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Shared risks Increasing Efficiency Development Partnerships tnerships alth in Africa Increasing Efficiency

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Engaging with the Private Sector in Health in Africa 14-16 May 2012 Dar es Salaam, Tanzania

Conference Synopsis

Organized by

In partnership with

on

Contents Preface

3

II Conference Parting Thoughts

18

Introduction

4

Appendix

22

I

Discussion Topics

6

List of Participants

22

I.I

Private Health Care Providers

8

Information about Partners and Sponsors

26

I.II Human Resources

10

I.III Access to Essential Medicines

13

I.IV Universal Health Coverage

15

I.V

Private Non-Health Companies’ Contributions to Health

17

Disclaimer Th is report summarizes presentations and discussions of the participants and does not necessarily express the views of the organizers and partners.

Shared risksHealth in Africa Public Private Dialogue 2

Preface The Regional Conference on Engaging with the Private Sector in Health in Africa – the first of its kind in Tanzania and jointly organized by various stakeholders – provided a unique opportunity for dialogue and exchange of experience among policy makers, private sector actors, civil society organizations, academia and development partners striving to improve health outcomes in Africa. By combining presentations, interactive discussions and networking space, the participants gained increased knowledge and understanding of the role and efficiency of private sector engagement in African health systems. The Government of Tanzania is responsible for providing quality health care services to all Tanzanians. However, recent data (2011) from the Ministry of Health and Social Welfare (MoHSW) show that 40% of the country‘s institutional health services are supplied by private health service providers, mainly Faith-based Organisations. Despite the Government’s effort to increase access to and quality of health services, financial and human resources remain major challenges. Even though the private sector is acknowledged as a significant actor in strengthening health systems in Africa, misconceptions and distrust between the sectors remain. In this light, the conference was amongst its participants widely perceived as an unique and much needed platform fostering open and transparent dialogue between state and non-state actors, which is needed to eliminate the existing aloofness and achieve the results desired by all. The conference gave all attendees, but particularly Tanzania as host of this international event, vital momentum and encouragement for further engagement on behalf of efficient public-private cooperation in African health sectors.

Hon. Regina M. Kikuli Acting Permanent Secretary Ministry of Health and Social Welfare of the United Republic of Tanzania

Synergies

Shared risks k Health in Africa

Increasing Efficienc 3

Introduction When it comes to health care, most societies face an ongoing challenge in ensuring adequate access to trained staff, equipment, appropriate infrastructure and financial resources; however, in low- and middle-income countries, this challenge assumes daunting dimensions. Th is is particularly true in sub-Saharan Africa (SSA) where health systems across the region face critical pressure. Th is region, which is home to 12% of the world’s population, has only 3% of the world‘s health workers and bears 26% of the global disease burden.1 Especially low-income households either cannot access health care services at all, due to high costs, or they face devastating expenditures when forced to pay out of pocket. Under such conditions, it is particularly important that societies account for, tap and consolidate all available resources – both public and private – and systematically resort to them to respond to their respective social challenges. Only in this way can they ultimately improve health outcomes and the overall quality of life2 and protect their people from the downward spiral of ill health, insupportable costs and subsequent impoverishment. Thus within the framework of strengthening health systems, fostering public and private dialogue, developing capacity and creating spaces for effective collaboration between sectors have emerged as priorities for development cooperation in Africa.

The Guest of Honour, Dr. Mary Nagu, during the opening ceremony

poorly integrated into efforts to strengthen health systems.4 5 The reasons that governments do not tend to engage with the private sector range from unawareness of private sector potential and a lack of capacity for engagement and outreach to outright distrust (well founded or not), compounded by the fact that the private sector is very diverse, fragmented and in many instances not sufficiently organized to produce concrete agendas and or articulate its positions with one voice. Public-private engagement is complex and challenging and does not automatically guarantee positive results for all parties involved.6 Different actors may pursue different though related goals. And in spite of the challenges and uncertainties, the pressing nature of health issues has elevated private sector engagement to a prominent place in the development cooperation agenda.7

The term „private health sector“ refers here to all nonstate entities operating formally or informally on either a for-profit or non-profit basis. The term applies to service providers, pharmacies, hospitals, pharmaceutical companies, producers and suppliers, retailers, and traditional healers.3 But the non-health private sector – e.g. private insurance companies or other private companies – also has potential for improving health in Africa. The role of the private sector in health in low- and middle-income countries has been steadily increasing in recent decades. But its contribution is often overlooked, discounted or not taken into consideration by governments and is

As part of an ongoing effort by development partners to strengthen health systems and improve health outcomes in sub-Saharan Africa, on May 14-16, 2012, more than 250 participants from 19 countries gathered in Dar es Salaam, Tanzania, to share their experience and knowledge, discuss best practices and explore different ways to foster the dialogue between public sector and private sector representatives. Nearly half of the people attending the conference actively contributed to the agenda as speakers on various panels, approaching the topic through a variety of angles. Th is pioneering conference, “Engaging with the Private Sector in Health in Africa: Learning

4 J. Jutting, 2002, “Public Private Partnerships in the Health Sector: Experiences from Developing Countries.” Extension of Social Security Paper 10, International Labour Office, Social Security Policy and Development Branch, Geneva; International Finance Corporation, 2008, “The Business of Health in Africa – Partnering with the Private Sector to Improve People’s Lives.” IFC, Washington DC; D. Hozumi, et al. 2009, “The Role of Private Sector in Health: A Landscape Analysis of Global Players’s Attitudes toward the Private Sector in Health Systems and Policy Levers that Influence these Attitudes.” Technical Paper 2, The Rockefeller Foundation-Sponsored Initiative on the Role of the Private Sector in Health Systems in Developing Countries, Results for Development Institute, Washington DC.

1 IFC, 2011, Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa, p.1, World Bank World Development Indicators Database, (Dec 2010); and WHO, Global Health Observatory Database, (Feb 2011). 2 It is expected that minimum levels of private sector engagement can contribute to better-quality health in Africa. WHO, 2007, Everybody’s Business – Strengthening Health Systems to Improve Health Outcomes: WHO Framework for Action (WHO, Geneva).

5 See also WHO (2000), “The World Health Report 2000: Health Systems: Improving Performance”, World Health Organization, Geneva, e.g. p. xv. 6 I. Baumgarten, presentation at Opening Plenary Session, May 15, 2012.

3 World Bank Group, Health Policy Toolkit Glossary, https://www.wbginvestmentclimate. org/toolkits/public-policy-toolkit/upload/Glossary-4-28-11a.pdf , (accessed July 28, 2012).

7 As reflected in the 36th World Health Assembly Resolution WHA 63.27 “Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services”.

4

Time

Monday 14 May 2012

08:30

Arrival

12:00

City Tour

14:00

free

Tuesday 15 May 2012 Opening Plenary Session: Setting the Scene

Discussion Topic 1a: Private Health Care Providers

Wednesday 16 May 2012 Info Market

Discussion Topic 2: Human Resources

16:00

Registration

17:30

Opening Ceremony

Info Market Center for Health Market Innovations

18:30

Reception

Dinner Launch of the GIZ Knowledge Hub

Discussion Topic 1b: Private Health Care Providers

Discussion Topic 3: Access to Essential Medicines

Discussion Topic 4: Universal Health Coverage

Info Market

Discussion Topic 5: Non-Health Companies World Café

Case Study

Case Study

Case Study

Case Study

Plenary Session Closing Session Farewell Drink

Figure 1: Overview of the conference set-up

from Experience”, was hosted by the Tanzanian Ministry of Health and Social Welfare and coordinated by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development (BMZ) in cooperation with United States Agency for International Development (USAID), Center for Health Market Innovations/Results for Development Institute, DANIDA and Kf W Development Bank. The quite diverse conference audience was made up of government representatives (24%), the private for profit sector (19%), international organizations (28%), local/regional NGOs (16%), and participants from academia and consulting agencies.

to health care providers, retention and capacity of chronically scarce human health-care resources, supply and distribution of essential medicines for optimal access, factors in universal health coverage, and the contributions of private non-health companies to health. In a series of forums and panels organized in parallel sessions, World Cafés and an information marketplace, the conference offered a unique opportunity to discuss the experiences of different stakeholders and experts from other countries in Africa and to draw attention to key capacities, pitfalls and best practices for implementing partnerships. See Figure 1 for an overview of the Program. The full Conference Program as well as all presentations for downloading can be found on the conference website: www.healthpartnershipafrica.com

During the conference, presenters and participants openly discussed key issues such as the availability of and access

Opening Ceremony (From left to right: Taji Liundi, Ali Mufuruki, Klaus Peter Brandes, Dr. Mary Nagu, Dr. Seif S. Rashid, Johnny Flento, Dr. Hashim Mohamed, Dr. Kebwe S. Kebwe)

5

I

Discussion Topics

Setting the Stage Opening remarks at the „Setting the Scene“ session pointed once more to the fact that while progress has been made in Africa some of the MDGs are not on line to be achieved.8 Progress in many SSA countries regarding health outcomes has not been as impressive as in other parts of the world that also began the decade facing nearly equally intimidating challenges. One example was given by D. Sanders,9 who points out how dismal economic performance can be as a result of the exodus of clinicians and other health professionals from the developing world, which needs them most, to more developed countries. Sanders points out that while this behavior might make good sense for the individuals who migrate, it only weakens structures that are already poor, such as a lack of qualified personnel. It is in such situations that engagement with the private sector, which is often able to keep professional cadres in usually underserved areas, makes sense in terms of developing and strengthening integrated health systems’ overall performance.

Prof. Dr. Khama Rogo during his presentation in the opening plenary session

such as access, convenience, price and perceived quality. Such individuals are basically “problem solvers”12 who stand to benefit from an integrated health system in which public and private actors work jointly to facilitate access to good quality health services and goods. Public-private engagement is understood here as the “deliberate, systematic collaboration of the government and the private health sector according to national health priorities, beyond individual interventions and programs”.13 However, it is important to mention that specific sessions in this conference also hihglighted the role of non-health private companies, since these have proven to be an important source of innovation in healthcare service delivery programs. Within this context, policy and dialogue, information exchange and regulation, financing and service delivery are key domains in any public-private collaboration. Therefore, creating conditions for fruitful dialogue is an essential precondition to the development of productive public-private collaboration.14

The challenges of providing accessible, quality services and forming a solid health workforce are exacerbated by the fact that the private sector in general is not consistently perceived as an integral element of a systemic approach to better health outcomes. That the importance of the private sector is purely nominal is reflected in the fact that although 39 of the 45 countries in SSA do have policies geared to engaging the Private Health Sector only 12 actually implement them. Additionally, in 30 countries the dialogue between the government and the private sector is insufficient or non-existent.10 Furthermore, only three of these countries actually request and acquire information from private health providers that goes beyond disease surveillance.11 With all the public health repercussions attendant upon the absence of proper observation, this lack of engagement has direct consequences for health systems performance and thus for health outcomes.

