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

Shakil Ahmed
Nossal Institute for Global Health, University of Melbourne

Abby Bloom
Menzies Centre for Health Policy, University of Sydney

Rohan Sweeney
Nossal Institute for Global Health, University of Melbourne

The Nossal Institute for Global Health

www.ni.unimelb.edu.au

KNOWLEDGE HUBS FOR HEALTH
Strengthening health systems through evidence in Asia and the Pacific

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ABOUT THIS SERIES
This Working Paper is produced by the Nossal Institute for Global Health at the University of Melbourne, Australia. The Australian Agency for International Development (AusAID) has established four Knowledge Hubs for Health, each addressing different dimensions of the health system: Health Policy and Health Finance; Health Information Systems; Human Resources for Health; and Women’s and Children’s Health. Based at the Nossal Institute for Global Health, the Health Policy and Health Finance Knowledge Hub aims to support regional, national and international partners to develop effective evidence-informed policy making, particularly in the field of health finance and health systems. The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aim is to stimulate discussion and comment among policy makers and researchers. The Nossal Institute invites and encourages feedback. We would like to hear both where corrections are needed to published papers and where additional work would be useful. We also would like to hear suggestions for new papers or the investigation of any topics that health planners or policy makers would find helpful. To provide comment or obtain further information about the Working Paper series please contact; niinfo@unimelb.edu.au with “Working Papers” as the subject. For updated Working Papers, the title page includes the date of the latest revision. Analysing relationship between the state and non-state health care providers, with special reference to Asia and the Pacific First draft – March 2011 Corresponding author: Shakil Ahmed Address: Nossal Institute for Global Health, University of Melbourne shakila@unimelb.edu.au Other contributors: Abby Bloom, Menzies Centre for Health Policy and Rohan Sweeney, Nossal Institute for Global Health, University of Melbourne This Working Paper represents the views of its author/s and does not represent any official position of the University of Melbourne, AusAID or the Australian Government.

Analysing relationships between the state and non-state health care providers, with special reference to Asia and the Pacific

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SUMMARY
This paper examines frameworks, typologies and taxonomies in current use for analysing the relationships between the state and non-state (‘private sector’) providers of health care. The paper was commissioned as background for a project aimed at assisting selected countries in Asia and the Pacific to assess and plan more effectively the role of the private sector in health care. The paper, originally conceived as a review of the literature, was developed further. It contains two parts: the first presents the methods and findings of a review of the literature, and considers existing taxonomies and frameworks. The second proposes a series of frameworks developed by the authors to assess more comprehensively and plan the respective roles of the state and nonstate providers. The review was guided by the following questions: 1. What types of 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 defining elements of each relationship between the state and non-state providers, and how can the relationships be analysed? 4. What different frameworks have been applied to assessing the relationships between public and private (state and non-state actors) in health care? 5. Which framework is the most useful for country-level policy research on the role of non-state providers?

BACKGROUND
This paper was commissioned to inform researchers preparing to undertake long-term studies of the role and relationships between the state and non-state providers in the Asia-Pacific region. Before commencing in-depth projects in several countries, it was considered valuable to review how prior research had conceptualised and defined the relationships between state and non-state providers (NSPs). NSPs include large and small commercial companies, groups of professionals such as doctors, nurses, midwives, pharmacists, national and international non-government organisations (NGOs) and other individual providers, commonly including shopkeepers. Unfortunately, as explained in the paper, this straightforward definition does not capture either the complexity or ambiguity of ‘non-state providers’ in practice. In recent years increasing attention has been paid to the respective roles and impacts on health outcomes, cost and efficiency of health service delivery and equity of publicly owned and funded health care provision on the one hand and that of the private sector on the other. Much of this research indicates that, while the role and function of NSPs vary substantially from country to country, and even within a single country, and depending on the disease, NSPs typically play a significant role in health care. In the case of some common health problems—such as diarrhoea—80% of cases sought treatment from non-state providers (Bennett, Hanson et al 2005). As our main interest is countries in Asia and the Pacific, examples from this region have been selected wherever possible.

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METHODOLOGY
The review adopted standard methods for literature reviews. The scope of the review and the issues covered were subject to the availability of relevant literature. The review included peer-reviewed, published and ‘grey’ literature (unpublished reports and other documents).

RESULTS
The review encountered an important limitation familiar to scholars in the field: despite the fact that in most low-income countries the non-formal private sector accounts for half or more of all health care (National Demographic and Health Survey 2003), there is a dearth of systematic and comprehensive information on the non-formal sector. Consequently, the research looked only at formal non-state providers and the formal engagement of non-state providers in the health sector, and not at informal NSPs. The review considered typologies and models of NSP-state relationships with global application. The four main types of NSPs identified are: 1. formal for profit 2. informal for profit 3. formal not for profit 4. informal not for profit. There is a scarcity of material on, and analysis of, frameworks used to examine the relationship between the state and non-state providers of health care, especially in Asia and the Pacific, even taking into consideration the grey literature. In particular, information on providers and services in the important category of informal for-profit providers is scant and tends to be found in the grey literature in studies of health-seeking behaviour, including the anthropological literature. Nevertheless, the authors did find some relevant frameworks, although none was adequate for the breadth of state-NSP relationships uncovered.

