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Establishing non-state sector research priorities in developing countries using a participatory methodology

13 August 2009

Prepared by Damian Walker, Claire Champion, Shahed Hossain, Tania Wahed, Rukhsana Gazi, Tracey Pérez Koehlmoos, Delius Asiimwe, M. Kent Ranson and Sara Bennett

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Executive Summary Background: The non-state sector (NSS) plays a very significant role in the delivery of health services, and the provision of health and health-related commodities in developing countries. In spite of concerns regarding the quality of NSS providers, governments and donors have increasingly recognized that the health Millennium Development Goals (MDGs) are unlikely to be achieved without these providers’ active engagement. Nevertheless, donor funding for NSS health policy and systems research is inadequate and is often poorly aligned with national priorities. This paper describes work carried out by the Alliance for Health Policy and Systems Research and its partners to generate consensus about a core set of research issues that urgently require attention in order to facilitate policy development. Methodology: There were three key inputs into the priority setting process: key informant interviews with health policy makers, researchers, community and civil society representatives across 24 low- and middle-income countries in four regions (Latin America & Caribbean (LAC), East Africa, South-East Asia and Middle East/North Africa); an overview of relevant literature reviews to identify research completed to date; and inputs from nine key informants (largely researchers) at a consultative workshop. Findings: A list of 18 priority research questions emerged from key informant interviews across the 24 low- and middle-income countries. While each broad research topic was common to several countries or regions, the more specific ‘sub-topics’ of interest varied considerably. The overview of systematic review provided little insight into the relative importance of the research questions. Many of the questions received little or no attention in the review literature. Even where questions had been addressed (or partially addressed) by the review literature, the authors of the review papers generally suggested that additional primary, or research of higher quality, was still required. However, this overview of reviews was instructive in showing which NSS topics have had comparatively little written about them, despite being identified as important by key informants. At the consultative workshop, a group of nine researchers refined and ranked the priority research questions. The four top-ranked questions were as follows: 1. How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes?

2. What is the quality and / or coverage of health care services provided by the non-state sector for the poor?

3. What types of regulation can improve health systems outcomes, and under what conditions? 4. How best to capture data and trends about private sector providers on a routine basis? Conclusions: This work on research priorities in the non-state sector, along with similar work being conducted on human resources for health and health systems financing priorities, will complement calls for increased health system research and evaluation by providing concrete, detailed suggestions as to where new and existing research resources can best be invested. The identified list of high priority, tractable NSS research questions are being communicated to research funders through Alliance health policy and health systems publications and advocacy work in order to influence global patterns of NSS research funding.

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Introduction The non-state sector (NSS) plays a significant role in the delivery of health services, and the provision of health and health-related commodities in developing countries. In spite of concerns regarding the quality of non-state providers (NSPs), governments and donors have increasingly recognized that the health Millennium Development Goals are unlikely to be achieved without these providers’ active engagement. Nevertheless, donor funding for NSS health policy and systems research is inadequate and is often poorly aligned with national priorities. To advance this area of heath policy and systems research, the Alliance for Health Policy and Systems Research and its partners developed a work program to generate consensus about a core set of research issues that urgently require attention in order to facilitate policy development. The paper has the following three specific objectives:

1. To identify the NSS policy concerns and research priorities of key stakeholders in low- and middle-income countries (LMICs);

2. To assess the extent to which existing NSS research addresses these policy concerns and research priorities;

3. To develop a preliminary list of core research priorities that require urgent attention to facilitate policy development.

This paper focuses on the provision of clinical services and commodities. It does not consider efforts to introduce private sector management techniques into the government sector, or private sector roles in financing health care or global level public-private partnerships (PPPs). This framework limitation is justified given that the NSS role in the provision of services is recognized as critical in LMICs but has to date received limited research attention. Evidence for this lack of research attention is highlighted in the overview of reviews of the non-state sector presented later in this report. Conceptual framework The focus of this report is on the NSS provision of services and commodities for which there is no broadly accepted conceptual framework. Therefore this section of the report attempts to develop a framework for the non-state sector. The purpose of the conceptual framework is to enable the mapping map of the field for possible research questions as articulated by policy makers, against research that has already been undertaken. We propose five primary dimensions to thinking about the role of NSPs: 1. types of providers; 2. types of services they may deliver; 3. public health outcomes; 4. interventions to affect these providers, services and outcomes; 5. policy and regulatory environment, which can also be affected by the interventions. Non-state sector providers Despite substantial investment in the last thirty years, in low- and middle-income countries the government can no longer be seen as the sole provider of health care. Recent years have witnessed an increased recognition of the role of NSPs in developing countries, and at the same a real expansion in their numbers. This is primarily due to the rise of small, often informal, providers who are increasing in numbers, scope, scale and impact to fill the gap left by weak state

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capacity. However it is important to note that the blurring of the boundaries between state and non-state is extremely complex (Mills et al. 2002)1. Palmer 20062 defines non-state providers thus:

“[They] are all providers who exist outside of the public sector, whether their aim is philanthropic or commercial, and whose aim is to treat illness or prevent disease. They include large and small commercial companies, groups of professionals such as doctors, national and international non governmental organisations, and individual providers and shopkeepers. The services they provide include hospitals, nursing and maternity homes, clinics run by doctors, nurses, midwives and paramedical workers, diagnostic facilities e.g. laboratories and radiology units, and the sale of drugs from pharmacies and unqualified static and itinerant drug sellers, including general stores.”

Services provided The types of services provided by NSPs vary from delivery of clinical services, to non-clinical social support, to management of hospitals, and to health-related services (e.g. training). It is important to categorize the different types of services provided because they differ in terms of (i) the degree of service complexity (e.g. for less complex services the market may work better and it is easier to contract them out etc.) and (ii) the nature of demand (e.g. for curative personal services there is likely to be a greater willingness to pay than for non-personal preventive services). The following comparative groups provide an initial framework for consideration:

• Modern versus traditional medicine;

• Preventive versus curative services;

• Personal versus non-personal services;

• Specific services (e.g. diagnostics, deliveries) versus broad range of services. Interventions to affect services and providers Public-private partnerships (PPP’s) have been defined as a “…system where government services are funded and operated through a partnership between a government and a private company or citizen-based organization.”3 PPP’s are used extensively in developed countries, which has led to their increased use in developing contexts. Contracting out arrangements are a type of PPP. Other types of interventions include (i) strategies targeting service providers (with sub-categories focusing on financing services, health workforce and service organization); (ii) strategies targeting users and consumers to enhance the contribution of (or diminish the harm from) the NSS by increasing knowledge (e.g. patient report cards, various IEC techniques); and (iii) strategies that restructure health care markets (involving both users and providers) (e.g. franchising). Public health outcomes Because NSPs often provide access to services in areas that are not covered by public sector service provision, one could infer that NSPs are pro-poor. However, such presumption must be weighted against the reality that they are often expensive and are not obligated to consider equitable access. Research has shown that poor people use private providers extensively in spite of the associated costs and the availability of (nominally) free at the point of service public sector health care. We consider the effectiveness of interventions in terms of their ability to affect the following measures of performance:

1 Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? Bull World Health Organ. 2002; 80(4): 325-330. 2 Palmer N. Non-state providers of Health Services. Briefing paper for DFID Policy Division. June 2006. 3 http://www.gsdrc.org/go/topic-guides/service-delivery/non-state-providers

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• Quality, i.e. both the technical and perceived dimensions of quality;

• Efficiency, i.e. inputs are not capable of producing more services;

• Equity, i.e. the extent to which the effects of NSP interventions reach the poor;

• Acceptability, i.e. the match between how responsive health service providers are to the social and cultural expectations of individual users and communities;

• Accessibility, i.e. in terms of geographic and financial accessibility. Policy and regulatory environment NSPs are under-regulated and often provide poor quality services. Weak state capacity, lack of information and a poor dialogue between the public sector and NSPs make regulation difficult. Whilst users are reliant on NSPs to fill the gaps left by public provision, governments are often wary of endorsing them due to concerns over quality and accessibility. However, governments that wish to engage with NSPs can create an enabling environment for NSPs. This includes promoting creative, alternative forms of regulation, improving dialogue and providing practical support. Thus, the policy and regulatory environment in which private sector strategies are implemented matters a great deal. Figure 1 illustrates these dimensions and their interactions. Figure 1: Conceptual framework for the Non State Sector

Services

Providers

Interventions

Outcomes

Policy &

Regulatory

Environment

Methodology There are three steps in this priority setting process: 1. key informant interviews with health policy makers, researchers, community and civil society representatives across 24 LMICs in four regions (Latin America and Caribbean, East Africa, South- East Asia and Middle East and North Africa);

2. overview of relevant literature reviews to identify research completed to date; 3. inputs from key informants (largely researchers) at a consultative workshop. The key informant interviews were used to identify a tentative list of priority research questions. The overview of relevant literature reviews was intended to provide a summary of the nature of the available evidence-base to answer the priority research questions. In addition it aimed to assess whether there were any notable omissions from the priorities identified by the policy makers, and to sharpen the focus of questions gleaned from the regional reports. The aim of the

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consultative workshop was to rank the priority research questions already identified and brainstorm around the top-ranked issues. Regional key informant interviews The Alliance competitively awarded grants to four organizations in different regions. Investigators in all four regions (representing 24 countries) conducted literature reviews of both published and ‘grey’ literature and key informant interviews among policy makers, researchers and community and civil society representatives. The regional case studies covered three themes: research priorities in the areas of the NSS, human resources for health and health system financing; this report focuses on the first of these themes. The precise methodologies varied between the four regions and are summarized in Table 1 (see Annex 1 for further details). The data were analyzed by the lead authors (DW and CC) in several phases. First, regional reports were read, and NSS policy concerns and research priorities were extracted, and categorized using the Conceptual Framework for the Non State Sector (see above). Second, cross-cutting policy concerns and research priorities were identified common to at least two countries within a region or two of the regional reports. Third, specific policy concerns and research priorities, as expressed by interview respondents, were extracted from the available country-level reports (Middle East and North Africa, and East Africa). This last step was intended to identify the consistency or breadth of topics included under any one of the cross-cutting policy concerns or research priorities. This report on NSS research priorities is the third in a series of reports commissioned by the Alliance, the others focusing research priorities in the areas of human resources for health4 and health system financing5. Some research topics/questions cut across this report and the report on human resources for health: the role of different models of regulating NSPs and more specifically how best to regulate dual practice. Thus, while these questions were included in the priority setting exercise at the workshop on human resources for health, they are included here because participants who are experts in the field of NSS may weigh the importance of these questions differently, particularly when set against other NSS-specific priorities.

