or engagement with thenon-state sector (or example, Bennett, Dakpallah et al 1994) and have proposed a checklist approach or

appraising the role o non-state providers. This checklist is intended or settings where NSPs are active and

where the state-non-state relationship needs to be ameliorated. While the usage may be complicated byporous boundaries between categories, checklists and matrices are still useul in analysing this complex topic.

Such use is consistent with current trends that ensure that health services are deployed thoroughly, logically

and in a orm consistent with available evidence (Gawande 2009). Table 3 synthesises the work o the papersauthored by Bennett, Dakpallah et al (1994) and Batley (2006).

Table 3. Checklist for Documenting and Appraising the Relationship between the State and

Non-State Providers

Whataretheobjectivesofexistingregulation:dotheyseektolimititemisedfeesforservice,stopexcessprovision,preventpoor

practice or a combination o these?

Isregulationconcernedwithbasicinfrastructurecharacteristics,thetrainingandaccreditationofstaff,ordoesitactuallyconsiderthe

outcome o care?

Whatisthebalancebetweenincentiveoptionsandregulation?

Whoaretheagentsresponsibleforsettingrulesandincentives,monitoringimplementationandenforcingsanctionsifrulesare

transgressed?

Aretheregulatoryapproachesactive,seekingoutlow-qualityproviders,oraretheypassive,awaitingpresentationofcomplaints?

HowfardotheincentivesforcollaborationttheincentivestructuresorsystemsofthestateandNSPs?

HowfardotheorganisationalformsofthecollaborationtwiththearrangementsofthestateandNSPsfordecisionmaking?

Howaredifferencesresolved?Whosearrangementsaredominant?Whatcompromisesemerge?

HowdoestheagendaforcollaborationtwiththeagendasofthestateandNSPs?

Doesthearrangementforcollaborationconformwithorchallengeinterests,goals,ideologiesandidentitiesofthestateandNSPs?

WhatistheinuenceoftheformalandinformaloperationoftherelationshipbetweenthestateandNSPsontheagendasofpublic

action that prevail? Do service characteristics infuence this?

Source: Bennett, Dakpallah et al (1994) and Batley (2006)


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Bennet, Dakpallah et al (1994) and Batley (2006) interpret a relationship primarily in terms o social interaction,

governance, confict management and alignment with state policy. Bloom, Champion et al (2009) also provide

a checklist, which includes health outcomes as an additional indicator. None o the lists include nancial oreconomic indicators o successul relationships.

Mechanisms o Engagement between the State and Non-State ProvidersThe literature search identied papers on types and typologies o mechanismsormal relationships in which

the state engages with other parties, which may or may not be legal or contractual relationships. For example,convening periodic meetings to update non-state providers and communicate or receive comment on the

states public health goals is a mechanism o engagement. Requiring a private hospital provider to allocate a

proportion o beds or non-ee-paying (public) patients is another example.

The International Development Department, University o Birmingham, studied situations in which government

health providers and NSPs entered into relationships or service provision in Bangladesh, India and Pakistan.

The study documented how these three states interacted with non-state providers in policy dialogue,

development o regulatory rameworks and contracting (Palmer 2006). In their model, incentives and training

were categorised under regulation and acilitation because they are intended to regulate quality bysupporting NSPs.

Other researchers examined seven strategic rameworks to assess the eectiveness o NSP-run child health(Waters, Hatt et al 2003) and sexual and reproductive health (Peters, Mirchandani et al 2004) interventions. The

rameworks examined three dierent eatures: market-based, administrative and public-empowerment.

In their review o non-state provision o basic health services, Moran and Batley (2004) described ormso intervention under three headings: regulatory approaches, support approaches and strengthening

accountability. They highlighted the importance o accreditation and legislation to assess the quality and

competence o NSPs, and sel-regulation by proessional bodies to maintain standards under regulatoryapproaches. Support approaches include inormation sharing, vouchers or increasing access, social

marketing or increasing demand, providing training, supplying drugs and equipment, ranchising, nancial

support or credit and contracting.