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CONCLUSIONS AND RECOMMENDATIONS
Among the available frameworks, the most useful is the classification put forward by Waters, Hatt et al (2003) and Peters, Mirchandani et al (2004). However, these frameworks, which drew on experience mainly in reproductive health projects, can be usefully expanded by incorporating experience from the health sector more broadly defined. We have sought to do this, and in doing so have generated what we believe to be a more comprehensive and useful ‘strategic framework’. Our recommended framework, like that of Waters, Hatt et al (2003) and Peters, Mirchandani et al (2004), is pragmatically based and aimed at decision makers responsible for appraising and implementing these initiatives. Comment and discussion on our proposed framework is encouraged. A comprehensive framework should enable users to: 1. determine the desired health, economic, political and other outcomes resulting from a relationship with nonstate providers; 2. define relationships that are likely to produce those outcomes; 3. assess the state’s capacity to meet the fundamental requirements to engage beneficially with non-state providers (e.g. regulatory, procedural, contractual, legal) and identify the steps needed so that the state can effectively manage each type of relationship; and 4. provide a structure for cross-country comparisons. Our proposed framework is an initial step for analysing both existing and new relationships between the state and non-state providers, and answering these fundamental questions. Future work will be required to answer all of these basic questions, especially on the capacity of states to manage different relationships. These must ultimately be done on a case-by-case basis.

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INTRODUCTION
In recent years, much research has focused on the role and impact of the state and non-state health care providers (Bloom, Champion et al 2009; Balabanova, Oliveira-Cruz et al 2008). In many low and middle income countries, NSPs provide half or more of all health care services. For some common health problems, including diarrhoea, NSPs can even be the sole provider (Aljunid 1995). Poorer people, in particular, are more likely to seek health care from informal for-profit providers, both forprofit physicians and hospitals providing modern care (Berman and Hanson 1993). In a study conducted in Indonesia of children aged less than five years who used services for an episode of illness (n=2478), 44.5% of families used formal NSPs and 16.8% used informal NSPs (Thind 2005). NSPs account for care sought in 60% of all illness episodes and 60% of all health care expenditure in Vietnam. A sizeable proportion of patients from low and moderate income groups attend private clinics in Papua New Guinea (Mulou 1992). The most common reason for choosing a private clinic was that treatment was easier and faster from private providers. NSPs were the major sources of primary health care in Bangladesh, India and Pakistan. In Bangladesh, 88% of households that sought health care went to NSPs (CIET 2003). The village doctor provided care to 43% of households seeking care. The greater part of health care in rural areas of Bangladesh is informal for profit (Claquin 1981; FHS Research Brief 2008). NSPs provided 79% of all outpatient care for those below the poverty line in India during 1995-96 (Peters, Yazbeck et al 2002). Protecting health and well-being, and ensuring safe and effective health care, are part of the ‘stewardship’ role of the state (Lagomarsino, Nachuk et al 2009). The state’s stewardship role, some maintain, does not necessarily require it to own or provide—or even completely finance—health 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 state’s health and health care objectives, and are looked upon as potentially useful complements of or adjuncts to state owned, financed and operated health care services (Bennett, McPake et al 1997). Given the extent of 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 al 2009; International Finance Corporation 2008). States and policy analysts have recently focused on identifying mechanisms that improve the means to achieve health care objectives. A major focus is on ‘harnessing’ or ‘leveraging’ NSPs, including both for profit and not for profit (Bennett, McPake et al 1997; Mills, Brugha et al 2002). The relationships between the state and non-state providers have been analysed in dozens of countries, and regions within countries have been compared. However, there are few comparative studies involving more than two countries or states. For this complex task, a clear framework is essential. This paper examines typologies/taxonomies and frameworks currently used, first to understand the roles of non-state providers of health care and secondly to analyse the relationships between the government (‘the state’) and non-state providers (‘the private sector’ and ‘civil society’) in relation to health care services. The framework, typologies and taxonomies used to describe and categorise the relationships between the state and NSPs are important for several reasons. At a fundamental level, Willis, Daly et al (2007) note, ‘Theories provide structured interpretations or models for investigating and understanding a problem’. The authors explain the influence of underlying theories as follows: Theory provides a framework for structuring a study and plays a central role in data collection and analysis. This use of 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 of the relationship between the state and non-state providers of health care, frameworks and typologies assist policy makers and program designers to understand better the current situation and to design a more effective future system. Frameworks are useful in uncovering the logic—or lack of it—in both the analysis of health care systems and their redesign.