4 Ranson MK, Chopra M, Dal Poz M, Bennett S. Establishing human resources for health research priorities in developing countries using a participatory methodology. September 2008. 5 Ranson MK, Law TJ, Bennett S. Establishing health system financing research priorities in developing countries using a participatory methodology. September 2008.

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Table 1: Methodologies used in four regional case studies Region East Africa Southeast Asia Latin America and the

Caribbean Middle East and North Africa

Regional hub Makarere Institute of Social Research, Makarere University, Uganda

National Institute of Health Research and Development, Jakarta, Indonesia

Bitrán & Associates, Chile

American University of Beirut, Lebanon

Countries included

Tanzania, Uganda

Indonesia, Thailand, Malaysia

Chile, Peru, Panama, Suriname, El Salvador, Bolivia, Argentina, Dominican Republic, Costa Rica, Nicaragua

Algeria, Egypt, Jordan, Lebanon, Morocco, Syria, Tunisia, Palestine, Yemen

Literature review Documents from: - government - multilateral and bilateral agencies - private health sector - research institutes

Documents from: - government - “regional agencies”

Scientific and grey literature, based on search of select databases and websites

- Published reports - Documents from websites of “professional institutions and ministries of health”

Key-informant interviews

Elite interviews: - MoH officials - heads of departments and programs In-depth interviews - heads of special programs/desk officers - heads of sections - heads of private facilities/NGOs - heads of research institutes

“Officials from identified national institutions / units / organizations and regional or international organizations”

In each country: - 7 policy makers - 2 researchers

Representatives of: - public sector - health professionals groups - academia - civil society groups, private sector, NGOs, faith-based organizations - Consumers

Categories investigated

1. health policy concerns

2. health research priorities

1. important current health topics

2. proposed health policy topics

3. current information needs

4. emerging research priorities

1. current policies 2. desired policies 3. current research 4. desired research

1. policy concerns 2. policy priorities 3. research

questions

Were respondents presented with a list of policy / research options?

No Yes First asked an open-ended question, but then presented with list for ranking exercise

Yes - presented with the first four broad categories of the conceptual framework

Ranking (vs. only identifying) priorities

No Ranking performed (although only for 2 of 3 countries)

Respondents asked to rank a pre-defined list of policy / research priorities

As a second stage -(results not yet available)

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Overview of systematic reviews and mapping of literature This section of the report looks at previously published materials. Although this review of the literature may not serve as a guide to policy and decision-makers’ current concerns or to their future needs it can be helpful to scope out existing work in the field. It is worthy of note that the literature review focuses exclusively on published reviews thus further limiting the contemporary nature of the literature. Search strategy The search used PubMed to generate a list of possible systematic reviews (defined broadly as syntheses of most any kind of research literature, e.g. primary, secondary, qualitative, quantitative, descriptive or experimental6) on NSS provision of health services and commodities in low- and middle-income countries. s (The search was conducted by SH). Search strategies for electronic databases were developed using the methodological component of the Effective Practice and Organization of Care (EPOC) search strategy combined with selected MeSH terms and their sub-headings and free text terms related to the NSS. The search strategy consisted of three parts used in combination: 1) search terms designed to generate a list of possible systematic reviews, 2) search terms designed to retrieve articles on NSS topics, and 3) search terms designed to restrict the search to developing countries (see Annex 2). The three parts of the strategy were combined using the ‘AND’ command to select only articles in all three categories, resulting in 1,153 citations. The search included all articles available in PubMed on 1 January 2002 through 1 May 2008, limited to human studies and publications in English, Spanish and French. The lower limit of our search was 2002 in order to coincide with the release of the seminal article by Mills, Brugha, Hanson and McPake, What can be done about the private health sector in low income countries?7 Appropriate reviews of non-state sector literature known to the authors and either published prior to 2002 and/or not identified by the search strategy was considered eligible for screening and inclusion in this review. Selection criteria Double screening was used to scan the titles, abstracts, or full text of the 1,153 PubMed citations using four inclusion criteria and one exclusion criteria. To be included, the review had to: 1) provide an indication that a search of a literature database had been conducted; 2) include some selection criteria that explain what sorts of articles were accepted; 3) include some discussion of NSS provision of health services; and 4) the primary research had been done in LMICs. Articles were excluded if they did not meet the inclusion criteria. Three reviewers (TK, TW and RG) independently screened the titles and abstracts of all articles obtained form the search. Full text articles were retrieved of all abstracts deemed eligible by the reviewers for closer inspection. Double screening was again used to determine eligibility of retrieved full text articles. Those that appeared to meet the inclusion criteria as abstracts but were deemed unsuitable for inclusion at the full-text screening are listed in Annex 3, together with the reasons for their exclusion. A fourth team member resolved disagreement between the reviewers (DW). Of the 1,153 PubMed citations, based on initial screening there were a total of 39 that at were considered suitable for full article retrieval. After reviewing the full text articles, 18 reviews were found eligible for inclusion. An additional nine studies that were either published prior to 2002 or were not identified by the search but that were known to the authors and met the inclusion criterion were further included in this overview of reviews, resulting in 28 reviews (Figure 2) (see Annex 4 for a full list of the selected reviews).

6 Therefore, it should be clear that we were not restricting ourselves to Cochrane-style systematic reviews. 7 Mills A, Brugha R, Hanson K, McPake B.What can be done about the private health sector in low-income countries? Bull World Health Organ. 2002; 80(4): 325-330.

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Figure 2: Development of a rapid review of reviews of the non-state sector in health care in low- and middle-income countries Coding Data extracted from each included review included the primary objective, conclusions and any suggestions made by the authors towards guiding future research topics. Further, the reviews were mapped onto the conceptual framework. Consultative workshop A group of nine experts in the NSS were assembled on the 10th of October 2008, in Bellagio, Italy (Annex 5). The experts were purposively selected to represent a diverse group of expertise and research interests on the topic of NSS. Two of the nine respondents are based at institutions in low- or middle-income countries (India and Bangladesh). Two of the participants are based at universities in high-income countries (USA and Sweden), two at international organizations (WHO), one works for a non-profit research institutions (Results for Development) and the remaining two work at foundations (Rockefeller and the Bill and Melinda Gates Foundations). In advance of the workshop, participants were provided with a draft paper based on the key informant interviews, the overview of reviews of the NSS and an unranked list of emerging priority research questions. At the workshop participants (1) discussed the list of priority research questions; (2) decided on the criteria (nature and relative weighting) to be used

Review articles included in non-state sector review of reviews (n=28) (see Annex 4)

Articles excluded based on the above listed criteria (n=21) (see Annex 3 for a full list of the excluded studies)

Medline citations retrieved for screening (n=1,153)

Full text articles retrieved for screening (n=39)

Abstracts excluded based on the following criteria: Not a review, not LMIC, not NSS, and/or not health service provision related (n=1,108)

Articles included based on the above listed criteria either published prior to 2002 or not picked up by the search strategy but previously known to the authors (n=9)

Articles identified by workshop participants (n=1)

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in ranking the research questions; (3) ranked the research questions based on three criteria: answerability8, potential impact on health and equity, and extent to which relevant research is lacking, and (4) discussed in detail the kinds of research that could best address the four questions that ranked highest. Results Regional reports The results presented hereafter are findings from focus groups discussions and in-depth interviews as well as literature review when available. Policy concerns Across regions, respondents recognized the increasing role of the NSS as a provider of health services. However, they expressed a number of policy concerns detailed in Annex 6. The below categories capture these concerns using the five dimensions described in the conceptual framework (although categories are grouped around issues relating to whom the NSPs are and what they do). All four regions expressed two major concerns, although the precise nature of these concerns and / or the ways in which they were expressed varied both by region and by country. The first concern relates to interventions and specifically to the inefficiency and low quality of existing public-private partnerships and current contracting mechanisms. The second policy concern common to all four regions relates to the policy and regulatory environment; the absence of appropriate regulation for non-state sector activities (including defining the roles and responsibilities of the NSS, monitoring activities and setting up precise and appropriate quality standards). It is noteworthy that none of the regional reports explicitly expressed policy concerns with regards to who NSPs are and what they do, or outcomes, although a concern for improved outcomes was often embedded in the broader concerns about the policy and regulatory environment. For example respondents from the Latin America and Caribbean region stated that non-state actors have the potential to increase health coverage and improve efficiency and transparency. With that in mind, policymakers should focus on creating the right environment to help non-state sector actors develop high quality services. The same respondents expressed the need to promote and increase NSS activities and to align those activities with those of the state. Respondents primarily defined private actors as agents to be contracted by the government to provide health services and did not envision their role as financing agents or producers of new technologies. Similarly the Middle East and North Africa regional respondents confirmed the rapid growth of the private health sector in their domain as well. They underlined the need to involve non-state actors in defining national health needs and priorities. Governments in this region are increasingly contracting the NSS to improve efficiency, access and quality of care. However,

