The Role of Non State Providers in Child

Health in East Asia and the Pacific

Dr Abby Bloom
Sydney Medical School & Menzies Health Policy Inst
Nossal Global Health Institute, Univ Melbourne
Dr Dominic Montagu
Univ California San Francisco, Global Health
Out-of-pocket spending on health
as a percentage of national Total Health Expenditure

Source: WHO, 2006 National Health Accounts Data: http://www.who.int/nha/country/en/index.html

Out-of-pocket spending on health
as a percentage of national Total Health Expenditure

Source: WHO, 2006 National Health Accounts Data: http://www.who.int/nha/country/en/index.html

 Source of Healthcare by Wealth Quintile

Source: DHS Data (Cambodia 2005; Indonesia 2007; Philippines 2003; Vietnam 2002)
A Wide Range of Models for NSP
Involvement in Child Health
 Contracting (“PPPs”)
 Purchasing
 Social marketing
 Social franchising
 Social entrepreneurship
 NGO and FBO direct provision of care
 Vouchers
 Insurance (including Social insurance)
 Accreditation
 Certification
 Output Based Aid
 Provider Training
 Patient Education
 Manufacturer-based supplements
 Manufacturer-based product subsidies
Source of healthcare: Cambodia

83% of
healthcare
from
private
providers

78% of
healthcare
from
private
providers

Source: DHS Data Cambodia 2005

Cambodia - Current Situation
 Poor health, but steady improvements

 Private Out of Pocket (OOP) is main source of

financing

 80% of population treated in private facilities

 Good examples of government & private

collaboration to increase access & quality for
priority health services
Cambodia: Malaria Treatment
 70% of fevers treated in the private sector
 Aim: to assure widespread coverage of ACTs.
 Government & PSI are partners in Affordable
Medicines Facility-Malaria (AMFm) initiative.
 PSI co-packages ACT and rapid test kits
 Comprehensive training provided
 IEC and BCC create market demand
 270,000 units sold in 2009
 Will be available in both private and Govt shops
and clinics
Source of healthcare: Indonesia

83% of
healthcar
e
from
private
providers

69% of
healthcar
e
from
private
providers

Source: DHS Data Indonesia 2007

Indonesia – Current Situation
 Private sector provides ¾ of all health services

 ½ of all financing for health is private

 “Dual practice” by government clinical staff

 Decentralization has led to financing challenges

within the national delivery system
 Self-treatment for simple ailments is common
Indonesian Midwives Association

 USAID-supported initiative to improve quality

standards among private midwives

 BidanDelima program for training and

certification

 7,800 members: 10% of all Indonesian Midwives

Source of healthcare: Philippines

75% of
healthcar
e
from
private
providers

46% of
healthcar
e
from
private
providers

Source: DHS Data Philippines 2003

Philippines – Current Situation
 Private health expenditure > than government
expenditure

 Poor most often seek healthcare from informal

sector: shops, friends, and relatives

 Pharmaceutical sales = 46.6% of THE

 Strong national leadership + well-managed

national health insurance program = foundation
for collaboration
 Philippines:Drugstore Franchising
 Philippines has highest retail drug costs
in EAP
 Government response: BotikangBayan
franchise of private drug stores
 Operated by PITC, governmental trade
company
 Central procurement from India, China,
and local generic manufacturers
 1,971 participating pharmacies across
the country

photo: www.pia.gov.ph/press/
 Key Message 1:
The private sector is pervasive and has been filling
the gap in EAP for some time

What’s wrong with the current situation?

 The private sector is often unqualified, usually unregulated,

overservices or provides ineffective care

 And… out-of pocket payment (OOPS) is regressive and

penalizes poor.
 Key Message 2:
Government engagement, let alone
"stewardship“, is very limited.

 “Stewardship Lite”

 But there is opportunity now to review and

strengthen.
Key Message 3:
There are already very impressive examples
of private sector initiatives contributing to
the health of children:

 Cambodia
 Indonesia
 Philippines, Vietnam, Fiji, etc.
 Key Message 4:
There is a very broad menu of mechanisms from
which Government can choose.

 Options are much greater than is generally considered –

and
 Most are much easier, and less risky, than traditional
“PPPs”, and
 Have much greater impact on the poor and on equity.
Key Message 5:
Government must answer 3 questions:

1. What are we trying to achieve?

 Lower infant mortality? Build and equip new hospitals? Replace inefficient work
practices? Improve equity????

2. What options have been proven to achieve these objectives?

 Look at the long list of options available – and choose the ones that are likely to
have the outcomes Government wants for poor children.
3. What is our country’s capacity to support these initiatives and mechanisms?
 To engage and manage the private sector for the "public good"?
 What is our capacity for stewardship?
 Are we ready now? If not, what can we do to be ready to manage technical, financial and economic risks?
Ex: Review & revise legislation, regulations and funding (Mongolia, Vietnam, Indonesia)
Ex: This Workshop: bringing together stakeholders, including Ministries of Finance and NSPs, not just
MOH, to consider strategies.
Contact details:
Dr Abby Bloom
healthinnovate@optusnet.com.au