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It is important to keep in mind that frameworks, their implicit assumptions and their categories all fundamentally influence and guide the user’s interpretation of real-world phenomena. As Willis, Daly et al (2007) highlight, frameworks are likely to influence the importance a researcher places on some data relative to other data, and the extrapolation of this data to hypotheses and generalisations. Thus, while frameworks may appear objective, even explicitly articulated frameworks act subjectively to colour our perception and interpretation of phenomena—in this case, the role and interplay between public and private in health care. The frameworks, models, typologies and taxonomies we use influence our interpretation of, and responses to, health systems. Moreover, the framework we apply thus affects not only our perception of the relationship between the state and non-state providers, but also the strategies and actions we use to develop that relationship. The purpose of this paper is to develop further the theoretical rigour underpinning an understanding of the relationships between the state and non-state providers, and to assist in the cross-country comparison of relationships between the state and non-state providers. While noting the potential biases that frameworks can introduce to an analysis, we believe this descriptive analysis of current ways of understanding and analysing the roles of and relationships between the state and non-state health care providers is important for policy makers and researchers. An additional focus of the literature review and subsequent discussion was the application of identified frameworks to Asia and the Pacific, where much of the authors’ work is directed.

DEFINITIONS
A framework is a model used for ‘… identifying elements and relationships among the elements that need to be considered for theory generation’; a typology is ‘…a system or the study of dividing a group of things into smaller groups according to the similar qualities they have’ (Walt, Shiffman et al 2008; Ostrom 2007; Longman 2009). For the purpose of this review, we used ‘relationships’ as a broad term to capture the range of mechanisms by which the private sector and civil society (non-state) engage with the public sector to fund or provide health care. The private sector includes both for-profit entities, such as corporations, as well as not-for-profit or civil society entities, which includes NGOs, a category that has long been involved in the funding and provision of health care. Civil society is: … the arena of uncoerced collective action around shared interests, purposes and values … in practice, the boundaries between state, civil society, family and market are often complex, blurred and negotiated … Civil societies are often populated by organizations such as registered charities, development non-Governmental organizations, community groups, women’s organizations, faith-based organizations, professional associations, trade unions, self-help groups, social movements, business associations, coalitions and advocacy groups (Centre for Civil Society 2004). ‘State providers’ describes health care workers and facilities 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 of the state (Bennett 1992; Smith 2001). Unfortunately, this straightforward definition captures neither the complexity nor the ambiguity of actual ‘non-state providers’ (Ferrinho, Lerberghe et al 2004). In particular, private non-profit funders and providers are in most contexts (a notable exception being the USA) distinct from private for-profit funders and providers (Swan and Zwi 1997). NSPs differ by type of services, legal status, training and institutional organisation. NSPs include individual providers (doctors, nurses, midwives, quacks) and groups of providers and facilities (clinics, nursing and maternity homes, hospitals, pharmacies, diagnostic facilities, NGO-run medical clinics). Some non-state providers do not have formal training and practice illegally (Bennett 1992). The definition of non-state providers does not always differentiate precisely between state and non-state (Berman 1996). For instance, some state providers may be considered NSPs when they practise in both state and NSP facilities (‘dual practice’). They may even practise privately within public sector facilities.

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METHODOLOGY
We used established methods for a literature review (Arksey and O’Malley 2005; Glasziou, Irwig et al 2001; WHO 2005). The search strategy used broad search terms (Table 1) in order to identify literature that presented frameworks and typologies for describing and assessing relationships between the state and non-state providers.

Search Strategy

The literature search was conducted in July 2009. The strategy explored three data sources: electronic bibliographic databases, an internet search engine and reference lists of identified papers. Details of the search strategy are included in the appendices. Electronic bibliographic databases Pubmed and Scopus were searched for literature published between July 1989 and June 2009 controlled by medical subject headings and free 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 of NSPs (traditional practitioners and healers, drug sellers, pharmacists, traditional birth attendants and indigenous systems medical providers). The complete search strings used are available in Appendix 1. Internet search engine Websites of the different organisations, research institutes and research networks were searched using the key terms in Table 1 to find technical reports. In addition, a Google general internet search was conducted. Search of reference lists The reference lists of selected journal articles and technical reports were checked to find additional articles and reports or documents particularly relevant to the relationship between the state and non-state providers.

Selection Criteria and Review Process

Titles, abstracts and executive summaries of the journal articles, technical reports and documents were read after completing the search strategies. Final selection of articles, technical reports and documents was based on the content criteria below. Papers and reports were included if their focus was primarily on the following issues: 1. Types, roles and mechanisms: the types, roles and services of non-state provider’s elements or mechanisms of the relationship (regulation, incentives, contracting out, policy dialogue, collaboration, financing and information). 2. Geographic: Asia-Pacific countries; developing countries; low-income countries; middle income countries. 3. Linguistic: English. 4. Publication period: 07/1989 to 06/2009. Given the nature of the review topic and subsequently the somewhat ethereal quality of frameworks and typologies identified, we did not exclude papers on the grounds of methodological quality.
Table 1. Key Terms
Non-state providers Private sector* Non-state relations Health care sector Private providers
* Medical subject headings and free text

Public private partnerships Health seeking behavior Utilization Service provision Delivery of health care

Regulation Legislation Contracting Incentive Training Collaboration

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RESULTS
The search strategy resulted in 471 references. Only 66 of these met selection criteria and were chosen for final review. Few of the 66 discussed the elements of relationship between the state and NSPs. The excluded references described experiences of public-private partnership. Many papers examining the impact of elements (for example evaluating, contracting out) were not included for review. The specific findings are presented below.