Foundations for effective dialogue Private sector assessments conducted by international organizations, such as the USAID funded SHOPS projects, in partnership with national governments have been instrumental in increasing government understanding of the private health sector’s capacity, scope and reach. A number of countries in the region have used either the Private Sector Assessment to Action or the Participatory Partnership Landscape Analysis (PLA) approach. Despite the differences, these complementary approaches have assisted African government to better understand the private sector’s contribution in the health sector as well as propose policy reforms to create a more enabling

African health consumers are forced to navigate a disjointed health care system, choosing services from either public or private entities depending on a variety of factors

8 WHO, various reports; I. Baumgarten, presentation at opening plenary session, May 15, 2012; FC, 2011, p. 13. 9 D. Sanders, “Key Considerations in Addressing Africa’s Health Crisis: Can the Private Sector Deliver? A View from Civil Society,” presentation at opening plenary session, May 15, 2012. 10 IFC, 2011, “Healthy Partnerships”, p. 34. Also referred by Rogo, K. “Strengthening Engagement with the Private Sector in Health in Africa” presentation at opening plenary session, May 15, 2012.

12 ibid, K. Rogo. 13 IFC, 2011, “Healthy Partnerships”, p. 1.

11 ibid., “Healthy Partnerships”, p. 40. Also referred by S. Conor, “Who is the Private Sector,” May 15, 2012.

14 IFC, 2011, p. 5.

6

Plenary Session: Setting the Scene

environment and identify concrete action to leverage private sector capacity.15 16

Creating government capacity As the public sector in Africa moves away from being a direct provider of health services, medicines and other health related goods and evolves into a sophisticated procurer, manager of complex contracts and regulator, different tools and new sets of skills are required among government cadres.20 Some countries in SSA have been establishing units (often referred to as “PPP Units”) devoted to planning and implementing public-private partnerships in order to strengthen effective and efficient engagement with the private sector. Development organizations have been assisting the building of their capacities.21 At the conference, representatives from the governments of Kenya, Tanzania and Uganda shared their experiences with setting up offices in their respective countries in charge of fostering private sector health engagement. In addition to brokering public-private partnerships, these offices build capacities for active engagement with the private sector, provide technical assistance, support program implementation, and conduct program monitoring and evaluation.

The assessment and dialogue approach has helped reduce the mutual distrust between sectors, and has served to create a space for common discussion of pressing policy reforms and opportunities for collaboration. Th is in turn has resulted in concrete partnerships between the public and private sectors.17 Th rough a panel interview, development organizations and government representatives from Kenya, Malawi and Namibia shared their experiences with the private sector assessments used in their respective countries. While different experiences account for different levels of success, the results are tangible. In Kenya, for instance, within only three years of a policy reform geared to expanding private sector participation, the Government of Kenya and private sector representatives completed up to 80% of the reform agenda.18 Sector-wide assessments provide governments with comprehensive information that allows them to understand the scope and reach of the resources available through the private sector. The establishment of units to develop purposeful partnerships with the private sector can align available resources with overarching health objectives. Presentations and related discussions made apparent that assigning public funds to these activities demonstrates political commitment to engage with the private sector to create a positive value equation for both the public and private sectors and for the populations they seek to serve.19

Participants could appreciate the inherent difficulties of actually engaging with the private sector, since basic functions such as coordination, information exchange or even creating conditions for dialogue are subject to political and financial constraints. In many instances, PPP Units do not enjoy priority status within volatile political agendas,22 and resources for collecting data and providing information are not always properly allocated.23 Still, governments resolved to strengthen their health systems by reaching out to the private sector have made progress in the formulation of public policy, thus laying the foundation for effective engagement to attain their proposed country health objectives.

15 N. Gitonga, “Country Assessment of Private Sector Engagement in Africa,” presentation May 15, 2012. 16 B. O’Hanlon, “Building MOH Capacity to Engage the Private Sector: Growing Experience of PPP Capacity in Sub-Saharan Africa,” presentation May 15, 2012. 17 “Creating Capacity to Engage the Private Sector: The Growing Experience of PPP Units in African Ministries of Health,” panel discussion with experiences from Uganda, Tanzania and Kenya, led by B. O’Hanlon, May 15, 2012.

20 K. Rogo, op. cit.

18 L. Kochellah Reforming the Policy Environment to Enable a Greater Private Sector Role: Kenya Private Health Sector Assessment 2009, Presented on May 15, 2012.

21 op. cit., presentations by Gitonga and O’Hanlon.

19 IFC, 2011, “Healthy Partnerships,” p.20.

23 K. Rogo, op. cit.

22 IFC, 2011, “Healthy Partnerships,” p.34.

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A common theme that emerged at the conference is that private sector engagement is one of many strategies to address complex health and social problems in Africa 24 Many hurdles, however, remain to engaging the private health sector, such as mutual distrust, fragmented and disorganized private sector, and limited government capacity to partner with private sector. Dr. Rogo admonished the government to undertake the required research to better under the private health sector activities and openly acknowledge the private sector’s contribution.25 Such existing challenges and hurdles, as well as already achieved progress and best practice examples, have been intensively discussed in the following focus topics in parallel sessions and working groups.

I.I

a true systemic approach to a form of health services delivery that would set common strategic objectives for all health providers.27 Th is increasingly important role for government calls for a proper execution of key functions such as information gathering and analysis. Also essential for government regulation of health care is a steady, credible and relevant flow of information from the private to the public sector, including provision for the accreditation of health facilities. Currently, out of 45 countries in the region, 33 require private sector facilities to provide such information. However, this information has actually reached the ministries of health of only three countries. A mere 6 countries have enacted a comprehensive registry of private facilities, even though all 45 countries supposedly perform the required inspections.28 These gaps between actual and theoretical reach run counter to any climate of mutual trust and instead reduce governmental capacity to develop comprehensive national health strategies.

Private Health Care Providers

Estimates suggest that roughly 50% of all households in SSA potentially get health services from the private sector.26 Th is proportion applies to all levels of wealth as well as to rural and urban areas, so private providers do not serve any particular socio-economic group or geographic setting. In this context „private sector“ refers to non-public health care providers, whether practitioners of mainstream medicine or traditional healers, for profit or non-profit. During the conference, participants from the government, the private sector and development cooperation organizations stressed the importance of agreeing on a common definition that would permit assessment of the private sector‘s real magnitude and ability to contribute to a country’s health outcomes. Experience shows that in some instances, when certain elements of the private sector have not been included in health outreach programs – e.g. traditional medical practitioners – overall health efforts falter.

Direct procurement As part of its stewardship functions governments evolve from direct providers to administrators and regulators, a new set of tools and skills becomes essential for strategic purchasing and effective quality enhancement and control.29 In order to procure services from the private sector and increase access to health care, particularly in remote areas served by non-profit actors such as faith-based organizations (FBOs),30 certain government prerequisites need to be met, such as adherence to quality standards and the setting of prices attractive enough to draw provider interest and commitment, as well as conditions for continuity, such as proper budgeting and basic guidelines for contracting services. Experience shows that when these elements are not present, negotiations face unnecessary hurdles, jeopardizing potentially successful operations. It is therefore important that both public and private providers work together to address the current shortfalls in contracting in order to reach to ultimate objective – increasing access to health services.31

Governments have traditionally assumed the main role in providing health care, as is demonstrated by the high proportion of the services they provide (the other half of the market in SSA). However, efficient allocation of scarce resources, combined with the need to expand access and improve outcomes, has stimulated governments to consider working with the private health sector, partly shifting the role of the public sector towards stewardship rather than actual provision of health care. An acceptance of this perspective increases the possibility of developing

Africans are gaining experience in direct government contracting as an effective way to engage the private sector. The Rwandan Health Sector Strategic Plan (2009-2012), embedded in the country’s Vision 2020,

27 A. Makaka, panel presentation “Engaging Private Sector Providers: Rwandan Country Perspective” May 15, 2012 28 IFC, 2011, Coraza, J. “Public Ends, Private Means: Harnessing the Private Sector by Contracting for Health Services,” May 16, 2012. 24 Point shared in several presentations by persons favoring greater participation of the private sector, addressed to those who questioned it.

29 J. Coraza, op.cit. 30 R. Kumwenda-Ng’oma, “Case Study on Improving Service Delivery Th rough Service Level Agreements Between CHAM Hospital and Malawi Government-Ministry of Health,” May 16, 2012.

25 K. Rogo, op. cit. 26 IFC, 2011, “Healthy Partnerships”, P.14, C. Spreng “Who is the Private Sector?” presentation May 16, 2012

31 R. Kumwenda-Ng’oma, op. cit.

8

Parallel Session on Health Care Providers

specifically promotes private provider engagement. Within this context the Rwandan Government seeks periodic exchange with private sector representatives and has partnered with several providers, ranging from private facilities to community based workers. Rwanda is a particularly interesting case, since its Vision 2020, initially viewed as overambitious, has seen major revisions as the initial benchmarks were surpassed.32

effective claims processing systems, and facilitate transparency and effective controls.34 Vouchers can help to introduce useful health system concepts such as insurance and prepayment to governments, health providers and the general population. In addition vouchers are said to contribute to overall quality improvement by requiring certain standards and trained staff for those providers interested in entering or remaining within this payment mechanism.35 However, attention must be paid to integrating vouchers in existing health financing mechanisms in the respective country to avoid a duplication of structures and to ensure sustainability. While not a panacea, the case of Kenya has shed light on this system‘s potential effectiveness, particu larly in ensuring access to quality reproductive health services to poor women. These early successes encourage government planners to expand it to include assisted deliveries.36

Voucher systems Procurement services do not always require direct purchasing from a provider. A variety of sometimes novel approaches exists to meet a variety of quality, access and financial goals and align them with the goals of the health system. One example of these novel approaches is the targeted use of vouchers for health. In some instances these vouchers have a particular health objective, as in Kenya, where the Ministry of Health has developed a program to improve access to maternal health care as part of the larger strategy of “Vision 2030.“33 Against this background the Government of Kenya has identified several promoting factors to enhance access to health care. As an output-based instrument that aligns health objectives and accountability, it acts as a portable subsidy that empowers consumers to meet their needs. In addition it enables its beneficiaries to choose providers based on their own criteria (i.e. convenience, quality, etc.) while encoura ging healthy competition among providers.