Balabanova, Oliveira-Cruz et al (2008) identied dialogues, the sharing o inormation and accountability ortheir actions by NSPs, as a means by which NSPs and states engage. The authors also included regulation,

nancing and stewardship as distinct orms o engagement between the state and NSPs. They recommend that

states set minimum standards or quality o health care and enorce it through monitoring and sanctions. Therationale or engagement between the state and non-state actors is reinorced by the act that the state requires

inormation rom NSPs (e.g. utilisation statistics, some process and outcome indicators). The authors maintain

that because non-state providers are responsible or such a signicant proportion o health care delivery in theAsia-Pacic region, states must liaise with NSPs in order to monitor their activities and obtain accurate data on

health sector coverage. The authors go a step urther in relation to nancing, recommending contracting, or

alternatively tax credits, as a means o reducing health care costs.

Taylor (2003) classied state tools or infuencing NSPs in terms o intrusiveness. Tools include: direct provisiono health services, nancing, regulation and dissemination o inormation (less intrusive). Berman and Rose

(1996) broadly categorised state intervention in ve areas: public provision, public nancing, incentives,

regulation and public inormation. Mechanisms included social insurance, infuencing the legal and regulatoryenvironment or private provision, public taxes, subsidies and incentives.

Other authors ocus on very specic mechanisms o service delivery, including social marketing, social

ranchising and vouchers, and on specic interventions such as incentives. Incentives are present in two orms:nancial and non-nancial (A, Busse et al 2003; Kumaranayake 1997).


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Application o Typologies and Frameworks to Countries o theAsia-PacifcThe ull scale and scope o services provided by NSPs in the Asia-Pacic have proven dicult to document

systematically and comprehensively. Reasonable detail is available on some NSP services in Asia-Paciccountries, including amily planning, maternal and child health, childhood illnesses, immunisation, malaria,tuberculosis, sexually transmitted inection, curative care, laboratory and pharmacy services (Berman and Rose

1996; Grover 1996; McCombie 1996; Benjarattanaporn, Lindan et al 1997; Brugha and Zwi 1998; Hanson and

Berman 1998; Auer, Sarol et al 2000; Bhatia and Cleland 2001; Hu-Rousselle and Pickering 2001; Lonnroth,Thuong et al 2001; Stenson, Syhakhang et al 2001; Waters, Hatt et al 2003; Peters, Mirchandani et al 2004;

Newell, Pande et al 2005; Tuan, Dung et al 2005; Paulino, Angeles-Agdeppa et al 2005; Ali, Miyoshi et al 2006).

NSPs are also providing iron-olic acid supplements and maternity services both at home and at xed acilities

(Paulino, Angeles-Agdeppa et al 2005). Good examples o NSPs providing sae motherhood programs andpreventive and curative services or children are available in Indonesia and in other countries (Bustreo, Harding

et al 2003). While inormal or-prot providers in developing countries are known to play a signicant role in

health care provision, the available evidence on their scale is scant and unrepresentative because they are

rarely included in censuses or statistics (Claquin 1981; Aljunid 1995; CIET 2003; FHS Research Brie 2008).While these results provide some insight into the range o research on NSPs in Asia and the Pacic, we ound

no evidence o application o a comprehensive ramework in analysing NSP roles or the relationship betweenthe state and NSPs.

DISCUSSIONThis paper sought to examine typologies/ taxonomies and rameworks currently used, rst, to understand the

roles o non-state providers o health care and secondly to analyse the relationships between the government

and non-state providers in relation to the provision o health care services.

While useul typologies were ound, which helped describe the range o roles o NSPs in health care provision,

there were no such typologies ound that described the role o inormal NSPs, despite it being known that this

group is well represented in service provision, particularly in the Asia-Pacic region.

The literature review revealed a range o rameworks or analysing the relationship between the state and non-

state providers. Some o these overlapped, but they also had many dierent components. This demonstrates

that no one existing ramework encompasses the entire myriad o relationships by which governments currently

engage with NSPs.