Typology of Non-State Providers

While in most low-income countries the non-formal private sector accounts for half or more of all health care provision (National Demographic and Health Survey 2003), there is a dearth of systematic and comprehensive information on the non-formal sector. The search strategy was guided by review questions, and consequently we found only papers looking at formal non-state providers or the formal engagement of non-state providers in the health sector, and not at informal NSPs. Using the commercial orientation and the organisational form classifications, NSPs can be divided into four types (see Table 2): 1. formal for profit 2. informal for profit 3. formal not for profit 4. informal not for profit. These four broad types cover the range of individuals and organisations providing allopathic, traditional and indigenous health services through formal or informal structures or through voluntary organisations (Bhat 1993). But they may still not capture the diversity of NSPs, especially in low-income countries, where political and economic factors and the historical features of health systems have led to a wide variety of organisational types, for example the dual practice described earlier; dual practice is not always either legal or sanctioned, although it is perfectly legitimate in some countries. Contributing further to the blurry lines between state and non-state providers is the fact that in some countries, NGOs or privately owned mission health facilities receive subsidies from both the state and non-state actors, including international donors. Thus their ownership status is private (not for profit), but their funding is a mix of private and state funding. Their patients may include both public and private, fee-paying patients. For all these reasons, precise descriptions and quantification of the extent of non-state provider involvement in health services are challenging. Comparisons across countries are difficult because of differences in nature, size, participation and types of services. No current model adequately captures the complexity and variations of public-private ownership, funding and legal regulation (Lagomarsino, Nachuk et al 2009).
Table 2. Types of Non-State Providers Engaged in the Health Sector
Provider For profit Informal A wide range of individuals and enterprises including traditional healers, birth attendants, drug sellers, indigenous systems medical providers as well as drug shops and stalls. They operate on a for-profit basis offering mainly curative services largely in rural and semi-urban areas. Local unpaid midwife, volunteer village health worker are only some examples. They operate as volunteers and do not receive any cash benefit. Formal Small or large hospitals, clinics, diagnostic facilities, pharmacies and qualified individuals providing health services for profit or gain. These providers can earn revenue in excess of their expenses and have wide discretion on how to spend profits.

Not for profit

NGOs, community and faith-based organisations, charities and social enterprises offering a wide range of health services. Their aim is to achieve social goals rather than a profit. Some not-for-profit providers have cost recovery strategies while others are heavily dependent upon external and internal assistance. Still others do make a profit, which they re-invest in their activities; they are still not for profit in that their charter does not require them to make a profit.

Source: Adapted from Lagomarsino, Nachuk et al (2009),[13] and Oxfam International (2009)

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Several authors recommend a more detailed categorisation framework to capture some of this diversity. Using a common set of more detailed variables for categorising providers also enables comparison among countries. The most common set of broad categories was: A. Commercial orientation: for profit or not-for-profit. B. Therapeutic system: formal or informal, modern or traditional/alternative. C. Financing and taxation: public financing, private financing and donor funding. D. Organisational form: individual providers to tertiary hospitals. (Green 1987; Berman and Hanson 1993; Belly, Lonnroth et al 2001; Oxfam International 2009) Illustrative of the literature, Belly, Lonnroth et al (2001) describe these four categories in the following way: A. Commercial orientation Commercial orientation is used to distinguish for-profit from not-for-profit entities (USAID 2005). For-profit entities include hospitals, individual qualified providers and the large numbers of informal providers typically found in low and middle-income countries (Palmer 2006). They are owned by a clinician or corporation. Not-forprofit 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 (individual and networks), company-owned health clinics, hospitals; • ancillary services (for example laboratories, diagnostics); • doctors, nurses, midwives, paramedical staff, pharmacists, chemists, patent medicine vendors. The traditional/alternative system includes: • traditional practitioners and healers; • market drug sellers; • traditional birth attendants; • indigenous systems medical providers. C. Financing and taxation status The financing and taxation status can be examined under the following sub-groups: Proportion of financing by source: • public financing • private financing (private insurance and out-of-pocket financing) • funding by international source Contractual arrangements by type: • public health care sector • insurance company • other private providers Payment mechanisms (clinic and individual staff): • prepayment • capitation • fee-for-service Taxation: Type and level of taxation of services

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D. Organisational form An analysis of organisational form considers the following practice characteristics and functions of a non-state provider: • authorised or unauthorised (formal or informal) • size of company/organisation (number of health facilities by type, turnover etc) • number of staff in clinic by profession • proportion of the staff also employed in public sector • fixed or mobile location • opening hours • general orientation: preventive, general practice, specialist • linked to/member of professional association • inpatient service provided or not • number of beds • drug dispensing: selling drugs, yes/no • interaction with public health care and referral routines: established formal referral routines • gate keeping function.