Social franchising These are networks of providers, contractually integrated to provide services with a social objective under a common brand. Social franchising is particularly active in sub-Saharan Africa, since various international private organizations have helped establish franchise networks as vehicles for improving health care access, quality and equity. By working with social franchises, governments can incorporate into their health system existing networks that have attained the required levels of quality, staff training and performance. Continuous capacity building is central within the social franchising concept

When resorting to vouchers, governments must also take steps to prevent fraud (i.e. falsified vouchers), develop

32 A. Makara, op.cit.

34 A. Njeru, “How Does the Voucher Program Work,” presentation, May 16, 2012.

33 W. Bitchmann, Kf W, presentation “Contracting Private Providers by Means of Vouchers for Maternal Health in Kenya,” May 16, 2012.

35 S.K. Sharif, Ministry of Public Health and Sanitation, Kenya, presentation, May 16, 2012 36 W. Bitchmann, Kf W, op. cit.

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facilities but not with private ones).38 It is important in reaching out to private providers and effectively including them in overarching health systems that rules and regulations be applied transparently and clearly as part of efforts to attain health and social objectives.

to ensure brand integrity for pre-established health and communication objectives.37 Successful interventions across the region show potential for a model that supports the government in its role as regulator, while suggesting that the private sector, too, could engage in effective self-regulation.

I.II Human Resources

The private sector reaches out Many African governments express how difficult it is to engage the private sector because they are disorganized and fragmented into different entities. As a result, the private health sector in Africa is increasingly becoming organized through umbrella organizations that group the diverse range of private sector groups by the activities they perform. These umbrella organizations help unify the private sector voice and present a cohesive front when dialoguing and partnering with the government. There are different types of umbrella organizations in the region bringing together similar private groups in health. In Uganda and Kenya, for example, the Faith Based Organizations have organized into inter-faith groups. In Kenya, the private health sector formed the Kenya Health Federation (KHF) as part of the Kenya Private Sector Alliance. KHF brings together all commercial groups engaged in health, ranging from private provider facilities, to private hospital, to private pharmacies, to private pharmaceutical manufacturing. As one association, KHF meets directly with the Kenyan government to discuss a wide range of health sector and market conditions that affect its members.

The existence of a qualified workforce, one that is sufficient in number and appropriately deployed, is one of the most important pillars of a health system. More than any other continent, Africa faces a health workforce crisis, as the region has only 3% of global health workers but must bear 26% of the global disease burden.39 According to the latest available data, the density of the health workforce population in the African WHO region is 2.3 health workers per 1000, compared to 4.3 in South-East Asia and 18.9 in Europe. Moreover, these blanket figures are misleading in that they obscure both variations between countries and urban/rural differences,40 so that the proportions of the crisis appear less daunting than they actually are.It is difficult to shed light on the connection between the private sector and human resources for providing health services, as it is determined by the nature of the organizations involved (for-profit, non-profit, faithbased) in different tasks, from professional and technical education to health services delivery. “In the midst of a mixed public and private health system,” as it was framed in one conference presentation,41 the private sector can be considered a significant contributor to professional training.42 Faith-based organizations participate decisively in producing health workers. For instance, in Malawi 40% of the existing health workforce is trained by faith-based organizations.43 Along the same lines, in East Africa, Aga Khan University, for instance, has trained approximately 1800 health professionals to date.44 One can also witness an increase – not only in Africa but also globally – in for-profit health professional training. However, as these private organizations continue to produce new professionals, the regulatory function of the government becomes ever more relevant, as one of the main issues noted is the uneven quality of graduates,

Recently these efforts have been transcending national borders. The East Africa Health care Federation Conference held from May 1 to 3, 2012, assembled umbrella organizations from Kenya, Uganda, Tanzania and Rwanda. Despite substantial differences between these countries, several common areas do exist, such as the push to advance their agendas for the private sector to work with their respective public sectors. While there has been significant progress in developing productive and lasting relationships between government and private sector actors, some areas still merit further consideration. Examples included agent problems related to the implementation of norms and regulations, which in some countries means applying the same regulations in different ways (e.g. a lack of consistency of governments to apply rules, as panelists mentioned instances where regulations were ignored when dealing with public

38 Panel discussion: “Networking Amongst Private Healthcare Providers: Synergies and Efficiencies of scale,” May 16, 2012. 39 IFC, 2011, “Healthy Partnerships”. 40 B. McPake, presentation , “Health workers’ training and employment choices in the midst of a mixed public and private health system”, May 16, 2011. 41 ibid. 42 ibid. 43 D. Mwarey, presentation, “FBO Contributions to HRH in Africa: Experiences from the Africa Christian Health Associations (ACHA) Platform”.

37 Panel on Social Franchising, organized by Marie Stopes, International and Population Services International, attended by Mbongo Bunyi, Kenya; Edwin Mbugua, Kenya; Jon Cooper, Uganda; Romanus Mtung’e, Tanzania; and Caitlin Mazzilli, UK.

44 A. Yasmin, M. Michaela, presentation, “Towards the AKDN Integrated Health System in East Africa”.

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Parallel Session on Human Resources

possibly exacerbated by insufficient capacities for regulation and quality assurance.45

research suggests that a considerable number of public health services providers provide private services as well to supplement their salaries. Th is raises the question not only of the possible impact of dual practice on the quality of publicly provided care but also of its potential for retaining medical skills at the national level.49

Another important factor is professional employment. While exact figures are difficult to obtain, estimates indicate that in some countries in Africa up to two-thirds of doctors work in the private sector. Some characteristics of the public-private mix in employment, such as a concentration of the private for-profit sector in wealthier urban areas, are rather common, especially with respect to higher cadre levels. Th is might indicate that the distribution of the health workforce within the private for-profit sector is more inequitable than in the public or private not-for profit sectors, including the faith-based organizations.46 Faith-based organizations are major contributors to health service provision in sub-Saharan Africa: estimates in several countries suggest they provide between 30% and 70% of services delivered. They are of particular importance for services delivery in many remote, hard-toreach areas, despite the fact that in some countries these organizations are still not recognized in national plans and are in some instances affected by the migration of health professionals to the public sector.47

Innovation in human resources for health Since the private sector, too, must cope with human resources challenges, innovation has proved essential for its operations. The authors of a report by the Private Sector Task Force, operating under the aegis of the Global Health Workforce Alliance, have identified nine factors that, combined, constitute an enabling environment for increasing the supply and efficiency/effectiveness of the health workforce and for retaining that workforce: government, political will, professional health worker advocacy organizations, local ownership, education and training, technology, civil society, business and capital, and health innovators. The relationship between the private sector and its environment is bi-directional. While private sector capacities may be constrained by the environment the private sector must operate in, at the same time private sector activities influence this environment.50

The distribution of private and public health service providers is difficult to estimate, since public sector providers not uncommonly provide health services privately at the same time – “dual practice,”48 as it is known. Available

Concrete examples of private sector innovations and operations can be found, for example, in Mali, where physicians have been successfully installed in rural areas by using private sector and contract modalities and allow

45 B. McPake, presentation, “Health workers’ training and employment choices in the midst of a mixed public and private health system”, May 16, 2011. 46 ibid. 47 D. Mwarey, presentation, “FBO Contributions to HRH in Africa: Experiences from the Africa Christian Health Associations (ACHA) Platform”.

49 B. McPake, op.cit.

48 „Dual practice“ may also refer to public providers engaging in other non-health related activities for additional income (see, for example Kiwanuka et al. 2011, Dual Practice regulatory mechanisms in the health sector, a systematic review of approaches and implementation, London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, p.1); however, here referring to health-related, and primarily activities related to service provision.

50 Jeff rey L. Moe, presentation, “Health Workforce Innovation: Accelerating Private Sector Responses to the Human Resources for Health Crisis,” see also: „Report of the Private Sector Task Force on Human Resource for Health/ Global Health Workforce Alliance,“ in particular pp. 21-38, at http://www.who.int/workforcealliance/knowledge/resources/ privatesectorhrh_report/en/index.html

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ing on-going medical education. The Malian Rural Physicians Initiative launched in 1989 by the Medical Faculty of the University of Bamako and supported by the NGO Santé Sud has been able to sustain its operations right up to the present: 256 rural doctors currently provide services to approximately 3 million inhabitants, representing about 30% of the rural population and 20% of the entire population of Mali. Of the program‘s practitioners, 87% have been active for more than five years, some practicing in rural areas for as many as 22 years. Political support has been an essential factor in this success story.51

Partnerships and collaboration Engaging with the private sector to establish cooperation and build partnerships, to facilitate and scale up innovations and, where and when necessary, to find ways to eliminate counterproductive competition between the public and the private sector is essential in light of the scarcity of human resources for health. The positive effects of private sector engagement are not confined to innovative arrangements such as the e-learning nurse upgrading program model mentioned above but are also reflected in the memoranda of understanding signed between faith-based organizations and ministries of health and implemented in Ghana, Malawi, Zambia and Kenya. These include temporary secondment, competitive compensation and payroll management, and support for facilities and essential medicines. Collaboration between faith-based organizations and public- and other private-sector actors has also resulted in improved data sharing and better health sector human resources planning.55 Responding to the needs of communities, the Aga Khan Development Network (AKDN) seeks to establish long-term partnerships with local governments. To this end, Aga Khan University (AKU) has developed an integrated primary health care (IPHC) partnership model in collaboration with the University of California at San Francisco (UCSF) and Kaloleni District, Coast Province, in Kenya. The partnership focuses on education and capacity development for health professionals, quality assurance for health services, and research to channel knowledge and compile best practices on the community level to the secondary health care level, with a focus on primary health.56

In Uganda, the Private Midwives Association, established in 1948, has played an important role in keeping midwives practicing while ensuring their on-going skills development until they retire at age 60. Th is approach has reduced attrition and extended the productive life of experienced health professionals in an environment that actually needs them. While financial sustainability has been a challenge, factors enabling their operations include political and community support as well as favorable policies and regulations.52 Emerging technologies, such as information communication (ICT), also promote innovation. In Kenya the e-learning nurse upgrading program has been designed to enable nurses to carry out tasks newly assigned to them within the context of task shifting. It was introduced in 2005 as a public-private partnership between the Kenyan Ministry of Health, the Nursing Council of Kenya, Accenture and AMREF. The program started with a small pilot project that enrolled 145 students in 12 schools. Over the last six years it has grown exponentially: it now numbers more than 10,000 students in 34 schools and has graduated over 4,000 registered nurses during this period.53 Th is experience shows the importance of having national players such as the Ministry of Health and the Nursing Council of Kenya initiate the program to ensure that stakeholders buy in. Factors such as transparency, clear understanding and a clear statement of objectives for all parties involved were also essential. To make the program affordable for potential applicants, a PPP model was used, including AMREF, J&J and the Kenya Women Finance Trust to establish an appropriate funding mechanism.54 These interventions signal possible courses of action for effective private sector engagement.