8 Answerability was understood by workshop participants to mean “the likelihood that the research question can be answered”. Other groups / authors have used similar criteria, expressed in slightly different ways. For example, COHRED’s Working Group on Priority Setting assessed (among other things) “feasibility of carrying out the research in terms of the technical, economic, political, socio-cultural and ethical aspects” (Working Group on Priority Setting. Priority setting for health research: lessons from developing countries. Health Policy and Planning. 2000; 15(2): 130-136). The Ad Hoc Committee on Health Research assessed prioritized HPSR issues according to “Whether the research proposed will advance the current state of our knowledge about the issue, either globally or locally” and “The extent to which there is an appropriate match between the issues being investigated and the research methods to be used” (Ad Hoc Committee on Health Research Relating to Future Intervention Options. Investing in health research and development. Geneva: World Health Organization; 1996).

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respondents were concerned about governments’ capacity to design, award and manage those contracts with the private sector. PPPs have had mixed results so far in the region. Respondents reported factors such as poor regulation, service duplication and multiplicity and complexity of networks of providers and third-party payers. Additionally, the private sector, despite its growth, remains highly politically contested. In Algeria, respondents were concerned about the lack of control on private services’ quality and tariffs. Jordan’s respondents mentioned the large volume of non-prescription drugs sold by non-state actors. Palestinian respondents emphasized the issue of weak coordination and collaboration among the main stakeholders (government and non-governmental institutions). Similar themes were identified in the East Africa region, where both countries studied (Uganda and Tanzania) expressed concerns about the lack of effective PPPs. More specifically, in Uganda, respondents highlighted the lack of support from the public sector to the non-state actors and the very weak partnerships between private and public organizations. In Tanzania, respondents outlined the damaging mistrust between the government and for-profit actors. This mistrust is a legacy of the prohibition of for-profit activities in the health sector between 1971 and 1991 in the country. Opponents to the exponential growth of the NSS are concerned about access to services for the poor and quality standards. Tanzanian respondents also mentioned the lack of recognition and regulation of alternative medicines as a major policy concern. Finally, in the Southeast Asian region important variations were also reported between countries. Participants from Thailand mentioned two policy concerns that were not mentioned in other Asian countries: 1) defining the role of private sector in the provision of “Public Goods” and 2) strengthening government incentives to private health facilities for the promotion of health tourism (a topic that falls outside of the conceptual framework, but that was also mentioned by Jordanian respondents as a research priority – see below). Research priorities Surprisingly there was not always a high degree of congruence between stated policy concerns and research priorities, which is perhaps a function of both the manner in which these issues were addressed in the original work, but also of the challenge of translating research into policy, even at a conceptual level. Below is an attempt to categorize these research priorities using the conceptual framework for the non-state sector. Once again, the research priorities that emerged from the four regional reports differed by region and among countries in both content as well as degree of specificity and detail (see also Annex 7). In the Latin America and Caribbean region, respondents named the following two research topics as their top priorities: 1) how to regulate NSS activities and 2) how to increase health service coverage by engaging with the private sector. Then, the responses were evenly split for other research priorities such as facilitating participation of the non-state sector to increase external revenues, accessing local technologies or developing pilot experiences. Open-ended questions related to research priorities were answered by a list of diverse topics. In Argentina for example, respondents mentioned research topics such as measuring the impact of strengthening consumer defense organizations, how to encourage the work of patient/family associations and other non-profit organizations, and how to monitor quality of care. In Costa Rica, respondents mentioned as important research topics how to increase effective competition among private hospitals. Research priorities that emerged from the literature review differed significantly from priorities from interviews. The literature mainly focused on four topics: 1) contracting NSPs to increase health coverage (i.e. in areas with difficult access); 2) contracting NSPs to improve efficiency and transparency; 3) allowing or increasing NSS activities in the health sector (insurers, providers, etc.); and 4) facilitating participation of the NSS to address cultural and geographical

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barriers. Regulation was one of the less frequent topics in the literature, whereas it was found to be the most important topic for policy-makers. Thus, in line with the policy concerns from the Latin America and Caribbean region, the research priorities focused on the need to know more about how to improve outcomes, access and quality specifically. Indeed, research was demanded on the topic of how regulation can be best implemented to achieve or improve the quality of services. The Middle East and North Africa region respondents mentioned PPPs as a key research priority with a specific focus on identifying the foundations/elements that build strong partnerships (including effective contracting mechanisms) and on understanding the areas where state and non-state sectors can complement each other. Respondents also expressed the need to gather more information and knowledge about the private sector and build a national database. Respondents from Egypt mentioned research needs on how to empower the private sector to work as a large corporation rather than small and informal businesses. Jordan’s respondents included the need for impact assessment of medical tourism on quality and cost of health care. Yemen mentioned strengthening the capacity of the public sector to plan, monitor and regulate non-state actors. Literature about the NSS in the Middle East and North Africa region was qualified as “exceedingly minimal” in the regional report. Most information came from one major report, the Eastern Mediterranean Regional Consultation on Health Research for Development (2000) that underlines the lack of research capacity throughout the region and the urgent need to encourage additional research and establish links between research and decision making processes at the policy level. The report also expressed concerns about the low capacity of civil society. Thus again, the outcomes and policy and regulatory environment dimensions featured prominently in this region’s list of research priorities. In the East Africa region findings were not consistent across the two countries. In Uganda, respondents focused on the need to build a strong MIS system that will inform policy makers and enable them to include private sector actors in national strategic planning. They also insisted on the importance of doing formative research on the demand side or patients’ characteristics and needs. Tanzania’s respondents underlined the needs to conduct research to optimize the management of PPPs (including contracting out mechanisms, quality assurance, costing and accreditation schemes). Another research priority was about alternative medicines and how to integrate their activities into the national health system and monitor quality. The main challenge for research in Tanzania has been a significant lack of funding, thus impeding the implementation of any research agenda. In Southeast Asia, the three surveyed countries (Malaysia, Indonesia and Thailand) provided vastly different answers (see Annex 6). However, two research topics were ranked as priority in at least two out of the three countries: how to regulate the non-state sector and how to improve PPPs. From analysis of the above information, 18 research priorities questions emerge as detailed in Table 2.

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Table 2: Research questions identified from the regional reports

Who they and what they do? (Providers & Services) 1 What are the role, magnitude and capacity of the non-state sector in the provision of health care? Outcomes 2 To what extent can the non-state sector increase coverage and access to health care services? 3 To what extent can the non-state sector increase the quality and / or coverage of health care

services for the poor? 4 Conduct a national survey on customer satisfaction (not expressed as a research question) 5 Conduct costing studies of non-state actors’ activities (not expressed at a research question) Interventions 6 What is the role of PPPs? What are the key components of successful PPP? How can they be

strengthened? 7 What are the main contracting mechanisms to non-state sector? Are they cost-effective? 8 How to implement contracting and monitor quality of non-state providers? 9 What are the gaps in governments’ capacity to contract out health services? 10 What are the tools available to monitor the non-state sector’ activities and improve services

quality and affordability (regulations, licensing, accreditation, etc). How should those tools be used and in which context?

11 What is the role of the consumers/patients defense associations? Policy & regulatory environment 12 Under what conditions can regulation improve health systems outcomes? 13 How to build better collaboration, e.g. trust, between state and non-state sectors? 14 What is the impact of dual practice? Are regulations on dual practice required, and if so how

should they be designed and implemented? 15 How should/could government integrate non-state sector into national strategic planning and

policy? 16 How can the government create a better environment to foster the growth of quality and

affordable non-state actors that would complement state sector activities? How can government foster effective competition among non-state actors?

17 How best to capture data about private sector providers on a routine basis, for example through including them in HMIS?

Other 18 What is the impact of health tourism on the quality and affordability of health systems? Should

the government provide incentives to the non-state sector to develop health tourism?