Systematic Approaches to Assessing the Relationship

Several authors encouraged a return to fundamental questions about the rationale for engagement with the non-state sector (for example, Bennett, Dakpallah et al 1994) and have proposed a checklist approach for appraising the role of non-state providers. This checklist is intended for settings where NSPs are active and where the state-non-state relationship needs to be ameliorated. While the usage may be complicated by porous boundaries between categories, checklists and matrices are still useful in analysing this complex topic. Such use is consistent with current trends that ensure that health services are deployed thoroughly, logically and in a form consistent with available evidence (Gawande 2009). Table 3 synthesises the work of the papers authored 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
• hat are the objectives of existing regulation: do they seek to limit itemised fees for service, stop excess provision, prevent poor W practice or a combination of these? • s regulation concerned with basic infrastructure characteristics, the training and accreditation of staff, or does it actually consider the I outcome of care? • What is the balance between incentive options and regulation? • ho are the agents responsible for setting rules and incentives, monitoring implementation and enforcing sanctions if rules are W transgressed? • Are the regulatory approaches active, seeking out low-quality providers, or are they passive, awaiting presentation of complaints? • How far do the incentives for collaboration fit the incentive structures or systems of the state and NSPs? • How far do the organisational forms of the collaboration fit with the arrangements of the state and NSPs for decision making? • How are differences resolved? Whose arrangements are dominant? What compromises emerge? • How does the agenda for collaboration fit with the agendas of the state and NSPs? • Does the arrangement for collaboration conform with or challenge interests, goals, ideologies and identities of the state and NSPs? • hat is the influence of the formal and informal operation of the relationship between the state and NSPs on the agendas of public W action that prevail? Do service characteristics influence 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 of social interaction, governance, conflict management and alignment with state policy. Bloom, Champion et al (2009) also provide a checklist, which includes health outcomes as an additional indicator. None of the lists include financial or economic indicators of successful relationships.

Mechanisms of Engagement between the State and Non-State Providers
The literature search identified papers on types and typologies of mechanisms—formal 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 state’s public health goals is a mechanism of ‘engagement’. Requiring a private hospital provider to allocate a proportion of beds for non-fee-paying (‘public’) patients is another example.

The International Development Department, University of Birmingham, studied situations in which government health providers and NSPs entered into relationships for service provision in Bangladesh, India and Pakistan. The study documented how these three states interacted with non-state providers in policy dialogue, development of regulatory frameworks and contracting (Palmer 2006). In their model, incentives and training were categorised under ‘regulation’ and ‘facilitation’ because they are intended to regulate quality by supporting NSPs. Other researchers examined seven strategic frameworks to assess the effectiveness of NSP-run child health (Waters, Hatt et al 2003) and sexual and reproductive health (Peters, Mirchandani et al 2004) interventions. The frameworks examined three different features: market-based, administrative and public-empowerment. In their review of non-state provision of basic health services, Moran and Batley (2004) described forms of intervention under three headings: regulatory approaches, support approaches and strengthening accountability. They highlighted the importance of accreditation and legislation to assess the quality and competence of NSPs, and self-regulation by professional bodies to maintain standards under regulatory approaches. Support approaches include information sharing, vouchers for increasing access, social marketing for increasing demand, providing training, supplying drugs and equipment, franchising, financial support or credit and contracting. Balabanova, Oliveira-Cruz et al (2008) identified dialogues, the sharing of information and accountability for their actions by NSPs, as a means by which NSPs and states engage. The authors also included regulation, financing and stewardship as distinct forms of engagement between the state and NSPs. They recommend that states set minimum standards for quality of health care and enforce it through monitoring and sanctions. The rationale for engagement between the state and non-state actors is reinforced by the fact that the state requires information from NSPs (e.g. utilisation statistics, some process and outcome indicators). The authors maintain that because non-state providers are responsible for such a significant proportion of health care delivery in the Asia-Pacific 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 further in relation to financing, recommending contracting, or alternatively tax credits, as a means of reducing health care costs. Taylor (2003) classified state tools for influencing NSPs in terms of ‘intrusiveness’. Tools include: direct provision of health services, financing, regulation and dissemination of information (less intrusive). Berman and Rose (1996) broadly categorised state intervention in five areas: public provision, public financing, incentives, regulation and public information. Mechanisms included social insurance, influencing the legal and regulatory environment for private provision, public taxes, subsidies and incentives. Other authors focus on very specific mechanisms of service delivery, including social marketing, social franchising and vouchers, and on specific interventions such as incentives. Incentives are present in two forms: financial and non-financial (Afifi, Busse et al 2003; Kumaranayake 1997).