Two examples of challenges to overcome and points to consider are the risks that dual practice may gradually bring about a privatization of health services and that private sector interests and that regulatory bodies might not be kept distinct from one another as they must be. Still, it may prove possible to encourage private sector training that would improve job recruitment in the public sector, or that dual practice might retain qualified staff in the public sector and not necessarily eliminate its presence there altogether. Further research is needed on how to achieve these goals.57

51 N. Karamoko,”Medicalization of rural areas: The example of rural doctors in Mali”, presentation May 16, 2012

55 D. Mwarey, presentation, “FBO Contributions to HRH in Africa: Experiences from the Africa Christian Health Associations (ACHA) Platform”.

52 M. Micheal, presentation, May 16, 2012.

56 A. Yasmin, A. Michaela, op. cit.

53 C. Mbindyo, “The eLearning Nurse Upgrading Programme”, presentation May 16, 2012

57 B. McPake, presentation, “Health workers’ training and employment choices in the midst of a mixed public and private health system,” May 16, 2011.

54 C. Mbindyo, op. cit.

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I.III Access to Essential Medicines Access to essential medicines is a must for proper care. A concerted effort is needed to see that good quality drugs and materials reach patients, and this does not happen as often as planned or desired. Many steps have to be considered, from procurement and manufacturing to distribution and timely and consistent delivery of products. In nearly all of the steps in the supply and distribution of medicines, challenges to private sector engagement arise.

Session Moderator Francis Aboagye-Nyame

To engage with the private sector in facilitating access to essential medicines, the capacity and know-how at hand in the private and public sectors and the scope and constraints on the engagement must be taken into consideration.58 Certain questions must be addressed. For example, what are the motives and interests of the private sector? Can it reach out to poor or remote populations? If so, under what conditions can it distribute medicines of acceptable quality?59 At the same time, it is of the upmost importance that the public sector have in place the necessary capacity and control mechanisms to enforce regulatory frameworks and compliance to standards, rules and regulations and to ensure consumer protection and equitable access.60

national) funding, capital, skilled labor, and the fostering of entrepreneurial spirit, so that an environment is created that is favorable to strategic and productive public-private partnerships. While a growing sense of local entrepreneurship is in evidence, the overall climate for doing business in Africa – pivotal in attracting private investors to develop productive or distribution capacity – is in some instances weak. Whether it comes to enforcing contracts or paying taxes, ordinary business-related activities are always time-consuming.63 Local entrepreneurs must also cope with difficulties such as an absence of utilities and general infrastructure and in many instances a dearth of skilled workers and technicians as well. These factors make competition even more difficult for local manufacturers: to get established in the first place and to succeed thereafter.64 Finally, there are limitations on what can be manufactured domestically; manufacturers may still need to import raw materials and equipment.65

Production Africa relies heavily on imported medicines. In East Africa, for example, only 25% of medicines are locally manufactured, which must be taken into account wherever the demand actually met is almost evenly distributed between the public and private sectors. Where the gap between demand and supply reaches a staggering 70%, however, there is an exaggerated dependence on imported medicines (whether brand medicines or not).61 62 It is within this sphere that local manufacturing may improve access to essential – in this context critically scarce – medicines. One factor influencing the level of activity can be the priority that government political agendas give to the consideration of health issues generally and to access to essential medicines in particular. One indicator would be guarantees of political support for local manufacturers of pharmaceuticals, including public sector preferences for generic medicines, the existence and effective enforcement of appropriate regulatory frameworks, relatively stable socioeconomic conditions, the availability of (inter-

Supply and distribution Inadequate warehousing, transport and forecasting capacities, faulty product traceability, and deficient financing options are not uncommon. So beyond the actual manufacturing process, to ensure access, a distribution system that is aligned with the country’s health strategy is a must. The commercial private sector (whether health care related or not) has well-founded experience in product distribution. Worthy of consideration are private sector approaches to improving public sector supply chains, which could contribute to more cost-effective logistics while addressing the challenge of meeting an increasing demand for health commodities when supply does not grow proportionally. For instance, vendor-managed inventory models and possible alternative roles for centralized medical stores might be “ways the private

58 F. Aboagye-Nyame, “Access to Essential Medicines: Private Sector Engagement in Supply and Distribution,“ May 16, 2012. 59 A. McCabe, “Private Sector Pharmaceutical Supply and Distribution Channels Focus on Ghana, Malawi and Mali”, presentation May 16, 2012. 60 A. McCabe et al., op. cit. 61 R. Madabida, T. Walter, presentation, “Local Pharmaceutical Production in Africa Challenges and Opportunities”, May 16, 2012.

63 IFC, 2011, “Healthy Partnerships”

62 R. Madabida et al., op. cit.

65 R. Madabida et al., op. cit.

64 R. Madabida et al., op. cit.

13

sector can enable the integration of public health supply chains.“66 Health systems might also learn from the experience of commercial distributors – or it could contract them – in going the “last mile” in line with the „CocaCola model“ (a reference to the famously successful distribution of the ubiquitous drink).67 While such effective distribution systems have ensured commercial distributors sustainable sources of income, it is important, from a health systems perspective, that inefficiencies resulting from redundant structures be properly addressed and quantified and decisions made accordingly.68 Additionally, for engagement, the capacities and capabilities of the different stakeholders for involvement (e.g. the ability to operate on a national scale or to deal with procurement agents,69 as well as the level of business knowledge70 and regulatory capacities) must be taken into account. Further, models have been set up that employ institutionalized dialogue structures and involve faithbased structures to improve the management and distribution of medicines. These also incorporate a solidarity mechanism that can narrow the gap in the costs of supply and distribution in easier-to-access and remote areas respectively.71

While the possible role of private actors in this area is still mired in controversy,74 when asked, private retailers from Ghana and Kenya see a major role for the government, since effective consumer protection can come only from actively ensuring – through regular and consistent inspections – that drugs are of good quality and that sales of counterfeit drugs are consistently punished.75 Retailers see the government‘s role – as an effective and trustworthy regulator ensuring transparent market competition76 and a consumer educator informing the public about health issues, related products and healthy behavior – as essential to increasing access to quality medicines.77 Potential for increasing safe consumer access to essential medicines may also lie in expanding the self-regulation capacities of existing private provider associations (e.g. The Patent Medicine Vendors in Nigeria).78 In sum, governments, in their efforts to improve health outcomes, should consider getting to understand the private sector better and working with it more effectively, so that the contribution of the private sector and the objectives of the government can become better aligned. The continent already offers interesting examples. For instance, much can be learned from the Tanzania experience of transforming existing drug shops into government-accredited ADDOs (Accredited Drug Dispensing Outlet) to increase access to quality medicines. The conversion involved setting standards, training, business incentives, and regulatory adaptations and enforcement. A decentralized approach to implement activities in the districts combined with maintenance of an overview on the national level meant that ownership could be secured, implementation costs mitigated and scale-up more easily enabled. As a positive by-product, ADDOs have also imcreased employment opportunities for women in rural areas, as more than 90% of the trained dispensers are women.

Retailing There is growing evidence that the private sector is sometimes the first or even the main point of access for many consumers,72 as witnessed by anti-malaria drugs. First, there are many kinds of private outlets, from private forprofit pharmacies to street hawkers. Their respective share in supplying the population with antimalarial medicines varies from country to country. Further, depending on the outlet type, the availability of WHO-recommended ACTs is generally low in the private sector, while nonartemisinin therapy continues to be widely available. Hence, the quality of products and services, as well as inequity – more prevalent where the private sector dominates the market – remain central elements that need further investigation and should be addressed to protect customers.73

As part of efforts to develop more comprehensive, fair and effective health systems in the region, much may be gained by considering ways to engage with and take into account potential private sector contributions at each level and in every dimension of access to essential medicines. It is worthwhile looking into and assessing incentives, framework conditions, regulation and the capacity needs

66 O. Dia, “Leveraging Commercial Sector Practices to Improve Public Health Supply Chain Performance,” presentation, May 16, 2012. 67 Muja, M. “Pharmaceuticals Supply and Distribution”, Tanzanian case study from the Medical Stores Department (MSD), presentation, May 16, 2012.

of private and public actors alike.

68 Plenary discussion notes. 69 O. Dia, “Leveraging Commercial Sector Practices to Improve Public Health Supply Chain Performance,” presentation, May 16, 2012. 70 A. McCabe, „Private Sector Pharmaceutical Supply and Distribution Channels Focus on Ghana, Malawi and Mali,“ presentation, May 16, 2012.

74 N. Burger, J. Yoong, op. cit. and T. Shewchuk, T. op. cit.

71 G. Eppel, “How to improve, in a sustainable way, access to essential medicines through dialogue structures; The Regional Funds for Health Promotion in Cameroon,” presentation, May 16, 2011.

75 N. Burger, J. Yoong, op. cit. 76 N. Burger, J. Yoong, op. cit.

72 N. Burger, J. Yoong, “Public Engagement with Private Pharmacies and Implications for Access: Evidence from Kenya and Ghana,” presentation, May 16, 2012.

77 S. Kimatta, H. Silo, “Experience from the Accredited Drug Dispensing Outlet (ADDO) Program,” presentation, May 16, 2012.

73 T. Shewchuk, “Consumer Access to Essential Medicines through the Private Sector in 7 African Countries: the Case of Antimalarial Medicines,” presentation, May 2012.

78 O. Oladepo, V. Mamah, “Experiences of Patent Medicine Vendors in Engaging the Public Sector for Malaria Control in Nigeria,” presentation, May 16, 2012.

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insurance with community-rated contributions or a purely commercial form, with risk rated contributions.82 Then there are as well social security schemes operated by private agents/insurers as in Switzerland or Ghana. Therefore, in reality the differentiation between public and private insurance often becomes artificial, and the line between the two forms is blurred. For this reason organizations like WHO are advocating the more relevant differentiation between voluntary and mandatory insurance, as this has greater implications for health financing policy choices.