Overview of reviews A description of the nature of evidence and the main findings from the overview of reviews is provided in the following sections. Providers A number of studies describe the composition of the NSS. Some have done this in general terms, e.g. early work in the field by Hanson and Berman (1998); others have focused on a description of the types of providers for a particular program area or service. For example, in 1996 Berman and Rose noted that private providers are less important for ‘public good’ type services such as immunization, whereas they contribute significantly to the provision of curative services, which are less subject to market failures. Waters et al. (2003) note that a very heterogeneous private sector is the most commonly consulted source of care for child illnesses in many countries, offering significant opportunities to expand the reach of essential child health services and products. While several reviews clearly described the composition of the NSS for specific services, there has not been a comprehensive assessment of the levels and composition of private health care provision in developing countries building upon the preliminary work done by Hanson and

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Berman (1998). Indeed, while lamenting the fact that few of the government experiences of engaging with the private sector to improve child health have been clearly described, monitored, and evaluated, Bustreo et al. (2003) opine that the starting point should include the evaluation of the “presence and potential of the private sector, including actors such as professional associations, producer organizations, community groups, and patients’ organizations”. Services Following on from the review by Waters et al. (2003) many studies describe the significant role of the NSS in providing specific services, e.g. maternal, family planning, and child health services (Berman and Rose 1996; Brugha and Pritze-Aliassime 2003; Peters et al. 2004), malaria (Brugha et al. 1999; Goodman et al. 2007) and tuberculosis (Borgdoff et al. 2002; Thomas 2002). While recognizing that a burgeoning private health sector exists in low-income countries, consisting of a variety of providers delivering a range of preventive and curative services, and used by a wide cross-section of the population, many authors note that there are substantial concerns about the care given, especially at the more informal end of the range of providers. The following sub-section looks at what is known with regards to the effectiveness of care provided by the NSS. Outcomes and Interventions Effectiveness of care reviews looked at the role of the non-state sector by engagement mechanisms and/or disease-specific interventions. Further, the subcategory of assessing the non-state sector through specific filters like equity falls into this category. Specific mechanisms for intervening in the non-state sector provision of health services were discussed in reviews by Liu et al. (2008) and Koehlmoos et al. (2009). Liu et al. (2008) conducted a review of the literature on the effectiveness of contracting-out of primary health care services and its impact on both program and health systems performance in LMICs. Overall, while the review of the selected studies suggests that contracting-out has in many cases improved access to services, the effects on other performance dimensions such as equity, quality and efficiency are often unknown. Moreover, the review concluded that little is known about the system-wide effects of contracting-out. Koehlmoos et al. (2009) conducted a systematic review of the effect of social franchising on access to and quality of health services in low- and middle-income countries. Despite finding a relatively enthusiastic literature supporting social franchising, they found no eligible studies for inclusion in the review and recommended rigorous, purposefully designed evaluations of social franchising that would capture both process and outcome measures. A number of reviews looked at a wider set of interventions. Patouillard et al. (2007) conducted a systematic literature review on the effectiveness of interventions that work with the private for-profit sector to improve utilization of quality health services by the poor – the interventions included were social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The review unearthed few studies that provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. The authors concluded that “Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.” The effectiveness of private sector strategies for sexual and reproductive health services in developing countries was reviewed by Peters et al. (2004). The strategies examined were regulating, contracting, financing, franchising, social marketing, training and collaborating. The authors found that the evidence about effectiveness of private sector strategies on sexual and

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reproductive health services is weak. Most studies did not use comparison groups, or they relied on cross-sectional designs. Nearly all studies examined short-term effects, largely measuring changes in providers rather than changes in health status or other effects on beneficiaries. Five studies with more robust designs (randomized controlled trials) demonstrated that contraceptive use could be increased through supporting private providers, and showed cases where the knowledge and practices of private providers could be improved through training, regulation and incentives. The authors concluded that “without stronger research designs, key questions regarding their [tools to work with the private sector] feasibility and impact remain unanswered.” The literature on interventions to improve the malaria-related practices of medicine sellers who are widely used for fever and malaria treatment in sub-Saharan Africa was reviewed by Goodman et al. (2007). Sixteen interventions were identified, involving a mixture of training/capacity building, demand generation, quality assurance, and creating an enabling environment. Although evidence is insufficient to prove which approaches are superior, tentative conclusions were possible; interventions increased rates of appropriate treatment, and medicine sellers were willing to participate. Waters et al. (2003) also noted that relatively more is known about contracting, training and social marketing than other interventions. Less is known about how to regulate well (see next section), or how well informing the public and other demand-side interventions can work. Powerful interest groups, such as commercial interests in the private sector, unions in the public sector or ideologically based political organizations, may have strong opposition or support for specific measures. Probably least is known about how to identify and work with these interest groups in designing or implementing private sector strategies. The impact of the non-state sector on tuberculosis has been more extensively reviewed than other areas. Borgdorff et al. (2003) described how not-for-profit nongovernmental organizations have contributed successfully to tuberculosis control, but noted that the involvement of other private sector providers is more problematic. Worryingly case detection and cure rates in the private sector are often unknown. Malmborg et al. (2006) reviewed whether public-private collaboration can promote tuberculosis (TB) case detection among the poor and vulnerable. The authors concluded that such collaborations can promote TB case detection among such groups. However, the existing evidence focuses narrowly on not-for-profit organisations. Recently though, a review by Dewan et al. (2006) noted that public-private mix activities in India were associated with increased case notification, while maintaining acceptable treatment outcomes (and many of the projects reviewed dealt with private providers). Finally, Lönnroth et al. (2006) reviewed 15 initiatives involving “for-profit” private health care providers in national TB control efforts with respect to contractual arrangements, quality of care and success achieved in TB control. The authors concluded that for-profit providers can be effectively involved in TB control through informal, but well defined drugs-for-performance contracts. However, they called for further research to assess whether such “soft” contracts are sufficient to scale up private for-profit provider involvement in TB control and other priority health interventions. Sheikh et al. (2005) illustrate the problems and potential of working with private providers, explore themes of equity and access arising in private sector delivery of care for TB and HIV, and highlight future policy directions for involving private medical providers in public health programmes. The authors conclude that PPPs can enhance continuity of care for patients with TB and HIV/AIDS. Again in India, Duggal and Ramachandran (2004) and Duggal (2004) reviewed the political economy of abortion, where services remain predominantly in the private sector. The reviews

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illustrate the importance of regulating abortion economy in India, both services and the medical profession, in order to rationalize costs and assure safe abortions for women. Nayar and Razum (2003) reviewed the performance of health co-operatives in the industrialized countries where they originated and analyzed experience from developing countries, in particular China, and Gujarat and Kerala in India. In China, co-operatives functioned mainly as a financing mechanism; in the state of Gujarat in India, they performed a mixed function of both as a delivery (mainly primary health care) and financing of health care; and in the state of Kerala in India, co-operatives existed as a mechanism mainly to deliver curative services. The review of existing experience suggests that the co-operatives are not a general solution that can be “prescribed” to compensate for deteriorating access to health services following market-oriented health sector reforms, particularly not in view of the increasing demand for clinical care in the coming years. Traditional birth attendants (TBAs) were examined in three reviews. Sibley et al. (2004) conducted a review to summarize published and unpublished studies completed between 1970 and 2002 on the relationship between TBA training and increased use of professional antenatal care (ANC). Although the findings cannot be causally attributed to TBA training, the results suggest that training may increase ANC attendance rates by about 38%. The authors felt that this magnitude of improvement could contribute to a reduction in maternal and perinatal mortality in areas where women have access to quality antenatal and emergency obstetric care. In a similar vein, Ray and Salihu (2004) reviewed the results of 15 TBA- and midwife-based interventions that aimed to improve skilled assistance in delivery and recognition and referral of complications. Programs with the greatest impact utilised TBAs and village midwives within multisectoral interventions, suggesting that TBAs and village midwives contribute to positive program outcomes through their ability to make referrals. Finally, Kruske and Barclay (2004), recognizing that there has been a refocus of priorities on the provision of “skilled attendants” to assist birthing women, concluded their review by stating “that policy-makers risk ignoring the important cultural and social roles TBAs fulfill in their local communities and fail to recognize the barriers to the provision of skilled care”. Policy & regulatory environment The review by Waters et al. (2003) suggests that the environment in which private sector strategies are implemented matters a great deal. Where the rule of law is stronger and where the public has higher expectations of transparency and accountability from government and the private sector, working with the private sector has a greater chance of success. It is not clear, however, whether strong government organization and capacity is a precondition for the success of strategies seeking to work with the private sector. These considerations are particularly relevant for those strategies that involve multiple actors and require the public sector to play an intermediating role, such as for contracting and regulating. Governance issues and the level of social capital may not be as important for those strategies that do not place as many new demands on the public sector, such as social marketing or training private providers. The evidence on approaches to improve antibiotic use in low-income countries was reviewed by Radyowijati and Haak in 2003. Probably the most important finding of the review was the scarcity of research. Specifically, little is known about the role of dispensers in mediating antibiotic use. Little research has been carried out on what dispensers actually know on correct antibiotic use, on how dispensers acquire their knowledge on antibiotic use, where the opportunities for knowledge exchange are located, or other critical pathways in shaping antibiotic use behaviors in this group.

