IFI governance


The private sector and poverty eradication

Experiences from the health sector

23 April 2013 | Minutes


Paul J Gertler, University of California
Jishnu Das, senior economist, development research group, World Bank
Kim Longfield, director for research and metrics, PSI

Gwen Hines, World Bank Executive Director for the UK
Aaltje de Roos, Ministry of Foreign Affairs, the Netherlands

Guy Stallworthy, Bill and Melinda Gates Foundation


Jishnu Das

  • Gates foundation funded work
  • Health sector and markets in low income countries
  • Private sector and results focus of presentation, in particular for IFC
  • Do we talk about private sector in terms of specifics, or in terms of policy, and how do we define results
  • Traditionally if there is no health sector in a village, we should introduce it – but story was wrong
  • A village in India had a number of health providers, eg 100 – India one of the densest providers in the world
  • On average 5 providers in a village, more than in the US
  • But the poorest places had more health providers, and used them very often
  • Very few public sector, most private sector, most with no medical qualification, some have another degree
  • Steps from access, to access with quality
  • Measuring quality – research finding that qualifications is not competence, private sector operators diagnosis better, treatment better
  • It’s not what doctors know, only partly
  • Qualifications and availability of medical equipment are very poor predictors of quality of medical advice
  • Implications for regulation and policy
  • Quality multidimensional

Kim Longfield

  • working group of 9 organisations, two funders
  • social franchising for health
  • provide a set of services, including branding, training, standards and access to commodities
  • goals including, health impacts, equity, quality, health market expansion, cost effectiveness
  • most working in family planning, also tuberculosis, malaria, etc
  • stakeholders: programme managers, agency headquarters, other stakeholders
  • Equity: improved metric – I know I reach the poor because X% of my clients are poor (rather than just work in a poor area)
  • Metric attributes: easy to collect, low cost, comparable to national context and across countries
  • Wealth index: relative measure, uses DHS data, vs PPI – chose Wealth index due to cost

Paul J Gertler

  • how we can use measures to improve performance:
  • knowing how well you are doing: enables intrinsic and extrinsic motivation
  • let consumers know – enhances competition
  • let the market know – access to finance and investment
  • examples: pay for performance
  • primary health care in Rwanda
  • pay for more higher quality, rolled in national rollout
  • result: higher quality & improved health outcomes
  • African Health Equity Markets: scale up private primary health in Kenya, Ghana and Nigeria
  • constraints: access to finance, standardising and monitoring quality and management process
  • solutions: franchising, management systems & finance, all involve performance measurement
  • measuring performance, allows knowing what you are doing
  • use of intrinsic and extrinsic incentives
  • competition, access to finance, scaling up


Aaltje de Roos

  • since 2007 been trying to involve private sector in health programme
  • HIV/AIDS, found large proportion of private clinics underutilised as couldn’t pay for treatment, eg in India and Nigeria, 50-60 per cent health care through private clinics
  • fund to support private companies to develop insurances for low income groups to attend private clinics – subsidised private system
  • also privately funded investment fund in Africa, attract investment to improve quality
  • small private clinics need finance, access to finance added to insurance
  • need quality standards, too, trying to standardise quality, also to improve quality
  • working with health in Africa initiatives, including IFC

Gwen Hines

  • use results measurement key messages
  • board of WB group, including looking at investments if they are good enough – often look at results matrix
  • this is where evidence comes in, are we maximising impact
  • UK this year 0.7 goal on ODA, need to ensure we do the right thing, have to justify for tax payers
  • Challenges:
  • Results measurements, can you tell the difference between input, impact, output, etc
  • Language is a challenge
  • Quality of care important
  • How to distinguish who is poor
  • Women – how do we specifically target girls and women, including whether it is targeting the elite
  • What to do when targets aren’t achieved, how to check the results, eg self reporting and are people telling you the truth
  • Like the idea of mystery shoppers, I generally go for triangulation
  • Technology, teachers sub contracting their jobs
  • What do we do with all of this
  • Focus on mid course evaluation
  • Have to be prepared to learn from failure
  • Need to prepare incentives for people
  • Have do we really make WB a knowledge bank



  • broad brushed baskets where things are going, but not why they are going there
  • micro based, are our assumptions correct
  • but how do we empower businesses that partner with us to get strategic clarity


  • to what extent are you ready to tolerate failure in Africa


  • effectiveness, how to implement on how to collect data
  • skills to collect the information
  • challenge to attract quality staff, how to deal with
  • what data is needed, who need it, etc, India situation is not unique

Kim Longfield

  • try not to measure too much
  • by getting people involved, get them incentivised
  • challenge people to think beyond outputs to outcomes
  • so far doing toolkits, building up capacity of staff

Jishnu Das

  • access to finance for private sector important
  • are the private sector responding to people’s demand
  • informal providers already biggest health system, lot of thinking about how to deal with these – decentralised providers in a competitive market
  • IFC role: specific investments in particular firms or bodies, can pick a winner who can be a winner only with IFC support – need to find a way of picking out about a million of these guys

Paul Gertler

  • as money start to pour into private health sector especially health insurance, will see expansion
  • seeing some novel technologies and opportunities
  • will this be better than going to the bank for a loan
  • other technology, digitalising patient information through phone, eg in Africa

Aaltje de Roos

  • should allow failure as quite a new area and field of working, not everything goes right from the first moment
  • under scrutiny of public scrutiny
  • in Nigeria, progressing very well, but some challenges, which might result in an interesting business model

Gwen Hines

  • yes, have to tolerate failure, and do have to be innovative
  • have to balance your portfolio, have to show enough results, but retain a small percentage of high risk
  • debate need to be up front what percentage this is – what is the minimum level of result you can have to justify
  • eg P4R forces you to think up front
  • behaviour change the most difficult
  • need to learn from what is already out there
  • need to think about incentive structure
  • also need to know when to quit