As a consequence, the subsequent analysis presents a suggested approach and rameworks or more

comprehensive appraisal o relationships between the state and non-state providers. This ramework is

designed to refect the ull range o relationships identied in the literature review. The rameworks are designedor application to in-country analysis and appraisal o existing relationships. The ramework is presented

in Table 4a, which describes the main strategies and mechanisms used by states and by NSPs, including

the range observed in Asia and the Pacic. It draws on Waters, Hatt et al (2003), Peters, Mirchandani et al(2004) and the authors cumulative research and experience in the region. It also articulates the objectives, or

results, expected rom each strategy. Table 4b presents an application o this comprehensive ramework using

examples rom the region.

We believe that these rameworks are more useul because they incorporate the ull range o mechanisms thatstates can employ, within three main categories: 1. market-based, 2. legal and administrative and 3. public

empowerment strategies and mechanisms. These categories represent what the authors believe are the main

approaches or infuencing the dynamics o the market or health care.

This more comprehensive ramework enables a descriptive analysis o a wide range o relationships between

the state and non-state providers that exist in a wide range o health systems, making it more useul or cross-

country comparisons than other rameworks identied in the literature.


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Table 4a. Non-State Providers Framework: Strategies, Defnitions and Objectives

STRATEGIES DEFINITIONS OBJECTIVES

1. Market-based approaches

1.1 Financing mechanisms

1.1.1 Social insurance Predetermined, equitable levels o undingor provision o stipulated levels o healthcare to dened population. A program whererisks are transerred to and pooled by anorganisation, oten governmental, that islegally required to provide certain benets

Generate predetermined, equitable levels o undingor provision o stipulated level o health care to denedpopulation

1.1.2 Financial incentives Use o nancial instruments, such asgrants, subsidies, tax incentives and in-kindsupport to infuence behaviour o privateproviders (Peters, Mirchandani et al 2004).Also includes manuacturer-based productsubsidies. (Montagu and Bloom 2010)

Stimulate private providers to deliver specic services withpublic health goals to dened population

1.1.3 Contracting Purchasing services rom private providers,and applying benchmarks or the typeso services provided, quality o care,amount o services and/or health outcomes(management, clinical services etc.) (Peters,Mirchandani et al 2004)

Increase range o choice and encourage more ecient andhigher quality services (management, clinical services etc.)(Montagu and Bloom 2010)

1.1.4 Purchasing Buying goods and services or limited time;lower risk and commitment than contracting(Montagu and Bloom 2010)

Increase value or money to public sector in goods andservices by expanding range and increasing eciencythrough competition (Montagu and Bloom 2010)

1.2 Marketing mechanisms Actions aimed at creating in the market new sources osupply and demand or goods and services with publichealth benets

1.2.1 Social marketing Using commercial channels, techniquesand communications approaches to market

products with a public health benet (Peters,Mirchandani et al 2004)

Increase population coverage and eectiveness oproducts with a public health benet: more geographically

comprehensive and potentially more cost-eectivecommercial channels, techniques and communicationsapproaches (Peters, Mirchandani et al 2004)

1.2.2 Social entrepreneurialprograms

Establishment, training and support onetworks o individuals (typically in smallvillages) to provide socially benecial healthservices and products or prot

Substantially increase reach o goods and services with apublic health benet

1.2.3 Social ranchising Using commercial channels, techniquesand communications approaches to marketnetworks o service providers (Peters,Mirchandani et al 2004).

Substantially increase reach o goods and services with apublic health benet

1.3 Organisationalcollaboration

Actions aimed at changing marketconditions to increase private providers

appetite/incentive to cooperate with thepublic sector

Change market conditions to increase par ticipation byprivate providers in programs/initiatives designed to improve

public health

1.3.1 Alliances amongproviders

Establishing and encouraging ormal linksand collaboration among providers

Increase private sector contribution to public health goals bycreating groups with economies o scale or more ecientpublic-private collaboration and more economical units orprivate sector initiatives (or example purchasing).