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Many countries have implemented managed care techniques, which are driven by policy efforts to increase quality or to control costs. Peabody and Luck (2002) illustrate that successful implementation of managed care, however, appears to depend on five major preconditions. One precondition is an adequately developed formal wage sector in which patients have a sufficient ability to pay for healthcare services. Another is an adequate labor supply of trained professionals to support managed care administration, foster competition, and use available information technology. Thus for many developing countries, implementation managed care depends on attaining macroeconomic preconditions. Reflecting on the conceptual framework, most reviews addressed the “Outcomes and interventions” dimension, while the least is known about the “Policy and regulatory environment” and “Types of providers and the services they provide.” Within the latter category, some of the reviews are more than a decade old; so that while they helped raise the profile of this field of work at the time, and brought attention to the private sector, there have not been any recent updates of such information (perhaps because it is now more difficult to publish this kind of research?). This information gap was duly noted by a number of the regional reports where it was argued that what is really needed is an investment in health and information management systems (HMIS) so that NSS data are available on a routine basis thus taking away the need for cross-sectional, descriptive studies. An important mismatch between, in particular, the strong ‘demand’ for research on the policy and regulatory environment stated in the regional reports and the weak ‘supply’ of available evidence identified in the overview of reviews was noted – perhaps this is a function of the complexity of conducting rigorous research on this topic. In terms of the quality of the reviews identified across the different dimensions, for the most part authors noted the paucity of relevant studies, and suggested that more studies, of higher quality, be performed. From all of the systematic review papers, authors’ comments regarding gaps in existing research and suggestions for future research were extracted. It was anticipated that this might permit the removal of questions from the list of questions from the regional reports (if, for example, authors felt that the field had been exhaustively researched) or tailor the research questions (if the question had been partially addressed, but a more specific question remained). None of the review authors suggest that the existing research was sufficient, although this process did help in sharpening a number of the priority research questions (see Annex 8). Ranking of research questions Participants at the workshop spent time discussing the 18 questions generated from the regional reports, towards developing a common understanding of the questions. In some cases, minor changes were made to the wording of questions to make the meaning of the questions clearer (Annex 9). Based on a literature review of previous priority setting exercises, the authors proposed three criteria for ranking the 18 questions:

- Can the research question be answered? - How large is the impact on social welfare likely to be? (This was intended to include both health and equity impacts)

- Is there a lack of research on this topic? Participants agreed on these three criteria, but decided that the second of these criteria should receive twice the weight of the other two criteria, in the combined index. Each of these criteria was applied to the 18 priority research questions using a five-point Likert scale (1 = no (or low for the second criterion); 5 = yes (or high for the second criterion). Participants noted that the first criterion implicitly included the timeline (to be interpreted as “could the research be done in

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the next five years?”), the cost of the research and capacity to do the research. For the second criterion regarding the impact of the research on health, participants noted that there were two parts to this question (i) is the research fundamental to the successful implementation of the intervention and (ii) is the intervention relevant to health? Each of the nine participants assigned scores individually using a self-administered questionnaire. Index scores were then calculated for each individual (applying the above mentioned weighting) and summed across individuals, giving equal weight to each individual. The four top-ranked questions were as follows (see Annex 10 for a list of the top 10 ranked priorities with mean score and range): 1. How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes?

2. What is the quality and / or coverage of health care services provided by the non-state sector for the poor?

3. What types of regulation can improve health systems outcomes, and under what conditions? 4. How best to capture data and trends about private sector providers on a routine basis? On seeing this ranked list (including those ranked 5-10 – see Annex 10), participants were, in general, not surprised by the order. But given the small differences in the scores among those questions that ranked among the top, it was felt that there were really rather marginal differences between them. One participant suggested that all of the top ten questions really deserved to be supported. Participants also acknowledged that the four top-ranked questions are quite broad, and that more specific questions about interventions, e.g. accreditation, certification, contracting, etc., tended to be ranked lower. Again, they felt this to be appropriate. Finally, for the four top-ranked research questions, the group discussed in some detail how the research question might be addressed (e.g. more specific research questions that might fall within the broader one, appropriate methodologies, whether there should be a focus on a particular country or countries). Table 3 summarizes the discussions on some of the more specific research questions that might be addressed by investigators, towards addressing the four broader research questions. It became apparent that some of the research questions would need to be linked to an intervention or change of some sort, while others could either be done in cross-sectional comparisons or as descriptive or analytic case studies. For instance, under the question “What types of regulation can improve health systems outcomes, and under what conditions?” in Table 3 below, impact evaluations were mentioned as a possible means to answering the question. This implies that the research needs to be conducted in parallel to some form of change, whether as a national policy change, or as some kind of policy experiment. In general, in thinking about research methods and opportunities it is important to recognize that some of the questions about the effectiveness of interventions (including changes in the regulatory system) can only be answered through examining the effects of some kind of change. This usually requires researchers to set up partnerships with governments / other implementers (e.g. NGOs) and intervention funders, since it involves some kind of change in policy or practice.

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Table 3: Summary of discussion about the four top-ranked questions Research question Unpacking the question Potential methods and approaches Potential countries and regions How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes?

What was meant by “environment”. The participants felt this could include: - Characteristics of the health sector: information flows, the extent of information asymmetry, education and training, clarity of regulation, effectiveness of regulatory bodies, health financing interventions / contracts, accreditation, laws and norms (“rules of the game”), degree to which the private sector is organized; - Broader contextual factors: taxation, trade policies, general market liberalization, market efficacy, degree of communication and dialogue between state and non-state actors, donor issues, access to capital / capital markets While participants felt that the question encompassed many different facets of the environment they noted that the value of the question lay in addressing all these facets together in a holistic fashion, rather than focusing in on one or two specific elements.

Qualitative, cross-country research, which might include: - Cross country comparisons inclusive of some countries where the environment is “fostering”; - “Natural experiments” that assess a particular outcome “pre- and post” implementation of a particular policy - Qualitative research among non-state sector actors to find out how they think the environment might be enhanced - Cross-country evaluation of professional associations (e.g. medical councils) to find out where they were working well, and why - Somehow draw from experience in other sectors Participants also suggested that case study approaches would be appropriate, and that institutional analyses and political economy analyses could be employed.

Participants did not want focus on a particular region. Felt it would be useful to look at a diverse set of countries across regions in order to tease out differences. Thought it might be useful to look at countries that are undergoing rapid change (e.g. rapid increases in the number of NGOs and how the environment is changing in response to that).

What is the quality and / or coverage of health care services provided by the non-state sector for the poor?

- Focus on particular service? E.g. Public health interventions, preventive programs - Poor needs to be emphasized: distinguish between relative and absolute poverty. Poor have less choices and more disease – other barriers to accessing care, e.g. cultural, empowerment. Do we want to include the vulnerable (e.g. people with chronic illness)? - Need to examine the question of

- Surveys - GPS mapping - Focus on particular service / intervention and/or conditions (e.g. TB vs. diarrhoea – chronic vs. acute / complex vs. simple) to aide assessment of quality – series of discrete studies. But compare and contrast to enhance generalisability - In depth studies of impact on the poor and health implications of seeking care in

No region of focus was recommended.

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empowerment of the poor, to what extent are they better able to negotiate with private providers than public ones. - Quality: perceived vs. technical: are the poor getting effective care? - Coverage: which NSPs provide care to the poor and can they be scaled up? - What are the implications for the poor of care seeking in the private sector for example in terms of affordability, effectiveness? We need a better understanding of the overall experience of the poor. - Should we add the ‘how to improve the situation’, i.e. Interventions, to this question? Do we need to compare to public sector? - Look at trends over time: are things getting better of worse? - Quality / quantity trade-off

NSS rather than public sector: longitudinal rather than cross-sectional studies

What types of regulation can improve health systems outcomes, and under what conditions?

Many different sorts of regulations could be studied: - Formal legislation versus guidelines or procedures - State versus self-regulation - Carrots (positive means of enforcement) versus sticks (negative) - Look carefully at issues of implementation and enforcement: is it possible to make the type of regulation that is effective in industrialized countries work in low and middle income countries? - Need to link the question of appropriate regulation to government capacity: which regulatory rules are most likely to be enforced in a fair and transparent manner, particularly given limited government capacity. What role can professional associations play?

- Studies that compare what is in place “in the books” versus what has actually been implemented - Studies examining national versus sub-national differences - Studies looking at the role of different institutions in the success or failure to implement - Cross-country comparisons of the role of professional associations - Impact evaluations (presumably a more quantitative form of evaluation)

Particularly important in countries where governments have limited capacity, e.g. fragile states, or in countries where regulations have rapidly changed or been scaled up (e.g. Bahrain, Former Soviet Republics).

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- Look at regulatory innovations (e.g. requirement that Indian insurers cover poorer populations)

How best to capture data and trends about private sector providers on a routine basis?

HMIS should be able to capture data on how many non-state providers there are, who they are, what they’re doing (in terms of services provided) and who uses them Need to consider effectiveness of alternative approaches to capturing data on the non-state sector: sentinel sites (track over time), use data from census (occupations??), HH surveys, HMIS, rapid assessment techniques, provider surveys, mapping methods, looks beyond health sector. Costs and sustainability, comprehensiveness, ownership, flexibility, e.g. Aggregation, (parallel with NHAs?) What are the conditions that will encourage private sector providers to report data and help ensure the reliability of data? What role do professional associations play in this process? How can household surveys be used better to distinguish where people are seeking care - typically household survey questions about type of provider are poorly answered especially with respect to different types of private provider. How can these questions be strengthened?

- Use sentinel site data and compare with data using other data capture methods.

Places with lots of informal providers. Places where one wants to increase NSS participation.