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Application of Typologies and Frameworks to Countries of the Asia-Pacific

The full scale and scope of services provided by NSPs in the Asia-Pacific have proven difficult to document systematically and comprehensively. Reasonable detail is available on some NSP services in Asia-Pacific countries, including family planning, maternal and child health, childhood illnesses, immunisation, malaria, tuberculosis, sexually transmitted infection, 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; Huff-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-folic acid supplements and maternity services both at home and at fixed facilities (Paulino, Angeles-Agdeppa et al 2005). Good examples of NSPs providing safe motherhood programs and preventive and curative services for children are available in Indonesia and in other countries (Bustreo, Harding et al 2003). While informal for-profit providers in developing countries are known to play a significant 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 Brief 2008). While these results provide some insight into the range of research on NSPs in Asia and the Pacific, we found no evidence of application of a comprehensive framework in analysing NSP roles or the relationship between the state and NSPs.

DISCUSSION
This paper sought to examine typologies/ taxonomies and frameworks currently used, first, to understand the roles of non-state providers of health care and secondly to analyse the relationships between the government and non-state providers in relation to the provision of health care services. While useful typologies were found, which helped describe the range of roles of NSPs in health care provision, there were no such typologies found that described the role of informal NSPs, despite it being known that this group is well represented in service provision, particularly in the Asia-Pacific region. The literature review revealed a range of frameworks for analysing the relationship between the state and nonstate providers. Some of these overlapped, but they also had many different components. This demonstrates that no one existing framework encompasses the entire myriad of relationships by which governments currently engage with NSPs. As a consequence, the subsequent analysis presents a suggested approach and frameworks for more comprehensive appraisal of relationships between the state and non-state providers. This framework is designed to reflect the full range of relationships identified in the literature review. The frameworks are designed for application to in-country analysis and appraisal of existing relationships. The framework 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 Pacific. 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 from each strategy. Table 4b presents an application of this comprehensive framework using examples from the region. We believe that these frameworks are more useful because they incorporate the full range of mechanisms that states 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 for influencing the dynamics of the market for health care. This more comprehensive framework enables a descriptive analysis of a wide range of relationships between the state and non-state providers that exist in a wide range of health systems, making it more useful for crosscountry comparisons than other frameworks identified in the literature.

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Table 4a. Non-State Providers Framework: Strategies, Definitions and Objectives STRATEGIES 1.1 Financing mechanisms 1.1.1 Social insurance Predetermined, equitable levels of funding for provision of stipulated levels of health care to defined population. A program where risks are transferred to and pooled by an organisation, often governmental, that is legally required to provide certain benefits Use of financial instruments, such as grants, subsidies, tax incentives and in-kind support to influence behaviour of private providers (Peters, Mirchandani et al 2004). Also includes manufacturer-based product subsidies. (Montagu and Bloom 2010) Purchasing services from private providers, and applying benchmarks for the types of services provided, quality of care, amount of services and/or health outcomes (management, clinical services etc.) (Peters, Mirchandani et al 2004) Buying goods and services for limited time; lower risk and commitment than contracting (Montagu and Bloom 2010) Generate predetermined, equitable levels of funding for provision of stipulated level of health care to defined population DEFINITIONS OBJECTIVES

1. Market-based approaches

1.1.2 Financial incentives

Stimulate private providers to deliver specific services with public health goals to defined population

1.1.3 Contracting

Increase range of choice and encourage more efficient and higher quality services (management, clinical services etc.) (Montagu and Bloom 2010)

1.1.4 Purchasing

Increase value for money to public sector in goods and services by expanding range and increasing efficiency through competition (Montagu and Bloom 2010) Actions aimed at creating in the market new sources of supply and demand for goods and services with public health benefits

1.2 Marketing mechanisms

1.2.1 Social marketing

Using commercial channels, techniques and communications approaches to market products with a public health benefit (Peters, Mirchandani et al 2004) Establishment, training and support of networks of individuals (typically in small villages) to provide socially beneficial health services and products for profit Using commercial channels, techniques and communications approaches to market networks of service providers (Peters, Mirchandani et al 2004). Actions aimed at changing market conditions to increase private providers’ appetite/incentive to cooperate with the public sector Establishing and encouraging formal links and collaboration among providers

Increase population coverage and effectiveness of products with a public health benefit: more geographically comprehensive and potentially more cost-effective commercial channels, techniques and communications approaches (Peters, Mirchandani et al 2004) Substantially increase reach of goods and services with a public health benefit

1.2.2 Social entrepreneurial programs

1.2.3 Social franchising

Substantially increase reach of goods and services with a public health benefit

1.3 Organisational collaboration

Change market conditions to increase participation by private providers in programs/initiatives designed to improve public health Increase private sector contribution to public health goals by creating groups with economies of scale for more efficient public-private collaboration and more economical units for private sector initiatives (for example purchasing).