World Café

I.IV Universal Health Coverage

For any given country context, four private health insurance options may be distinguished. The first is private health insurance that provides basic health coverage only. Alternatively, private health insurance schemes may provide coverage that is complimentary to public (social) health insurance schemes. Supplementary schemes cover services not covered by public health insurance. Finally, duplicative schemes cover the same services as public schemes, but allow access to different providers.83 The four different options will also have different positive and negative implications for the achievement of universal health coverage.

Universal health coverage entails concepts to provide a country‘s entire population with access to affordable quality health services, including prevention, promotion, treatment and rehabilitation. It particularly stresses concepts for keeping people from falling into poverty due to health care expenditure.79 In SSA, out-of-pocket (OOP) payment is widely prevalent (up to 60% of all health expenditures are OOP). The practice is deemed to be socially recessive: it reduces many people‘s access to health care services, and the health care expenditures involved, which are overwhelming for economically fragile persons, can push people under the poverty line. A continuum of health financing exists for achieving universal coverage. Social health protection, as the most comprehensive concept for universal coverage, comprises all health financing mechanisms based on prepayment and pooling. These can be clustered around tax-based financing, social health insurance schemes (or usually a mix of both) and some forms of private health insurance, including communitybased schemes.80

The specific way in which governments and the private sector interact, and the way health insurance markets are structured, depends largely on the country context.84 In its quest for universal coverage, a government can consider integrating voluntary health insurance within national health financing frameworks, providing clear guidelines and „rules of engagement.“85 Different questions arise in different contexts. The crucial question in some countries, such as Mali, Benin, Senegal and Nigeria, is how to integrate small-scale communitybased health insurance into the national health financing framework in order to attain universal coverage. Or how to transform them into some form of social health insurance. The example of South Africa, also discussed in this session, posed yet a completely different question: How to accelerate progress to universal coverage via public insurance, when the existing health financing system has a huge (commercial) private health insurance market?

Private health insurance is often defined along the divide with social health insurance. Social health insurance schemes provide coverage for a large part of the population, based on mandatory contributions by employers and employees that are required and regulated by law, whereas private health insurance is generally not regulated by the government and is financed through direct payment of premiums to insurers.81 Nevertheless, several different forms of private health insurance can be identified, such as (employer-based) group health insurance, private social health insurance, and voluntary health insurance. The latter can take the form of community-based health

Analysis of household survey data in Nigeria indicates that willingness and ability to pay for health care – even by those considered poor – is significantly greater than the government’s capacity to gain revenues through taxation.86 Tapping these resources would be a tremendous 82 I. Mathauer, op. cit.

79 World Health Report 2010, p.6

83 I. Mathauer, op. cit.

80 I. Mathauer, “Private health insurance and its contribution to in moving towards Universal Coverage,” presentation, May 16, 2012.

84 I. Mathauer, op. cit.

81 I. Mathauer, op. cit.

86 Intervention of Ladi Awosika, May 16, 2012.

85 I. Mathauer, op. cit.

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achievement, but doing so efficiently poses a challenge. Innovative solutions like the use of mobile phones could lower transactional costs and make the collection of these resources feasible. In a context such as SSA, in which the informal sector is significantly larger than the formal sector, these interventions might provide the infrastructure needed to expand access to existing health systems it is estimated that the informal sector serves 75% of the population in Nigeria.87 These approaches might incorporate peripheral resources into the larger, mainstream pool, creating foundations for long term sustainability, the empowerment of the habitually destitute and the meeting of demand among them. In this case, countryspecific government interventions88 on both the supply and demand sides,89 on regulation, targeted subsidization and capacity building of government staff might be areas for effective engagement with the private sector90 in a common effort to expand service coverage and build the road towards universal access to health care.91 Successful country cases of integrating small-scale community health insurance into the national health financing framework for universal health coverage include Ghana, where voluntary community-based health insurance schemes were expanded into a national insurance scheme, and Rwanda, where against a backdrop of fragmentation, several community-based health insurance schemes switched from voluntary to mandatory enrolment.92

fragmented systems. Regulation and enforcement are necessary to ensure equity of access and health financing and to move towards universal health coverage.94

If coverage is to become universal, private and public sector actors must overcome a profound mutual mistrust that possibly arises from not using the same language to refer to complex issues concerning costs, coverage and the perceived ability to deliver.93 Private health insurance simply must be considered in public health sector plans and health financing strategies and prejudice against such possibilities overcome. Policy makers must be clear about the role they wish to assign to voluntary health insurance and about how to make such insurance complementary (see Figure 2). Governments must thus also be clear about what a core public/obligatory scheme would cover. Regulation is another important challenge: a lack of regulation of voluntary health insurance markets will lead to highly

Role of VHI

Positive implications on UC

Negative implications on UC

Substitutive

If contributions are higher than in public scheme: - possibly overall more money in the system; possibly cross-subsidization at provider level

Fragmentation => unequal p.c. expenditure between schemes; inequity in access May result in twoclass health care provision

Complementary

Reduces OOP expenditure and thus incidence of catastrophic fi nancing

Adverse selection; induces moral hazard; increased overall expenditure of primary coverage scheme; inequity in access

Supplementary

Potentially crosssubsidization at provider level

Duplicative

More money for those in primary coverage scheme (without duplicative coverage)

Often leads to two-class health system; inequity in access

Figure 2: Roles of Voluntary Health Insurance (Source: I. Mathauer, Presentation May 16 2012)

87 H. Uweja, “Roll-Out Strategies in Implementing Community Based Health Insurance Programme in Nigeria,” presentation, May 16, 2012. 88 M. Kimball, “How to integrate health micro-insurance into health fi nancing frameworks for universal coverage: What role can community-based health insurance play?” presentation, May 16, 2012. 89 B. Ruff, “Reform of the South African Private Insurance Healthcare sector,” presentation, May 16, 2012. 90 Ladi Awosika, May 16, 2012. 91 A. Johnston, “Reforming Healthcare in South Africa: What is the Role for the Private Sector?” presentation, May 12, 2012. 92 I. Mathauer, op. cit. 93 I. Mathauer, op. cit.

94 I. Mathauer, op. cit.

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I.V Private Non-Health Companies’ Contributions to Health When talking about private sectors contribution towards effective health outcomes, even corporates with core business in other sectors than health have come up with viable solutions and various innovations, such as helping governments use emerging technologies (i.e. information communication technology (ICT)) to collect and make use of data. Another example are managerial innovations such as using existing supply chains as a conduit for health programs (Heineken company in several countries in Africa). Moreover, employee wellness programmes and various other creative partnerships to develop business ventures involving health issues (Global Alliance for Improved Nutrition in Tanzania) can be found in many African countries.

Parallel Session: Case Studies

over government responsibility for ensuring their societies’ wellbeing, but are to complement larger public programs instead.98 Room for innovation in this ever-changing environment is vast, and for that reason, attractive. Examples abound: Namibia follows a strategic approach to promote workplace programmes and private sector resource mobilisation through complementary contributions by the government, the private sector and trade unions. Th is approach, agreed in the Tripartite Agreement supported by the ILO and GIZ, was signed in 2011. In order to ensure effective implementation of the tripartite approach, participants agreed on the importance of strengthening national ownership by involving overarching institutions such as the Office of the Prime Minister and the ILO. Private sector bodies such as the Namibian NABCOA are to articulate the private sector viewpoint and its needs and to pave the way to more holistic health approaches, such as Employee Wellness Programmes.99

According to WHO, “a healthy workplace is one in which workers and managers collaborate to use a continual improvement process to protect and promote the health, safety and well-being of all workers and the sustainability of the workplace[...]”95 Th is definition includes the physical and psychological well-being of the workers, their families and their communities. There are encouraging examples of innovative employer interventions, through which non-health companies have achieved tangible benefits by transcending the usual approaches to workplace health programs and engaging workers and communities in health efforts.96 As evidence accrues that investments in health care at the workplace often produce positive financial results,97 commercial companies are increasingly searching for means to help improve their employees’ situations and, concomitantly, increase their productivity. As African economies expand and manufacturing activities follow suit, integrating workplace interventions into larger health systems is of essence for attaining positive health outcomes. These interventions can create positive synergies, as the public sector adds private resources into the health systems, while commercial companies benefit from public structures and know-how.

Taking an very innovative approach, Biolands International, a cocoa trading company operating in Tanzania, led an effort with the staunch support of the local government of Kyela District to setting up of a Community Health Insurance Fund (CHIF) Association in charge of the Community Health Fund (CHF) premium management to provide access to affordable and sustainable quality care to over 16,000 district residents by encouraging real participative governance and ownership. In addition the scheme is built on professional insurance management principles and on a contracting approach between public and private health providers and CHIF Association. Th is has made the product more attractive particularly by including access to a faith-based hospital (Matema Lutheran Hospital) and to private

Since some acute conditions have become chronic, as in the case of HIV-positive persons who are under treatment, workplace programs can help keep individuals healthy and productive through targeted interventions that facilitate access to medicines and treatment. It is understood that these programs are not meant to take 95 WHO, 2010, “Healthy workplaces: a model for action: for employers, workers, policymakers and practitioners,” p. 11. 96 S. Segbaya, “Scaling Up Indoor Residual Spraying in Ghana: The AngloGold Ashanti experience,” presentation, May 16, 2012.

98 Buch von Schroeder, C. H. Schilthuis , L. Luyalu, “Extending HIV Workplace Programmes to Bralimas’s Supply Chain,” presentation, May 16, 2012.

97 “Mitigating the impact of HIV and AIDS in the private sector” GIZhttp://www.giz.de/ themen/en/35665.htm, accessed Aug 26, 2012.

