Speakers:

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

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

Moderator:
Guy Stallworthy, Bill and Melinda Gates Foundation

Presentations:

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

Respondents:

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

Q&A

Q:

• 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

Q:

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

Q:

• 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