1.3.1 Alliances among providers

1.3.2 Coordination/ alliances between public and private 1.4 Policy dialogue

Establishing and encouraging formal links Foster actions by private sector that promote public health and collaboration between public and private objectives, including MDGs; increase private sector participation Engaging NSPs in the discussions: may extend to consultation in development of legislation, standards, regulatory and facilitation systems (Batley 2006).

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2. Legal/administrative approaches 2.1 Regulation 2.1.1 Accreditation/ certification 2.1.2 Licensing 2.1.3 Pricing mechanisms Setting and enforcing standards— organisations Setting and enforcing standards—individual providers Setting, monitoring and enforcing prices of drugs, devices, medical consultations, immunisations, etc. Formal state approval and reimbursement structures, process and enforcement Includes anti-monopoly/competition laws, consumer protection mechanisms and enforcement Educating and supporting private providers (Waters, Hatt et al 2003) Communicating with and educating the public about health-promoting behaviours, health service use and information on private providers (Peters, Mirchandani et al 2004) Establishing formal opportunities for the public to communicate their opinions about .services and service providers. The establishment of formal, paid positions supervising and ensuring adherence by private providers; ombudsman-like positions in public-private initiatives. Capacity to recommend/impose sanctions. Raise standards of care/health outcomes/efficiency by enabling empirical basis for judging quality as well as comparison across organisations Raising standards of individual practitioners by setting and enforcing criteria for practice State monitors and enforces price of essential drugs and medical technology State controls safety, efficacy and cost of health care by regulating availability/sale of pharmaceuticals and medical technology. State protects citizens from (high) monopoly pricing

2.1.4 Technology regulation

2.1.5 Market regulation

2.2 Training 2.2.1 Provider training 3. Public empowerment 3.1 Information dissemination Communication with/educating the public about healthpromoting behaviours, health service use and information on private providers (Peters, Mirchandani et al 2004) Provide opportunities for public opinion input Improving standard of care of private providers (Waters, Hatt et al 2003)

3.2 Participation

3.3 Formal communication/ feedback roles and channels

Create advocacy roles for public interest within new publicprivate entities

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Table 4b Non-State Providers: Strategic Framework, Examples
STRATEGIES 1.Market-based 1.1 Financing mechanisms 1.1.1 Social insurance Vietnam: Compulsory Health Insurance Fund (<6 yrs; Voluntary Health Insurance Fund >6yrs) + Health Care Fund for the Poor. Philippines: PhilHealth, which provides reimbursement to private midwives for safe deliveries and to private lung specialists for treatment of TB. Indonesia: Jamkesmas, social insurance for vulnerable groups. 1.1.2 Financial incentives 1.1.3 Contracting 1.1.4 Purchasing 1.2 Marketing mechanisms 1.2.1 Social marketing 1.2.2 Social entrepreneurial programs 1.2.3 Social franchising Cambodia: social marketing of subsidised malaria medication, diagnostics and nets; social marketing of oral rehydration and other basic medications through public and private channels. India: Visionspring—‘vision’ entrepreneurs to provide affordable eyeglasses to villagers. Vietnam: Tinh Chi Em Franchise Program (Atlantic: provincial ministries of health; CHSs, Atlantic Philanthropies, Marie Stopes Intern’l). Pakistan: Green Star franchises a range of family planning services. Philippines: Botikang Bayan private dispensing of basic pharmaceuticals. 1.3 Organisational collaboration 1.3.1 Alliances among providers 1.3.2 Coordination/alliances between public and private 1.3.3 Policy dialogue, communication 2. Legal/Administrative 2.1 Regulation 2.1.1 Accreditation/ certification 2.1.2 Licensing 2.1.3 Pricing mechanisms 2.1.4 Technology regulation 2.1.5 Market regulation 2.2 Training 2.2.1 Provider training 3. Public empowerment 3.1 Information dissemination 3.2 Participation 3.3 Formal communication/ feedback and channels Indonesia: State-operated health centres contain prominently placed posters alerting patients to their rights to free health care, that health staff are not to elicit extra payments and, if they do, the telephone number that patients should call to report these unlawful payments. Indonesia: Bidam Delima Program—IBI, Indonesian Midwives’ Association, with USAID grant. Updated, evidence-based, clinical midwife training program. Malaysia: Hospital accreditation via Malaysian Society for Quality in Health; UNICEF’s BabyFriendly Hospitals program. India, Thailand, South Korea: Accreditation schemes in place. Philippines: PhilHealth (national health insurer) licensing of private midwives. India: National Pharmaceutical Pricing Authority (Ministry of Chemicals and Fertilisers) sets and publishes prices for drugs. Thailand and other countries of Asia have in recent years adopted pharmaceutical and medical devices regulations harmonised with those of Australia and the EU. Thailand: A new law (2010) is proposed to compensate victims of medical negligence: all hospitals nationwide will contribute financially to a fund for victims of malpractice. India: Universal immunisation program based on alliance between public and private sectors. Bangladesh: National TB control program. State of Bangladesh and BRAC partnership. India, Bangladesh: Policy dialogue: Opportunities for formal dialogue were increased. Indonesia: Muhammadiyah—expansion into TB control with GFATM grant; USAID grant to implement culturally sensitive family planning programs. Bangladesh: Urban Primary Health Care Project and Bangladesh Integrated Nutrition Project. Cambodia: contracting in primary health care services from private (NGO) providers. EXAMPLES