99 Poster on Case Study Namibia

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pharmacies; but also via the low price of the premium through a premium subsidy by Biolands for cocoa producers and by the Council for non cocoa producers.100

Interventions based on ICT can support low-income countries in effectively conducting disease surveillance and analysing data in order to strengthen their ability to respond timely to threats as they arise. The Health Tanzania partnership is a MOHSW-led innovative initiative that seeks to scale up Electronic Disease Surveillance, using mobile communication technologies (mobile phones and PDAs), to facilitate reporting, surveillance and response to prevent diseases and control outbreaks, and thus attain health objectives. Th is initiative seeks to establish partnerships with the private sector that offer clear advantages to all parties. For the private sector side, benefits associated with new markets and business development, enhanced public relations, increased brand appreciation and marketing value, while improving relations with the government, are becoming in themselves reason enough to warrant participation in this program: they thus create favorable conditions for sustainability.105

Private non-health companies’ health programs are not confined to the working environment. In Ghana, Ashanti Gold carries out indoor residual spraying in an effort to prevent malaria. Th is is an example of a commercial non-health company interested in the profit-related elements of the public health agenda, mainly as they affect a significant portion of the workforce and result in significant rates of lost manpower days per month, which also places a significant financial burden on the affected families.101 As these programs contribute to addressing health care deficits, it is important that governments incorporate these interventions within the larger context of national health systems. As such, collaboration based on policies that facilitate commercial sector participation, such as tax exemptions for materials,102 could contribute to the attaining of proposed health objectives. Active engagement in dialogs between private and public sector representatives are crucial in ensuring good coordination between actors.103 In addition, within this context, it is essential that governments develop institutional capacities and allocate the resources needed to implement, coordinate and harmonize those activities. Th is will ultimately reduce donor dependence, while ensuring that most (if not all) health efforts carried out by non-health companies are part of the national health agenda. It is furthermore crucial that adequate legal frameworks be developed, as partnerships between public and non-health private companies are usually not covered under classical PPP legislation.

While support from non-health companies can definitely contribute to the achievement of government health objectives, in all of the examples mentioned it is essential that transparency prevail, so that broad societal support for these interventions is ensured.

II

Conference Parting Thoughts

Political leader, policymakers and high-level leaders from the private sector, along with development agency representatives, actively participated and contributed to Conference’s proceedings. Th roughout the two days deliberations, the Conference participants shared knowledge and experiences, thereby increasing understanding of each other’s contributions and roles in improving health services for all in the region. The conversations between the public and private sector on how to best engage the private sector, direct and at times quite candid, provided a welcomed opportunity to talk and learn from each other. At the end of the day, the Conference not only achieved but exceeded its goal to create a platform to exchange ideas on how the public and private sector can better work together to achieve health outcomes in Africa.

Apart from interventions targeting occupational health, non-health companies can contribute to the improvement of the overall health outcomes of the population by supporting governments as they seek to incorporate new technologies into activities to improve management systems104, monitor disease progress or use them in circumstances requiring health service support. Governments can multiply their scarce resources by channelling them to those in need, mainly the poor, for instance in the case of maternal health interventions that are based on information communication technology.

The lively, well-informed debates gave rise to a wealth of reflections, which were captured by several rapporteurs and a core editing team in order to enable a selection of the most prominent issues and key points. As a result, the Conference organizers presented the following

100 P. Van Wyk “A Strategic Approach to Promoting Workplace Programmes in the Labour Sector”, Presentation May 16, 2012 101 Segbaya,S., “Scaling up Indoor Residual Spraying in Ghana: Th e AngloGold Ashanti experience”. presentation, May 16, 2012. 102 S. Segbaya, op. cit. 103 S. Segbaya, op. cit. 104 D. Kiragga, ”Use of mHealth technology to improve data and inventory management at Private Clinics in Uganda”.

105 S. Emerson, “Public-Private Partnerships in m-Health: Experience from Tanzania in Electronic Disease Surveillance,” presentation, May 16, 2012.

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even policy dialogue. Many participants recommended establishing a common understanding and meaning for PPPs. Social issues relating to health are complex. Clearly, the objectives of the private sector may differ from those of the public sector, but these differences need not constitute a barrier to the development of productive partnerships and effective engagement. For the government to engage the private sector, the public sector will have to acquire new skills and capacity. Recently, many African governments have drafted new policies on PPPs in general as well as specific to health and established new institutional arrangements, like PPP Units within Ministry of Health. Although a first step, many of these initiatives require support from governments and development partners: Government can support these fledgling PPP Units through political commitment, clear mandates and sufficient resources while development partners can provide resources to build capacity and design needed policies and systems.

Closing Ceremony

observations during the closing session as parting thoughts for the participants to carry home and share with their colleagues. Prominent Issues During the event, presentations and discussions revolved around numerous alternatives for strengthening health systems through the involvement of private sector actors. Of these, some emerged repeatedly as pivotal points of reference. Others helped build a common understanding among the diverse participants in the audience, while still others will continue to spark healthy debate for some time to come. Pivotal points were:

Key Points The conference covered key health areas as they relate to potential engagement with the private sector, including health care providers, human resources development, access to essential medicines, universal health coverage and involvement of non-health private organizations. Th rough a process of participation and engagement, participants discussed and developed ideas that are well worth considering for the assessment and stimulation of private sector participation.

The private sector is a significant actor in healthcare in Africa. Different assessments, studies and analyses have created a new and important body of knowledge on the size and scope of the African private sector. Government acknowledgment of the private sector’s contribution and increased understanding of the private sector’s potential role are important first steps for productive engagement of the private sector.

Engaging with the private sector can be a win-win situation. The private sector should be engaged in a way that contributes to national health objectives, and this requires developing and implementing appropriate frameworks. In reality, citizens already solve their health care needs by navigating between public and private sector facilities.

Mistrust and suspicion between the public and private sector still remains a significant barrier to greater cooperation and collaboration. Conference participants frequently called for the creation of “formal” dialogue mechanisms based on balanced representation, shared leaderships, open and transparent communications and mutual accountability between the sectors. Participants also recognize that public-private dialogue is a necessary condition to build trust and is on-going over time. Despite the lingering mistrust, a growing number of African governments are moving away from “competing” to ”partnering” with the private sector, as evidenced by the number and range of cooperation examples shared at the Conference.

Private sector engagement relies on clear and transparent regulatory framework that establishes the rules of the road and how the public and private sector will interact with each other. Many African countries are in the process of updating and modernizing their health policy framework. Systematically involving the private sector throughout the reform process is critical to drafting policies that meet not only public sector concerns but also address private sector issues. Also, consistent and fair application of the policy and regulations is another key to successful private sector engagement.

The term “private sector” could mean different things to different audiences, so a clear definition of terms in the context of public-private partnerships is essential. Also the term “PPPs” is often used interchangeably for contracting, MOUs, infrastructure transactions,

19

PPP units need clear mandates and adequate capacity to optimize their functions as effective interfaces between the public and private sectors, advancing the public agenda on relevant health issues while continuing to safeguard the interests of the government. Beyond Dar es Salaam The organizers look forward to step up the emerged momentum on the issues discussed during this symposium. The results are clear: all actors are committed to action, to finding environments for effective collaboration, and to seeking ways to create win-win partnerships within the public and private sectors to accomplish the health goals proposed. Real and substantive steps towards a new approach were made during the conference, and although one must allow for local differences, the outcomes of the conference can and should inform how we can respond to challenges and opportunities as we move forward.

Dr. Oberlin Kisanga and Dr. Seif S. Rashid during the closing ceremony

Health fi nancing is a potential game changer for private sector engagement. Government can use financing mechanisms to create incentives that will motivate private sector to organize, deliver essential services, comply with quality standard, and share information as evidenced by the different examples presented on vouchers, contracting and health insurance. Th is is an expanding area that offers ample room for innovation. Forming umbrella private sector associations yields benefits and can lessen competition concerns. For the private sector, structuring the diverse range of private stakeholder groups unifies the private sector voice and builds strength in numbers when dialoguing with the government. For the public sector, governments can confidently engage the private sector knowing the umbrella groups are representative. Additionally, the umbrella organizations facilitate partnership opportunities. Public-private dialogue is a long, involved process that requires mutual trust and respect. It is important that each side listen to the other and that private providers have a voice in the sphere of policy. Emerging technologies can lend themselves to creative (public-private and private-private) partnerships, which can contribute to the achievement of health goals within the context of integrated health systems.

Networking

Synergies

Increasing Efficiency Health in Africa

Shared risks

Collective Action 20

Participants‘ Voices

„The conference brought us together with different goals and ideals – which was great!“

„Make this an annual event with ‘tracking progress’!“

“Th is should be a regular event for comparing progress and exploring joint project possibilities!”

„The conference opened up new horizons where there are opportunities for partnerships in health for all.“ „Very innovative approaches to training so we can close the human resources gap in the health sector.“

“This was an excellent opportunity to get to know what others are doing; I much appreciated the information on federation issues and private sector associations in Kenya.”

„In the essential medicines session, I liked the presentation showing evidence of quality of services provided by the private sector!“ „I was impressed by the variety of approaches in the sessions.“ “Panel discussions that engage regulators will help identify and address most of the PPP barriers.”

„This was a very effective conference! More conferences like this one are needed.“

„I agree that the private sector should be engaged, but client perspectives should not be forgotten.“

21

Appendix List of Participants Information about Partners and Sponsors

List of Participants Surname

Name

Country of residency USA

AboagyeNyame Adekynle

Francis Nafi sah

Nigeria

Adhiambo

Mercyline

Kenya

Organisation/ Institution Management Science for Health NHIS

Afidra

Ronald

Uganda

Ahawo

Komi Alain

Guinea

Institute of Health Policy Management & Research FHI360-Goldstar Network Flour Fortification Initiative GIZ

Aigner

Cordula

Germany

GIZ

Akahloun

Leila

South Africa BroadReach Healthcare

Amarsi

Yasmin

Kenya

Adungosi

John

Kenya

Amiri

Saidi

Tanzania

Amy

Etiang

Uganda

Anonyuo

Nkiru

Nigeria

Aga Khan University, School of Nursing and Midwifery Tanzania Investment Centre Deloitte

Surname

Name

Country of residency Ethopia

Organisation

Bishaw Brandes

Mekonnen Ayichiluhm Klaus-Peter

Tanzania

GAMBY Teaching General Hospital German Embassy

Bremer

Annette

Germany

GIZ

Brown

Heidi

Tanzania

Marie Stopes Tanzania

Bunyi

Mbogo

Kenya

PSI

Burger

Nicholas

U.S.A

RAND

Callahan

Sean

USA

Charman

Nikki

Kenya

Chikopa

Andrew

Malawi

Coarasa

Jorge

Kenya

Abt Associates Strengthening Health Outcomes through the Private Sector (SHOPS) Project Population Services International Malawi Business Council on HIV/AIDS (MBCA) IFC

Degbotse

Daniel

Ghana

Ministry of Health

Appelt

Bernd

Society for Family Health South Africa GIZ

Armand

Francoise

USA

Aryee

Derek Nii Armah

Ghana

Asfaw

Aregash

Kenya

Awosika

Ladi

Nigeria

Total Health Trust

Eppel

Gerd

Cameroon

GIZ

Badry

Dina

Germany

Bundesverband der Deutschen Industrie (BDI) e.V. USAID

Eshun

Joe

Tanzania

Deloitte

Eyong Efobi

Bate John

Cameroon

Farrell

Marguerite

USA

Ministry of Public Health USAID

Feachem

Neelam

USA

Feeny

Thomas

Dominic

Ghana

GIZ

Dia

Ousmane

Tanzania

John Snow Inc

Diallo

Guinea

Dimovska

Chaikou Yaya Donika

USA

Doerken

Axel

Tanzania

Guinea Chamber of Mines Results for Development Institute GIZ

Emerson

Sarah

Tanzania

USAID/CDC

Baleva

Jasmine

Barth

GIZ

Basstanie

Beate Chris- Germany tiane Hilde Tanzania

Batz

Franz-Josef

Germany

GIZ

Baumgarten

Inge

Tanzania

GIZ

Ferentinos

Janita

United Kingdom Tanzania

PharmAccess Foundation Namibia EPOS Health Management GmbH Ministry of Health and Social Services

Fimpel

Julia

Kenya

Kf W Entwicklungsbank

Finkbeiner

Thomas

Tanzania

Beer de

Ingrid

USA

Cardno Emerging Markets USA, Ltd. Ghana Business Coalition Against HIV & AIDS GIZ

Deme-Der

Namibia

Bergmann

Helge

Kenya

Beuekes

Hendricus Christianus Ralph

Namibia

Health Focus GmbH

22

The Healthcare Redesign Group Inc HANSHEP mHealth Tanzania

Ghassmi

Afshin

Tanzania

Premier Care Clinic / Capsele ltd Acumen Fund Inc

Gillam

Victoria K.