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Discussion Summary: the emerging priorities A list of 18 priority research questions emerged from key informant interviews across the twenty-four LMICs. While each broad research topic was common to two or more countries or regions, the more specific ‘sub-topics’ of interest varied considerably. The overview of systematic reviews provided little insight into the relative importance of the research questions. Many of the questions received little attention in the literature reviews, or were addressed in a very general fashion. Even where questions had been addressed (or partially addressed) by the literature reviews, the authors of the reviews generally suggested that additional primary research, or research of higher quality, was still required. However, this overview of reviews was instructive in showing which NSS topics have had comparatively little written about them, despite being identified as important by key informants. Furthermore, the overview helped further sharpen some of the initial questions gleaned from the regional reports. At the consultative workshop, a group of nine researchers refined and ranked the priority research questions. Included among those ranked highest were questions about: ways to create a better environment to foster non-state providers in the achievement of health systems outcomes, determining the quality and / or coverage of health care services provided by the non-state sector for the poor, types of regulation that can improve health systems outcomes and how best to capture data and trends about private sector providers on a routine basis. Strengths and weaknesses of methodology The study has several important methodological strengths: 1. The process used in the three steps of the study has been carefully documented and described, and thus should be replicable.

2. An iterative process was used to generate the list of questions, favoring those that were expressed by more than one country, and increasing the generalisability to other developing countries.

3. The study sampled a very diverse group of stakeholders, including researchers, policy makers, civil society representatives, and community members across four regions and twenty-four countries.

4. This study focuses primarily on the research needs of developing countries; few other research priority setting processes have had such a focus.

5. By focusing on select health policy and systems research (HPSR) thematic areas (NSS, health sector and human resources for health) this study has been able to generate quite specific research questions. Previous priority setting exercises have tended to deal with HPSR in a fairly broad / cursory manner, without breaking research issues down into questions that can easily be turned into aims and objectives for research.

The methodological weaknesses are several: 1. Respondents seemed to have less to say about the NSS than for the two other themes (human resources and financing). This might be because the NSS questions came last or, alternatively, that respondents had less to say about this area. However, it should also be noted that the regional reports typically did not include many private sector respondents, and this potentially influenced both the number and nature of the questions raised.

2. There was a lack of standardization in study methodology across regions: It is very difficult to compare results, for example, between the Latin America and Caribbean region where a relatively more quantitative (and deductive) approach was used and the Middle East and North Africa region where the approach was more qualitative (and inductive). Similarly, it has been difficult to compare between the many different policy and research categories investigated. For example, the different policy categories looked at included: policy concerns,

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important current health topics, proposed health policy topics, current policies, desired policies and policy priorities. There were different interviewers in most of the 24 countries, which of course hinders standardization. The types of respondents also varied across countries; only the Middle East and North Africa region, for example, interviewed ‘consumers’ of health care.

3. Sometimes research questions identified were in reality policy questions, that needed further refinement to make them into research questions – we tried to ensure that the final list of questions were indeed researchable while remaining faithful to what was reported in the regional reports.

4. There are weaknesses in the analysis and presentation of qualitative data in some country- and regional-level reports. Data from interviews were in some cases presented alongside data from background documents and the authors own perceptions, leaving one unclear as to what was actually expressed by respondents.

5. Regions, countries and respondents were purposefully (rather than randomly) selected. Thus there may be concerns about the representativeness and generalisability of the results.

6. Ex-ante, regional PIs intended to distinguish between responses given by policy-makers vis-à-vis researchers. However in none of the regional reports do authors differentiate between responses given by policy makers and researchers (or civil society representatives or consumers).

The systematic review of literature reviews has a number of methodological strengths. First, by identifying, selecting, assessing and synthesizing existing literature reviews in a timely yet systematic way it allows policy-makers and stakeholders to get a quick sense of the state of research evidence. Second, mapping the available research evidence against the framework serves to highlight the significant gaps in the current evidence-base. Third, broadening the search to include not just systematic reviews but all literature reviews gives a more holistic sense of the evidence-base, including both quantitative and qualitative research. There are also several important weaknesses in the systematic review of literature reviews. First, there was no search of the grey literature for exiting reviews of the non-state sector. Second, in an attempt to identify more recent, and more relevant, literature the search in PubMed was from 1 January 2002 the year of the release of the seminal private sector paper; even though we included older literature familiar to the authors that met our inclusion criteria, we may have excluded useful reviews by limiting the search in such a way. Third, the search strategy focused exclusively on reviews pertaining to LMICs. This may explain a failure to to identify any cross-national or global-level studies that looked both at developed and developing countries. This contrasts with the two other thematic reports on human resources for health and health sector financing, which included many studies (including several Cochrane reviews) that were nominally “global” but drew largely from data in high income countries. Of course, this may also be a function of the relative unimportance of or vastly different nature of the NSS in many high-income countries. Policy implications: what next? A stronger body of knowledge about the effectiveness of varying health policy and health system strengthening strategies is urgently needed9. However at present funding for such research is inadequate. With recent increases in funding for health systems strengthening, there have also been calls for appropriate investments in evaluation and research10 – the most recent being a call

9 Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004; 364(9437): 900-906. 10 Murray CJ, Frenk J, Evans T. The Global Campaign for the Health MDGs: challenges, opportunities, and the imperative of shared learning. Lancet. 2007; 370(9592): 1018-1020.

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for health systems research and learning in the context of the G8 Hokkaido Toyako Summit11. It is hoped that this work on the non-state sector research priorities (along with similar work being conducted on health workforce and health financing priorities) will complement these calls by providing concrete, specific suggestions as to where new and existing research resources can best be invested.

11 Reich M, Takemi K, Roberts M, Hsiao W. Global action on health systems: a proposal for the Toyako G8 summit. The Lancet. 2008; 371(9615): 865-869.

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Acknowledgments We would like thank the many colleagues who contributed to the Alliance’s priority setting work, including: Delius Asiimwe and Gaspar Munishi (East Africa report); Gonzalo Urcullo, Rodrigo Muñoz and Ricardo Bitrán (Latin American and the Caribbean report); Soewarta Kosen, Siripen Supakankunti and and Syed Mohamed Aljunid (Southeast Asia report); Fadi El-Jardali, Judy Makhoul, Diana Jamal and Victoria Tchaghchaghian (MENA report); Shirley Williams; the many country-based investigators; and participants in the workshop in Bellagio (Annex 5). We would also like to thank April Harding (Centre for Glocal Development) and Kara Hanson (London School of Hygiene and Tropical Medicine) for providing comments on an earlier draft of this report.

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Annex 1: Methodology Literature Review: LAC Report: The following databases were used: Ovid MEDLINE(R) 1996 to Present with Daily Update, Ovid MEDLINE(R) without Revisions <1950 to Present>, Jounals@ovid, Books@ovid, Global Health database (1973 to September 2007) and Ageline database. The search was restricted to abstracts in publications between 1996 and 2007. Review for grey literature was done through a set of web national and international web sites. ASIA Report: Authors collected “published and unpublished documents/background documents/information, study reports, minutes of hearings with National Parliament, web-sites materials and program statements by respective program managers/decision makers in the three countries (Malaysia, Indonesia and Thailand)” (Asia report). MENA Report: Literature review was conducted through Medline/CINAHL and EMBASE. AFRICA Report: Literature review to search for official documents and grey literature was conducted through libraries, information centers and internet. Interviews: LAC Report: 90 interviews were conducted in 10 countries selected as being representative of the LAC region (Argentina, Bolivia, Chile, Peru, Suriname, the Dominican Republic, Costa Rica, El Salvador, Nicaragua, and Panama). In each country, 7 policy makers (2 high-level decision makers at the ministries of health; 1 health sector officer at the ministries of finance or planning; 1 member of the national congresses’ health commissions; 2 members of health professionals associations, such as medical programs or nursing schools; and 1 member of international development and donor organizations (WHO/PAHO, USAID, IDB, World Bank)) and 2 researchers from public health schools or universities were interviewed. The data collection instrument had two parts: 1) an open-ended question (What do you consider to be the most important topics regarding the role of the non-governmental sector in health?) 2) Four close-ended questions (respondents were asked to rank a pre-defined lit of priorities for current and desired policies and current and desired research). The list of policy/research priorities for the LAC open-ended questions was: a. “Increase regulation of the non-state sector activities b. Contract non-state sector services to increase health coverage (e.g. in areas with difficult access)

c. Contract non-state sector services to improve efficiency and transparency d. Allow or increase non-state sector activities in health (e.g. insurers, providers, etc) e. Facilitate participation of the non-state sector to increase external revenues f. Facilitate participation of the non-state sector to increase local revenues from the private sector

g. Facilitate participation of the non-state sector to address cultural or geographical barriers h. Facilitate participation of the non-state sector to access new technologies (e.g. organization of health services, modalities of care, etc)

i. Facilitate participation of the non-state sector to develop pilot experiences j. Others (specify).”

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ASIA Report: 35 Interviews (19 for Indonesia, 13 for Malaysia and 3 for Thailand) were conducted with key informants/officials from identified national institutions/units /organizations and regional/international agencies (ASEAN, APEC, WHO-SEARO, WHO-WPRO). Survey questionnaire started with close-ended questions (respondents were asked to rank a pre-defined list of priorities for current and desired policies and current and desired research) and ended with an open-ended question asking for any priorities not present in the list. The list of policy/research priorities for the open-ended questions was: a. Quality of care in private health facilities b. Licensing of private health care facilities c. Role of the private health sector in serving the poor d. Role of the private health facilities in provision of “Public Goods” services e. Interaction between private and public health facilities (referral, disease notification) f. Financing of the provision of services by private health care facilities g. Government incentives to private health facilities in promoting health tourism h. Contracting out of the Public hospital services to the private sector (laundry, food, dispensary, clinical services).