1.3.2 Coordination/alliances between publicand private

Establishing and encouraging ormal linksand collaboration between public and private

Foster actions by private sector that promote public healthobjectives, including MDGs; increase private sectorparticipation

1.4 Policy dialogue Engaging NSPs in the discussions: mayextend to consultation in developmento legislation, standards, regulatory andacilitation systems (Batley 2006).


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2. Legal/administrative approaches

2.1 Regulation

2.1.1 Accreditation/

certication

Setting and enorcing standards

organisations

Raise standards o care/health outcomes/eciency by

enabling empirical basis or judging quality as well ascomparison across organisations

2.1.2 Licensing Setting and enorcing standardsindividualproviders

Raising standards o individual practitioners by setting andenorcing criteria or practice

2.1.3 Pricing mechanisms Setting, monitoring and enorcing priceso drugs, devices, medical consultations,immunisations, etc.

State monitors and enorces price o essential drugs andmedical technology

2.1.4 Technology regulation Formal state approval and reimbursementstructures, process and enorcement

State controls saety, ecacy and cost o health care byregulating availability/sale o pharmaceuticals and medicaltechnology.

2.1.5 Market regulation Includes anti-monopoly/competition laws,consumer protection mechanisms andenorcement

State protects citizens rom (high) monopoly pricing

2.2 Training

2.2.1 Provider training Educating and supporting private providers(Waters, Hatt et al 2003)

Improving standard o care o private providers (Waters, Hattet al 2003)

3. Public empowerment

3.1 Inormationdissemination

Communicating with and educating thepublic about health-promoting behaviours,health service use and inormation on privateproviders (Peters, Mirchandani et al 2004)

Communication with/educating the public about health-promoting behaviours, health service use and inormation onprivate providers (Peters, Mirchandani et al 2004)

3.2 Par ticipation Establishing ormal opportunities or thepublic to communicate their opinions about.services and service providers.

Provide opportunities or public opinion input

3.3 Formalcommunication/ eedbackroles and channels

The establishment o ormal, paid positionssupervising and ensuring adherence byprivate providers; ombudsman-like positionsin public-private initiatives. Capacity torecommend/impose sanctions.

Create advocacy roles or public interest within new public-private entities


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Table 4b Non-State Providers: Strategic Framework, Examples

STRATEGIES EXAMPLES

1.Market-based

1.1 Financing mechanisms

1.1.1 Social insurance Vietnam: Compulsory Health Insurance Fund (6yrs)+ Health Care Fund or the Poor.

Philippines: PhilHealth, which provides reimbursement to private midwives or sae deliveriesand to private lung specialists or treatment o TB.

Indonesia: Jamkesmas, social insurance or vulnerable groups.

1.1.2 Financial incentives Indonesia: Muhammadiyahexpansion into TB control with GFATM grant; USAID grant toimplement culturally sensitive amily planning programs.

1.1.3 Contracting Bangladesh: Urban Primary Health Care Project and Bangladesh Integrated Nutrition Project.

Cambodia: contracting in primary health care services rom private (NGO) providers.

1.1.4 Purchasing

1.2 Marketing mechanisms

1.2.1 Social marketing Cambodia: social marketing o subsidised malaria medication, diagnostics and nets; socialmarketing o oral rehydration and other basic medications through public and private channels.

1.2.2 Social entrepreneurial programs India: Visionspringvision entrepreneurs to provide aordable eyeglasses to villagers.

1.2.3 Social ranchising Vietnam: Tinh Chi Em Franchise Program (Atlantic: provincial ministr ies o health; CHSs,Atlantic Philanthropies, Marie Stopes Internl).

Pakistan: Green Star ranchises a range o amily planning services. Philippines: BotikangBayan private dispensing o basic pharmaceuticals.

1.3 Organisational collaboration

1.3.1 Alliances among providers India: Universal immunisation program based on alliance between public and private sectors.