Namibia

GIZ

Surname

Name

Organisation

Surname

Nelson

Country of residency Kenya

Gitonga Gosta

SHOPS Kenya

Konteh

Eriksson

Tanzania

Biolands International

Kowald

Name

Organisation

Sisawo

Country of residency Tanzania

Claudia

Tanzania

GIZ

Aga Khan Foundation

Groot de

Kira

Germany

GIZ

Krueger

Norbert

DRC Congo GIZ

Guillebert

Josselin

Tanzania

DCIDR

Kuper

Meinolf

Tanzania

GIZ

Hadgu Abraha Hammond

Zemen Feskidus Maxwell

Ethopia

TIGRAI Regional health Bureau GIZ

Laoye

Folashade

Nigeria

Lema

Zacharia

Tanzania

HYGEIA Nigeria Limited GIZ

Hanlon

Patrick

Switzerland

Lewis

Trevor

USA

Hashim

Tanzania

Liana

Jafary

Tanzania

Linden

Victor

Germany

Results for Development Institute (R4D) Management Science for Health GIZ

Haverkamp

Shariff Mohamed Abdallah Geert

Tanzania

Swiss Tropical & Public Health Institute Association of Private Health Facilities in Tanzania (APHFTA) Pharmaccess

Liundi

Taji G.

Tanzania

T.B.C

Hennig

Jennifer

Germany

GIZ

Lottes

Dara

Tanzania

German Embassy

Heuschkel

Christoph

Germany

GFA Consulting Group

Lotti

Kingori

Tanzania

KSP

Hussen

Abdu

Ethiopia

Lungu

Edgar

Malawi

Ministry of Health

Iroko

Nigeria

USAID/ SPSFP RH

Lungu

Ghana

GIZ

Lwanga

Douglas Komani Joanita

Malawi

Jensen

Ayodele Adeyoola Sarah Lena

Johnston Joshua

Alexander Martias

Mabuba

Geoff rey K.

Tanzania

Jugert

Ute

South Africa Consultant Malawi Ministry of Health and Social Welfare Germany GIZ

Society of Medical Doctors in Malawi Ugandan Health Federation APHFTA

Maclet

Alexis

France

French Embassy

Kachule

Timothy

Malawi

SHOPS

Madabida

Ramadhan

Tanzania

FEAMP/TPI

Kahuure

Kahijoro

Namibia

MoHSW

Maduki

Peter

Tanzania

Kameko

Nichols

South Africa Riders for Health

Kante

Fatoumata

Guinea

Makaka

Rwanda

Kanyinyi

Pascal

Tanzania

Makame

Paul John Andrew Mohamed

Christian Social Services Comission (CSSC) Ministry of Health

Tanzania

Path

Kariithi

Charles

Kenya

Malangalila

Emmanuel

Tanzania

Worldbank

Maliti

John Asanasio M.

Kenya

Kaseje

Margaret

Kenya

Kasesela

Richard

Tanzania

Friends of the Global Fund Africa Parlament of Tanzania

Mamah

Vincent Chika

Nigeria

Mambo

Mary

Kenya

Kenya Private Healthcare Providers' Consortium (PHP Consortium) Nigeria Association of Patent & Proprietary Medicine OBA Clinic

Mantel

Micheala

Kenya

Marcias

Jennifer

Tanzania

Masuki

Gerald

Tanzania

Mathauer

Inke

Switzerland

Matsiko

Uganda

Mazzilli

Michael Rwankole Caitlin

Mbapaha

Gabriel

United Kingdom Namibia

Ghana

Kebwe

Kebwe

Tanzania

Keita

Sidikiba

Guinea

Ministry of Health and Public Hygiene Kf W Entwicklungsbank Mission for Essential Drugs & Supplies (MEDS) Goldstar Kenya

Uganda

Kimambo

Adeline

Tanzania

Association for the Promotion of the Private and Public Partnership (APPP) TPHA

Kimatta

Suleiman

Tanzania

MSH

Kimball

Meredith

USA

Kimera

Deogratius

Tanzania

Kiragga

Dithan

Uganda

Kiria

Irenei

Tanzania

Results for Development Institute JSI, Supply Chain Management System (SCMS) Project Health Initiatives for the Private Sector Project SIKIKA

Kisanga

Oberlin

Tanzania

GIZ

Mbeeli

Thomas

Namibia

Kitambi

Mary

Tanzania

Mbindyo

Caroline

Kenya

Kleff mann

Piet

Kenya

Ministry of Health and Social Welfare Kf W Entwicklungsbank

Kocholla

Lilian

Kenya

Ministry of Medical Services

23

Senior Health Programme Officer IntraHealth International Action Medeor International Healthcare WHO Uganda Priva Midwives Assosication (UPMA) Marie Stopes International Namibian Medical Aid Fund (NAMAF) Ministry of Health and Social Services AMREF

Mboya

John R.

Tanzania

PMO

Mbugua

Edwin

Kenya

Marie Stopes Kenya

Mbugua Kaboro

Stephen

Kenya

Ministry of Public Health and Sanitation

Surname

Name

Mbuji

Peter

Country of residency Tanzania

McCabe

Ariane

USA

McPake

Barbara

UK

Mgaya

Joseph

Mgiloret

Henry

Mhando

Tanzania

Mildes

Michael C.T.M. Lisa

Minja

Gradeline

Mitiku

Petros

Organisation

Surname

Name

Country of residency Kenya

Organisation

Ministry of Health and Social Welfare GAVI Alliance

Mwarey

Doris Pierre

Africa Christian Health Associations DRC Congo DRC Ministry of Health

Mwela

Tanzania

Queen Margaret University MSD

Mwenda

Samuel

Kenya

Mzeru

Marcos

Tanzania

National Health Insurance Fund South Africa GIZ

Nafula

Maureen

Kenya

Tanzania

Nagu

Mary

Tanzania

Christian Health Association of Kenya (CHAK) Ministry of Health and Social Welfare The Institute of Health Policy, management and Research Prime Minister‘s Office

Tanzania

Deloitte

Namagala

Elizabeth

Uganda

ACP/MOH

Nazerali

Hanif

Ethiopia

Mmbando

Donan

Tanzania

Moe

Jeff rey

USA

Mohamed

Mohamed

Tanzania

Mokiti

Farida

Tanzania

Embassy of Denmark/ DANIDA The Southern Nations, Nationaities & Peoples Regional Health Bureau Ministry of Health and Social Welfare Duke University, North Carolina Ministry of Health and Social Welfare Local Government Authority Ministry of Public Health and Sanitation USAID

Momanyi

Zipporah

Kenya

Monehin

Joseph

Nigeria

Motemankele Mponda

Dieudonné

DRC Congo GIZ

Hadji

Tanzania

Josephine

Tanzania

Ahmed

Tanzania

Msambichaka Mshamu

Mtawa

Felix

Tanzania

Mtee

Gemini

Tanzania

Mtunge

Romanus

Tanzania

Mufuruki

Ali

Tanzania

Mugerwa

Benon

Uganda

Mukwahima Berthold Müller Mung'ong'o

Ulla Elisabeth Edwin

Musila

Timothy

Mwaluko

Gabriel

Mwamolo

Raphael T.

Mwananteba Dorothée Assina Mwandira Gilbert Maxwell

Ministry of Health and Social Welfare Populaton Services International Prime Minister's Office Regional Administration and Local Governance Biolands International Health Research and Development Center Populaton Services International Infotech

Mayanja Memorial Hospital/Foundation/Medical Training Institution Namibia Ohlthaver & List Group of Companies London Marie Stopes International (MSI) Tanzania Ministry of Health and Social Welfare Uganda Ministry of Health PPP Unit, Planning Department Tanzania TANESA and St Paul's Health Training Centre Tanzania National Health Insurance Fund DRC Congo GIZ Malawi

Africa Christian Health Associations

24

Tanzania

MoHSW

Ndamugoba Godwin

Tanzania

CSSC

Negrette

Juan Carlos

USA

Nett

Dorothe

Tanzania

John Hopkins MedIcine International GIZ

Ng'oma Kumwenda

Rose

Malawi

Ngowi

Prosper

Tanzania

Nimaga

Karamoko

Mali

Njeru

Alphan

Kenya

Njuvv

Helen

Tanzania

Nortey

Louis

Ghana

Nsabimana

Siméon

France

Private Health Sector Alliance of Ghana (PHSAG) CIDR

Ntim

Samuel

Ghana

GAIN

Nurani

Asifa

Kenya

Aga Khan Foundation

Odero

Kenya

O'Farrell

Martin Otieno Danny

Kenya

TA-Kisumu Medical & Education Trust Raiders for Health

Ogillo

Samwel

Tanzania

APHFTA

O'Hanlon

Barbara

USA

Okoeguale

Bridget

Ongara

Mariam

Nigeria, Abuja Tanzania

Ookok

Walter

Kenya

Osholowu

Adedayo

Nigeria

Peeperkorn

Rick

Tanzania

O'Hanlon Health Consulting LLC/SHOPS Project Federal Ministry of Health Ministry of Health and Social Welfare Kenya Health Care Federation Dayo Osholowu Medical Practice Group Netherlands Embassy

Pereko

Dineo Dawn Namibia

SHOPS

Peterson

Tatjana

Switzerland

Peuse

Gene

Tanzania

The Global Fund to Fight AIDS, Tuberculosis and Malaria USAID

CHAM (Christian Health Association of Malawi) Mzumbe University Association des Medecins de Campagne du Mali Price Water House Coopers Ltd CSSC

Pfleiderer

Christian

Germany

GIZ

Phillis

James

Tanzania

TCCIA

PicoGamboa

Gabriela

Germany

GIZ (Representing the German Healthcare Partnershp GHP)

Surname

Name

Plueschke

Alexandra

Country of residency Kenya

Quijada

Caroline

USA

Organisation

Surname

Name

GIZ

Stokes Subi

Rashid (MP) Seif S.