MENA Report: 77 Interviews were conducted in 9 countries with public sector (Ministry of Health, Ministry of Finance, Ministry of Education, and Ministry of Labour), health professionals’ groups (Order of Physicians, Order of Nurses, Order of Pharmacists, Order of Dentist (and other health professionals), syndicate of hospitals, and associations of public health), academic institutions (major universities, and key researchers and experts in the three themes), civil society groups (private sector, NGOs, faith-based organizations and media) and consumer groups. A mix of open and close-ended questions was used. Respondents were presented with the first four (broad) categories of the conceptual framework: government stewardship, regulation of the non-state actors, provision of services, financing of services and monitoring of performance and accountability. Thematic analysis was used for qualitative data. AFRICA Report: 35 interviews were conducted with organizations/agencies, associations, non-governmental organizations and government ministries. Qualitative approach was used. Only open-ended questions were asked.

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Annex 2: Search strategy used Role of Non State Sector delivering health care in low and middle-income countries Medline search through Pubmed Date May 22, 2008, Total Number of Hits: 1153 Search strategy used: Methodology: Review [tiab] OR review [ptyp] OR review*[tw] AND Non State Sector: (((private sector OR private practitioner*[tiab] OR private health care providers[tw] OR Private practices[MeSH] OR Private practi*[tw] OR Private provi* OR "private for profit"[tw]) OR (Non state sector OR Non state*) OR (formal OR non formal OR informal OR traditional OR licensed OR non licensed OR unlicensed OR drug vendors OR medicine sellers OR pharmacists OR social worker[tiab]) OR (NGO[tiab] OR General practitioners[MeSH] OR Corporate practices[MeSH] OR Organizations, Non profit[MeSH] OR Public Private Partnership[tw]) OR (Outsourced services[MeSH] OR Franchis* OR Contract* OR Community pharmacy services[tw] OR Voucher* OR Accredit*) OR Social marketing[mesh] OR entrepreneurship[tw] OR "Marketing of health services"[tiab] OR ("Community Health Centers/organization and administration"[Mesh] OR "Community Health Centers/utilization"[Mesh]) OR (Community network[MeSH] OR Counselling[Mesh] OR "Social responsibility"[tw]) OR ("Social Work/manpower"[Mesh] OR "Social Work/organization and administration"[Mesh] OR "Social Work/supply and distribution"[Mesh] OR "Social Work/utilization"[Mesh]) OR (Peer approach OR Community mobilization OR Health education) AND Population: (("Developing Countries"[MeSH]) OR (less developed countr*[tiab]) OR (third world countr*[tiab]) OR (under developed countr*[tiab]) OR (underdeveloped countr*[tiab]) OR (developing nation*[tiab]) OR (less developed nation*[tiab]) OR (third world nation*[tiab]) OR (under developed nation*[tiab]) OR (low income countr*[tiab]) OR (low income nation*[tiab]) OR (middle income nation*[tiab]) OR (middle income countr*[tiab]) OR (lmic OR lmics[tiab]) OR ("Africa south of the Sahara"[MeSH]) OR ("Asia, Western"[MeSH]) OR ("Asia, Southeastern"[MeSH]) OR ("Asia, Central"[MeSH]) OR (Mexico[MeSH]) OR ("South America"[MeSH]) Limits: (Humans[Mesh]) AND (English[lang] OR French[lang] OR Spanish[lang])))) AND (("2002/01/01"[PDat] : "2008/05/01"[PDat])

29

Annex 3: Table of Excluded Studies Article Reason for Exclusion 1 Aziz N, Gilani A, Rindh M (2002) Kushta(s): unique herbo-mineral

preparations used in South Asian traditional medicine. Medical Hypotheses, 59(4): 468-472.

Not a review

2 Caminero J (2003) Is the Dots strategy sufficient to achieve tuberculosis control in low- and middle-income countries: 1. Need for interventions in universities and medical schools, Int J Tuber Lung Dis, 7(6): 509-515.

Not a review

3 Caminero J (2003) Is the Dots strategy sufficient to achieve tuberculosis control in low- and middle-income countries: 2. Need for interventions among private physicians, medical specialists and scientific societies Int J Tuber Lung Dis, 7(7): 623-630.

Not a review

4 Foster G (2007) Under the radar: Community safety nets for AIDS-affected households in sub-Saharan Africa. AIDS Care 19 (supl 1): S54-S63.

Not related to health service delivery

5 McIntyre D, Thiede M, Dahlgren G, Whithead M (2005) What are the economic consequences for households of illness and of paying for health care in low- and middle-income country contexts? Soc Science Med, 62: 858-865,

Not related to non-state sector

6 Mellstedt H (2006) Cancer initiatives in developing countries. Annals of Oncology; 17(suppl 8): viii24-viii31.

Not a review

7 Mudur G (2003) India plans to expand private sector in healthcare review. BMJ; 326: 520.

Not a review

8 Ogilvie L, Mills J, Astle B, Fanning A, Opare M (2007) The exodus of health professionals from sub-Saharan Africa: balancing human rights and societal needs in the twenty-first century, Nursing Inquiry; 14(2): 114-124.

Not related to health service delivery

9 Palmer N, Mills A, Wadee H, Gilson L, Schneider H (2003) A new face for private providers in developing countries: what implications for public health? Bull World Health Organ 81(4).

Not a review

10 Pandian J, Srikanth V, Read S, Thrift A (2007) Poverty and stroke in India. Stroke; 38: 3063-3069.

Not a review

11 Rall M, Meyer S (2006) The role of the registered nurse in the marketing of primary healthcare services, as part of health promotion. Curationis, 29(1):10-24

Not LMIC

12 Brugha R (2003) Antiretroviral treatment in developing countries: the peril of neglecting private providers. BMJ, 326: 1382-1384.

Not a review

13 Butlerys M, Fowler M, Shaffer N, Tih P, Greenberg A, Karita E, Coovadia H, DeCock K (2002) Role of traditional birth attendants in preventing perinatal transmission of HIV. BMJ, 324: 222-224

Not a review

14 Conteh L, Hanson K Methods for studying private sector supply of public health products in developing countries: a conceptual framework and review. Soc Sci Med 2003; 57(7): 1147-61

Not related to health service delivery

15 Volmink, J. and P. Garner (2000). Interventions for promoting adherence to tuberculosis management. Cochrane Database Syst Rev(4): CD000010.

Withdrawn from the Cochrane library

16 Bateganya MH et al. Home-based HIV voluntary counseling and testing in developing countries. Cochrane Database Syst Rev 2007; (4): CD006493

Not non-state sector

17 Baskind R, Birbeck GL. Epilepsy-associated stigma in sub-Saharan Africa: the social landscape of a disease. Epilepsy Behav 2005; 7(1): 68-73

Not a review

18 Hubley J. Patient education in the developing world--a discipline comes of age. Patient Educ Couns 2007; 61(1): 161-4.

Not a review

19 Mathews et al. A systematic review of strategies for partner notification for sexually transmitted diseases, including HIV/AIDS. Int J STD AIDS 2002; 13(5): 285-300.

Not non-state sector

20 Shaikh BT, Hatcher J. Health seeking behaviour and health service utilization in Pakistan: challenging the policy makers. J Public Health (Oxf) 2005; 27(1): 49-54.

Not a review

21 Turner H. Literature review: Afghanistan womens health crisis, health service delivery, and ethical issues for international aid. Health Care Women Int 2006; 27(8): 748-59.

Not a review

30

Annex 4: List of reviews included in the overview of reviews 1. Berman P, Rose L. The role of private providers in maternal and child health and family planning services in developing countries. Health Policy Plan. 1996;11(2):142-55.

2. Borgdorff MW et al. Interventions to reduce tuberculosis mortality and transmission in low- and middle-income countries. Bull World Health Organ 2002; 80(3): 217-27

3. Brugha R, Chandramohan D, Zwi A. Viewpoint: management of malaria--working with the private sector. Trop Med Int Health. 1999;4(5):402-6..

4. Brugha R, Pritze-Aliassime S. Promoting safe motherhood through the private sector in low- and middle-income countries. Bull World Health Organ. 2003;81(8):616-23.

5. Brugha R, Zwi A. Improving the quality of private sector delivery of public health services: challenges and strategies. Health Policy Plan. 1998;13(2):107-20.

6. Bustreo F et al. Can developing countries achieve adequate improvements in child health outcomes without engaging the private sector? Bull World Health Organ 2003; 81(12): 886-95

7. Dewan PK et al. Improving tuberculosis control through public-private collaboration in India: literature review. BMJ 2006; 332(7541): 574-8.

8. Duggal R, Ramachandran V. The abortion assessment project--India: key findings and recommendations. Reprod Health Matters 2004; 12(24 Suppl): 122-9.

9. Duggal R. The political economy of abortion in India: cost and expenditure patterns. Reprod Health Matters 2004; 12(24 Suppl): 130-7.

10. Goodman C et al. Medicine sellers and malaria treatment in sub-Saharan Africa: what do they do and how can their practice be improved? Am J Trop Med Hyg 2007; 77(6 Suppl): 203-18.