1.3.2 Coordination/alliances betweenpublic and private

Bangladesh: National TB control program. State o Bangladesh and BRAC partnership.

1.3.3 Policy dialogue, communication India, Bangladesh: Policy dialogue: Opportunities or ormal dialogue were increased.

2. Legal/Administrative

2.1 Regulation

2.1.1 Accreditation/ certication Malaysia: Hospital accreditation via Malaysian Society or Quality in Health; UNICEFs Baby-Friendly Hospitals program. India, Thailand, South Korea: Accreditation schemes in place.

2.1.2 Licensing Philippines: PhilHealth (national health insurer) licensing o private midwives.

2.1.3 Pricing mechanisms India: National Pharmaceutical Pricing Authority (Ministry o Chemicals and Fertil isers) setsand publishes prices or drugs.

2.1.4 Technology regulation Thailand and other countries o Asia have in recent years adopted pharmaceutical andmedical devices regulations harmonised with those o Australia and the EU.

2.1.5 Market regulation Thailand: A new law (2010) is proposed to compensate victims o medical negligence: all

hospitals nationwide will contribute nancially to a und or victims o malpractice.2.2 Training

2.2.1 Provider training Indonesia: Bidam Delima ProgramIBI, Indonesian Midwives Association, with USAID grant.Updated, evidence-based, clinical midwie training program.

3. Public empowerment

3.1 Inormation dissemination

3.2 Participation

3.3 Formal communication/ eedbackand channels

Indonesia: State-operated health centres contain prominently placed posters alerting patientsto their rights to ree health care, that health sta are not to elicit extra payments and, i they do,the telephone number that patients should call to report these unlawul payments.


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CONCLUSIONS AND RECOMMENDATIONSThis research was undertaken to inorm policy makers and researchers examining the relationships betweenthe state and non-state providers, with special reerence to the Asia-Pacic region. The research was designed

to support in-country studies in Indonesia, Vietnam and Papua New Guinea. The aim o the research was toidentiy preerred rameworks, typologies and denitions or use in individual case studies and to provide acommon ramework and terminology or the research and or comparison amongst the three countries. In

addition, it was intended that the work be more widely applicable.

The research was undertaken at a single time. It conrmed that reliable research into the relationships betweenthe state and non-state providers is limited in both quality and volume. The authors ound no literature relevant

to the study aims that looked at inormal providers, especially inormal or-prot providers.

While the literature did provide a useul approach to categorising types o providers, available rameworks

or analysing and comparing these were o limited use because they did not include the ull range o currentmechanisms. The authors thereore constructed a ramework that provides a simple but more comprehensive

means o analysing and comparing relationships between the state and non-state providers in specic settings

and, the authors believe, should be helpul in comparing dierent settings.

The ramework applies an initial analysis o relationships. However, urther rameworks are required both to

assess the capacity o any specic state organisation to enter into each type o relationship and to appraise the

success o any relationship. These should be the subject o urther work.

It is recommended that the rameworks set out in Table 4a and applied in Table 4b be tested by application

in several countries in the Asia-Pacic. The objective would be to assess the useulness o the rameworks in

describing, analysing and appraising state-NSP relationships.

The results should then be used to revise the rameworks and to inorm the development o additional analytical

rameworks described above. A uture working paper should report on the applicability and useulness o the

ramework and typologies o mechanisms subsequent to this testing.


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APPENDIX 1. SEARCH STRINGSPrivate sector OR Non-state provider AND Asia Pacic countries OR Developing countries OR LMIC ORMiddle income countries

Private sector OR Non-state provider AND Non-state relations OR Health care sector OR Private providers

OR Public private partnerships OR Asia Pacic countries OR Developing countries OR LMIC OR Middleincome countries

Private sector OR Non-state provider AND Health seeking behavior OR Utilization OR Service provision

OR Delivery o health care OR Asia Pacic countries OR Developing countries OR LMIC OR Middleincome countries

Private sector OR Non-state provider AND Regulation OR Legislation OR Contracting OR Incentive OR