Tanzania

Rogo

Khama

Kenya

Rompel

Matthias

Germany

Abt Associates Strengthening Health Outcomes through the Private Sector (SHOPS) Project Ministry of Health and Social Welfare International Finance Cooperation GIZ

Rubambe

Joseph

Tanzania

Deloitte

Rubona

Josibert

Tanzania

Ruff

Brian

Ministry of Health and Social Welfare South Africa Discovery Health

Rugeiyma

Michael

Tanzania

Deloitte

Saidi

Mpendu

Tanzania

BAKWATA

Organisation

Claire

Country of residency Tanzania

Leonard

Tanzania

Taube

Guenther

Germany

Local Government Authority GIZ

Tayler

Liz

Tayub

Mohamed

United Kingdom Malawi

Tekle-Ab

Zaid

Ethiopia

Telemans

Erwin

Tanzania

Th akker

Amit

Kenya

Touré

Nava

Guinea

Tusiray

Melis

Germany

Kenya Healthcare Federation and Avenue Healthcare Group Central Bureau of Rural Electricity GIZ

Hope

Nigeria

Ministry of Health

PSI Tanzania

DFID Pharmaceutical Society of Malawi (PHASOM) Private Health Sector Program (PHSP) CCBRT

Sanders

David

South Africa Emiritus Professor

Uweja

Schilthuis

Herbert

Netherlands

Heineken International

Vail

Janet

USA

Path

Van den Hombergh van Wyk

Jan

Tanzania

PharmAccess Tanzania

Peter

Namibia

Vierck

Leonie

Germany

Namibian Business Coalition on AIDS (NABCOA) GIZ

Vincent

Th ierry

Kenya

French Embassy

Schönemann Yvonne

Germany

GIZ

Sealy

Stephanie

USA

Segbaya

Sylvester

Ghana

Sentumbwe

Simon

Uganda

Results for Development Institute AngloGold Ashanti Malaria Control Program SIM'S Medical Center

Shaaban

Tanzania

Shabban

Sonda Yusuph Latif N.

Shango

Winna

Kenya, Nairobi Tanzania

Shekalaghe

Elizabeth

Tanzania

Shewchuk

Tanya

Kenya

Shoo

Rumishael

Kenya

Sillo

Hiiti B.

Tanzania

Solzbacher

Wolfgang

Tanzania

Local Government Authority Supreme Council of Kenya Muslims (SUPKEM) MoHSW

Von Roenne

Franz

Germany

GIZ

Waazem

Dominic

USA

Worldbank

Walter

Thomas

Tanzania

EAC/GIZ

Wanyancha

John

Tanzania

PSI

Tanzania Food Drug Authority (TFDA) ACTwatch / Population Service International AMREF

Yansane

Mohammed Lamine

Guinea

Tanzania Food Drug Authority (TFDA) Kf W Entwicklungsbank

Yoong

Joanne

U.S.A

Yuldasheva

Surayo

Yusufali

Rizwan

Zhang

Muching

United Marie Stopes InternaKingdom tional (MSI) South Africa Global Alliance for ImprovedNutrition (GAIN) South Africa RTT Health Sevices

Spieker

Nicole

Netherlands

Pharmaccess

Spreng

Connor

USA

IFC

Stallworthy

Guy

USA

Bill and Melinda Gates Foundation

Woldegiorgis Afsawesen Ethiopia G. Yohannes

Abt Associates Inc. Ethiopia, USAID - Private Heath Sector Program (PHSP) in Ethiopia Ministry of Public Health and Sanitation of the Republic of Guinea RAND

Collective Action

Increasing Efficiency 25

Health H lth in i Africa Af

Results for Development Institute (R4D) is a non-profit organization whose mission is to unlock solutions to tough development challenges that prevent people in lowand middle-income countries from realizing their full potential. Using multiple approaches in multiple sectors, including Global Education, Global Health, Governance and Market Dynamics, R4D supports the discovery and implementation of new ideas for reducing poverty and improving lives around the world.

Information on Partners and Sponsors Partners USAID The U.S. Agency for International Development (USAID) is an independent agency that provides economic, development and humanitarian assistance around the world in support of the foreign policy goals of the United States. U.S. foreign assistance has always had the twofold purpose of furthering America’s interests while improving lives in the developing world. USAID carries out U.S. foreign policy by promoting broad-scale human progress at the same time it expands stable, free societies, creates markets and trade partners for the United States, and fosters good will abroad. Spending less than 1 percent of the total federal budget, USAID works in over 100 countries to: Promote broadly shared economic prosperity; Strengthen democracy and good governance; Protect human rights; Improve global health; Advance food security and agriculture; Improve environmental sustainability; Further education; Help societies prevent and recover from confl icts; and Provide humanitarian assistance in the wake of natural and man-made disasters. For more information go to http://www.usaid.gov

DANIDA Danida is the term used for Denmark’s development cooperation, which is an area of activity under the Ministry of Foreign Aff airs of Denmark. Denmark’s development policy aims to contribute to reducing global poverty and helping people to take charge of their own destinies. Th is is the overriding objective for which Danida works. Danida has responsibility for the planning, implementation and quality assurance of development cooperation. There are local and posted staff at Danish embassies and missions abroad who are responsible for the administration and management of development cooperation with the individual country. http://tanzania.um.dk/en/danida-en/health/ KfW Entwicklungsbank

The Strengthening Health Outcomes through the Private Sector (SHOPS) project is USAID’s flagship initiative in private sector health. SHOPS focuses on increasing availability, improving quality, and expanding coverage of essential health products and services in family planning and reproductive health, maternal and child health, HIV/ AIDS, and other health areas through the private sector. Abt Associates leads the SHOPS team, which includes five partners: Banyan Global, Jhpiego, Marie Stopes International, Monitor Group, and O’Hanlon Health Consulting. For more information go to www.shopsproject.org

On behalf of the Federal Government, we carry out Financial Cooperation (FC), one of the most important instruments of German bilateral cooperation. With FC, we contribute to reducing poverty and to ensuring that globalisation affords opportunities for everyone, to protecting the climate and conserving natural resources and to safeguarding peace. In keeping with the needs and development strategies of the partner countries, we provide finance, advice and support for development and climate protection projects and programmes worldwide. The foremost concern in cooperation is to achieve sustainable impacts. Strengthening the initiative, ownership and capacities of our partners is a major success factor.

The Center for Health Market Innovations (CHMI)/ Results for Development Institute (R4D) The Center for Health Market Innovations (CHMI) promotes policies and practices that improve health care delivered by the private sector for the poor in developing countries. Operated through a global network of partners since 2010, CHMI is managed by the Results for Development Institute. Details on more than 1000 innovative health enterprises, nonprofits, and policies can be found online at www.HealthMarketInnovations.org.

Social and economic infrastructure development centres on water supply, sanitation and refuse disposal as well as renewable energies and transport or public transportation. We promote the development of education and health care facilities, support campaigns against AIDS as well as vaccination programmes or schemes for family planning. We also help to establish efficient financial systems,

26

including microfinance, and grant loans to small and medium-sized enterprises. http://www.kfw-entwicklungsbank.de/ebank/EN_Home/ Sectors/Health/index.jsp

RTT Health Sciences RTT Trans Africa is the operational arm of RTT Health Sciences’ pharmaceutical supply chain into Africa. We bring together a range of RTT offerings to create holistic supply chain solutions for delivering essential medicines to developing markets. RTT Trans Africa was established in response to a pivotal contract that RTT secured in for 2005 with the US-based SCMS (Supply Chain Management Systems) set up by USAID to deliver for PEPFAR, the US President’s Emergency Plan for Aids Relief.

Sponsors Deloitte Deloitte’s mission in collaborating with the Public sector is simple – to assist governments to serve the 21st century citizen by applying best practices in strategy, scenario planning, operations improvement, technology integration, and human capital. Specifically, in the Public Health Space, Deloitte provides audit and advisory services in the fields of healthcare, medical management, health IT, as well as emerging trends/innovation and through our cross-functional offerings we aim to bring an informed, 360-degree perspective, to each public sector project we undertake. http://www.deloitte.com

To address the considerable challenges of providing a reliable and sufficient supply of ARVs to remote locations on the continent, RTT Trans Africa has developed Hubs Into Africa, an innovative and world-leading multimarket warehouse (MMW) pharmaceutical distribution model, resulting in ground-breaking success. Today we can boast an unrivalled footprint in this arena and our expertise is deployed in 16 African countries. For more information, please contact Maeve Magner, at [email protected] , or visit our website at: http://www.rtt.co.za

Networking Shared risks

Health in Africa

Collective Act

Increasing Efficiency 27

Imprint Published by Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, on behalf of the Federal Ministry for Economic Cooperation and Development (BMZ) Edited by GIZ Tanzanian German Programme to Support Health (TGPSH) GIZ Competence Center Cooperation with the Private Sector in Africa GIZ Competence Center Health GIZ Competence Center Social Protection Juan Carlos Negrette, Consultant Design and Layout ansicht kommunikationsagentur, Wiesbaden www.ansicht.com Printed by Top Kopie, Frankfurt Printed on FSC-certified paper Photo credits Savio Moshino Fonseca As at October 2012 Addresses of the BMZ offices Bonn Office Dahlmannstraße 4 53113 Bonn Germany Tel. + 49 (0) 228 99 535 - 0 Fax + 49 (0) 228 99 535 - 3500 [email protected] www.bmz.de

Berlin Office Stresemannstraße 94 10963 Berlin Germany Tel. +49 (0) 30 18 535 - 0 Fax +49 (0) 30 18 535 - 2501

Collective Action

Networking

Health lth iin A Africa