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CONCLUSIONS AND RECOMMENDATIONS
This research was undertaken to inform policy makers and researchers examining the relationships between the state and non-state providers, with special reference to the Asia-Pacific region. The research was designed to support in-country studies in Indonesia, Vietnam and Papua New Guinea. The aim of the research was to identify preferred frameworks, typologies and definitions for use in individual case studies and to provide a common framework and terminology for the research and for 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 confirmed that reliable research into the relationships between the state and non-state providers is limited in both quality and volume. The authors found no literature relevant to the study aims that looked at informal providers, especially informal for-profit providers. While the literature did provide a useful approach to categorising types of providers, available frameworks for analysing and comparing these were of limited use because they did not include the full range of current mechanisms. The authors therefore constructed a framework that provides a simple but more comprehensive means of analysing and comparing relationships between the state and non-state providers in specific settings and, the authors believe, should be helpful in comparing different settings. The framework applies an initial analysis of relationships. However, further frameworks are required both to assess the capacity of any specific state organisation to enter into each type of relationship and to appraise the success of any relationship. These should be the subject of further work. It is recommended that the frameworks set out in Table 4a and applied in Table 4b be tested by application in several countries in the Asia-Pacific. The objective would be to assess the usefulness of the frameworks in describing, analysing and appraising state-NSP relationships. The results should then be used to revise the frameworks and to inform the development of additional analytical frameworks described above. A future working paper should report on the applicability and usefulness of the framework and typologies of mechanisms subsequent to this testing.

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APPENDIX 1. SEARCH STRINGS
‘Private sector’ OR ‘Non-state provider’ AND ‘Asia Pacific countries’ OR ‘Developing countries’ OR ‘LMIC’ OR ‘Middle 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 Pacific countries’ OR ‘“Developing countries’ OR ‘LMIC’ OR ‘Middle income countries’ ‘Private sector’ OR ‘Non-state provider’ AND ‘Health seeking behavior’ OR ‘Utilization’ OR ‘Service provision’ OR ‘Delivery of health care’ OR ‘Asia Pacific countries’ OR ‘Developing countries’ OR ‘LMIC’ OR ‘Middle income countries’ ‘Private sector’ OR ‘Non-state provider’ AND ‘Regulation’ OR ‘Legislation’ OR ‘Contracting’ OR ‘Incentive’ OR ‘Training’ OR ‘Collaboration’ OR ‘Asia Pacific countries’ 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 ‘Asia Pacific countries’ 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 ‘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 of health care’ OR ‘Asia Pacific countries’ 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 ‘Regulation’ OR ‘Legislation’ OR ‘Contracting’ OR ‘Incentive’ OR ‘Training’ OR ‘Collaboration” OR ‘Asia Pacific countries’ OR ‘Developing countries’ OR ‘LMIC’ OR ‘Middle income countries’

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APPENDIX 2. WEBSITE HAND SEARCH
DFID Health Resource Center http://www.dfidhealthrc.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 of Hygiene and Tropical Medicine http://www.hsd.lshtm.ac.uk/links/index.htm HLSP institute—Private 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 of 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) for 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 for better health http://www.psp-one.org Results for Development Institute http://resultsfordevelopment.org/about/newsandevents/final-reports- roleprivate-sector-health-systems-initiative-are-now-available World Bank—Knowledge Services for 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 PROVIDERS—KEY REFERENCES FOR STRATEGIES, MECHANISMS AND RELATIONSHIPS
Policy Dialogue Regulation Contracting Social marketing, franchising, entrepreneur-ship Financing Incentives (financial, other) Palmer 2006 Batley, Hussein et al 2004 Batley 2006 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003 Moran et al 2004 Balabanova, Oliveira-Cruz et al 2008 Taylor 2003 Berman 1996 Balabanova, Oliveira-Cruz et al 2008 Balabanova, Oliveira-Cruz et al 2008 Taylor 2003 Berman 1996 Taylor 2003 Berman 1996 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003 Moran et al 2004 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003 Moran et al 2004 Balabanova, Oliveira-Cruz et al 2008 Taylor 2003 Berman 1996 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003 Collaboration Information

Palmer 2006 Batley, Hussein et al 2004 Batley 2006

Palmer 2006 Batley, Hussein et al 2004 Batley 2006 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003 Moran et al 2004

Palmer 2006 Batley, Hussein et al 2004 Batley 2006 Peters, Mirchandani et al 2004 Waters, Hatt et al 2003

Balabanova, Oliveira-Cruz et al 2008

Balabanova, Oliveira-Cruz et al 2008 Taylor 2003 Berman 1996

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KNOWLEDGE HUBS FOR HEALTH
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