Training OR Collaboration OR Asia Pacic countries OR Developing countries OR LMIC OR Middleincome countries

Traditional practitioners and healers OR Drug sellers OR pharmacists OR traditional birth attendants OR

Indigenous systems medical providers AND Asia Pacic countries OR Developing countries OR LMIC ORMiddle income countries

Traditional practitioners and healers OR Drug sellers OR pharmacists OR Traditional birth attendants

OR Indigenous systems medical providers AND Non-state relations OR Health Care Sector OR Private

Providers OR Public private partnerships OR Developing countries OR LMIC OR Middle income countries

Traditional practitioners and healers OR Drug sellers OR pharmacists OR Traditional birth attendants OR

Indigenous systems medical providers AND Health seeking behavior OR Utilization OR Service provision

OR Delivery o health care OR Asia Pacic countries OR Developing countries OR LMIC OR Middleincome countries

Traditional practitioners and healers OR Drug sellers OR pharmacists OR traditional birth attendants OR

Indigenous systems medical providers AND Regulation OR Legislation OR Contracting OR IncentiveOR Training OR Collaboration OR Asia Pacic countries OR Developing countries OR LMIC OR Middle

income countries


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APPENDIX 2. WEBSITE HAND SEARCHDFID Health Resource Center http://www.ddhealthrc.org/

Eldis www.eldis.org/go/topics/resource-guides/health-systems/health-service-delivery/non-state-providers

Health Systems 20/20 http://www.healthsystems2020.org

Health Systems Action Network http://www.hsanet.org

Health Systems Development Programme at London School o Hygiene and Tropical Medicine

http://www.hsd.lshtm.ac.uk/links/index.htm

HLSP institutePrivate sector in health http://www.hlspinstitute.org/privatesectorinhealth/

HRH Global Resource Center http://www.hrhresourcecenter.org/taxonomy/term/173

Id21 health http://www.id21.org/health/index.html

Non-State Provision o Basic Services http://www.idd.bham.ac.uk/research/service_providers.shtml#study

Private Health Care in Developing Countries http://www.ps4h.org/index.html

Public-Private Mix (PPM) or TB care and control, WHO http://www.who.int/tb/careproviders/ppm/en/

Private Sector Program in Health (PSP) http://www.psp.ki.se

PSP-One: private sector partnerships or better health http://www.psp-one.org

Results or Development Institute http://resultsordevelopment.org/about/newsandevents/nal-reports- role-

private-sector-health-systems-initiative-are-now-available

World BankKnowledge Services or Private Sector Development http://rru.worldbank.org/

World Health Organization (WHO)Partnerships management: Working with the private sector: Concepts and

issues and tools and guidelines http://www.who.int/management/partnerships/private/en


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APPENDIX 3 NON-STATE PROVIDERSKEY REFERENCES FORSTRATEGIES, MECHANISMS AND RELATIONSHIPSPolicyDialogue

Regulation Contracting Social market-ing, ranchis-ing, entrepre-neur-ship

Financing Incentives(fnancial,other)

Collaboration Inormation

Palmer 2006 Palmer 2006 Palmer 2006 Palmer 2006

Batley,Hussein et al2004




Batley 2006 Batley 2006 Batley 2006 Batley 2006

Peters,Mirchandani etal 2004







Waters, Hatt etal 2003







Moran et al2004

Moran et al2004

Moran et al2004

Moran et al2004

Balabanova,Oliveira-Cruzet al 2008



Balabanova,Oliveira-Cruz etal 2008



Taylor 2003 Taylor 2003 Taylor 2003 Taylor 2003 Taylor 2003

Berman 1996 Berman 1996 Berman 1996 Berman 1996 Berman 1996


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KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacic

A strateg ic partnerships ini tiative funded by the Aust ralian Agency for Inte rnational Development

The Nossal Institutefor Global Health

Documents

Analysing relationship between the state and non-state health care providers, with special reference to Asia and the Pacific (WP10)