11. Hanson K, Berman P. Private health care provision in developing countries: a preliminary analysis of levels and composition. Health Policy Plan. 1998;13(3):195-2

12. Koehlmoos T, Gazi R, Hossain S, Zaman K (2009) Effect of social franchising on access to and quality of health services in low- and middle-income countries. Cochrane Database of Systematic Reviews, Issue 1.

13. Kruske S, Barclay L. Effect of shifting policies on traditional birth attendant training. J Midwifery Womens Health 2004; 49(4): 306-11.

14. Liu X et al. The effectiveness of contracting-out primary health care services in developing countries: a review of the evidence. Health Policy Plan 2008; 23(1): 1-13.

15. Lönnroth K, Uplekar M, Blanc L. Hard gains through soft contracts: productive engagement of private providers in tuberculosis control. Bull World Health Organ. 2006; 84: 876-883.

16. Malmborg R et al. Can public-private collaboration promote tuberculosis case detection among the poor and vulnerable? Bull World Health Organ 2006; 84(9): 752-8.

17. Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? Bull World Health Organ. 2002;80(4):325-30

18. Nayar KR, Razum O. Health co-operatives: review of international experiences. Croat Med J 2003; 44(5): 568-75.

19. Patouillard E, Goodman CA, Hanson KG, Mills AJ. Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature. Int J Equity Health. 2007;6:17.

20. Peabody JW, Luck J. When do developing countries adopt managed care policies and technologies? Part I: Policies, experience, and a framework of preconditions. Am J Manag Care 2002; 8(11): 997-1007.

21. Peters DH et al. Strategies for engaging the private sector in sexual and reproductive health: how effective are they? Health Policy Plan 2004; 19 Suppl 1: i5-i21.

22. Radyowijati A, Haak H. Improving antibiotic use in low-income countries: an overview of evidence on determinants. Soc Sci Med 2003; 57(4): 733-44.

23. Ray AM, Salihu HM. The impact of maternal mortality interventions using traditional birth attendants and village midwives. J Obstet Gynaecol 2004; 24(1): 5-11.

31

24. Sekhri N, Savedoff W. Regulating private health insurance to serve the public interest: policy issues for developing countries. Int J Health Plann Manage. 2006;21(4):357-92

25. Sheikh K et al. Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India. Trans R Soc Trop Med Hyg 2006; 100(4): 312-20.

26. Sibley LM et al. Does traditional birth attendant training increase use of antenatal care? A review of the evidence. J Midwifery Womens Health 2004; 49(4): 298-305.

27. Thomas C. A literature review of the problems of delayed presentation for treatment and non-completion of treatment for tuberculosis in less developed countries and ways of addressing these problems using particular implementations of the DOTS strategy. J Manag Med 2002; 16(4-5): 371-400.

28. Waters H, Hatt L, Peters D. Working with the private sector for child health. Health Policy Plan. 2003;18(2):127-37.

32

Annex 5: List of participants at meeting, “Identifying and building consensus on non-state sector research priorities”, Bellagio, Italy, 10 October 2008

Delius Asiimwe Senior Research Fellow Makerere Institute of Social Research P.O. Box 16022 Kampala Uganda Claire Champion Health Systems Program Department of International Health Johns Hopkins University Bloomberg School of Public Health USA Dr Birger Forsberg Karolinska Institutet Nobels väg 9 171 77 Stockholm Sweden Dr Shahed Hossain Scientist and Senior Search Strategist Centre for Systematic ReviewHealth Systems and Infectious Diseases Division ICDDR,B Bangladesh Dr Gina Lagomarsino The Results for Development Institute 1825 Connecticut Avenue Washington DC 20009 USA Dr Dominic Montagu Lead, Health Systems Initiative UCSF, Global Health Group 50 Beale St, Suite 1200 San Francisco, CA USA Dr Stefan Nachuk Associate Director The Rockefeller Foundation 420 Fifth Avenue New York, NY 10018 USA Dr Krishna Rao

33

Head, Health Economics and Financing Public Health Foundation of India PHD House Srifort Institutional Area August Karanti Marg New Delhi India Guy Stallworthy Senior Programme Officer Bill and Melinda Gates Foundation P.O. Box 23350 Seattle USA Dr Damian Walker Health Systems Program Department of International Health Johns Hopkins University Bloomberg School of Public Health USA WHO PARTICIPANTS Dr Sara Bennett Manager Alliance for Health Policy and Systems Research Dr Knut Lönnroth Medical Officer TBS TB Strategy and Operations Dr M. Kent Ranson Technical Officer Alliance for Health Policy and Systems Research Dr Phyllida Travis Department for Health Systems Governance and Service Delivery (HDS) Mrs Shirley Williams WHO Temporary Adviser

34

Annex 6: Regional Policy concerns Latin America and the Caribbean

Southeast Asia Middle East and North Africa

East Africa

1. Regulation of the non-state sector activities (most desired by far)

2. Contracting mechanisms with non-state sector actors to increase health services coverage

3. Contracting mechanisms with non-state sector actor to improve efficiency and transparency

1. Regulation 2. Licensing and

accreditation 3. Oversight of private

health care facilities 4. Role of the private

sector in serving the poor

5. Interaction and partnership between private and public sector

6. Quality and patterns of care provided in private health facilities and how to influence them.

1. Regulation (contracting out, defining role and responsibilities in meeting health systems objectives, monitoring of performance, establishing quality standards for provision of services, better coordination between state and non-state sectors)

2. Involvement of the non-state sector in defining health needs, setting priorities and setting up PPP

3. Include non-state actors in national database

Uganda: 1. Weak current

ongoing partnership between none-state sector and government

Tanzania: 1. Mistrust between

government and for-profit operators (access to the poor, quality, etc)

2. Lack of recognition of alternative medicines

35

Annex 7: Research priorities Latin America and the Caribbean

Southeast Asia Middle East and North Africa

East Africa

1. How to improve regulation of the non-state sector activities

2. How to increase health service coverage with private providers

Indonesia: 1. How to improve

regulation of the non-state sector activities

2. How to optimize licensing and accreditation scheme

3. How to improve oversight of private health care facilities

4. How to encourage private health sector too serve the poor

5. How to build effective interaction and partnership between private and public health facilities

6. What is the role of the private health facilities in provision of “public goods” services?

Malaysia: 1. How to improve

quality of care in private health sector

2. How to build effective interactions and partnership between public and private providers

3. How to design adequate regulations to ensure patient safety in private health sector

4. What is the effect of dual practice in health care?

Thailand: 1. Whether and how to

design tax incentives for private hospitals to cope with NPLs from the patients

2. How to expand the role of private insurance for certain groups of patients who wants to be cured in private hospitals

3. How to increase cost-effectiveness of health services provided by public sector compared to private sector

1. Public-Private Partnerships: What are the foundation/elements for building strong public-private partnerships

2. How to define the role and responsibility of the non-state sector: national plan for the contribution of the non-state sector, effectiveness of the non-state sector in meeting health system objectives, areas where the state and non-state sector can complement each other

3. What is the magnitude and capacity of the non-state sector: scope, resources and services types (need for a national database on the non-state actors)

4. How to improve performance and evaluation: quality standards, accreditation, M&E, accountability, client satisfaction?

Uganda: 1. Need to generate

information about the non-State Sector through the development of a comprehensive HMIS

2. Gain a better understanding of the reasons for the weak/absence of relationships/synergies among different sub-sector of health care delivery

3. Conduct a national mapping of the private health facilities and providers (including data on pricing, patients information, cost and treatment procedures)

4. Conduct a national survey on customer satisfaction

Tanzania: 1. Conduct principal-

agency studies within the context of public-private partnerships

2. How to optimize management of service-level agreement (contracting out)

3. Conduct quality management studies (including accreditation)

4. Conduct costing studies of non-state actors’ activities

5. Conduct studies on options to implement accreditation systems for alternative medicines activities and standardization rules for quality assurance

6. Conduct research on how to improve environment to favor non-state sector growth

36

4. What is the appropriate tax policy on private hospital income from medical tourism?

37

Annex 8: Research priorities identified from the regional reports and final list of research priorities Regional reports Presented at workshop

1 What are the role, magnitude and capacity of the non-state sector in the provision of health care?

What are the role, magnitude and capacity of the non-state sector in the provision of health care?

2 To what extent can the non-state sector increase coverage and access to health care services?

To what extent can the non-state sector increase the quality and / or coverage of health care services for the general population?

3 To what extent can the non-state sector increase the quality and / or coverage of health care services for the poor?

To what extent can the non-state sector increase the quality and / or coverage of health care services for the poor?

4 Conduct a national survey on customer satisfaction (not expressed as a research question)

What are the levels of client satisfaction among those who access non-state providers and how can client satisfaction be improved?

5 Conduct costing studies of non-state actors’ activities (not expressed at a research question)

What are the costs of the private sector interventions? Are they are less expensive than public sector alternatives?

6 What is the role of PPPs? What are the key components of successful PPP? How can they be strengthened?

What is the role of PPPs and how can their performance be strengthened?

7 What are the main contracting mechanisms to non-state sector? Are they cost-effective?

Is contracting out of services an efficient way to expand coverage of services?

8 How to implement contracting and monitor quality of non-state providers?

Can contracting for services help improve service quality in the private sector, and if so under what conditions?

9 What are the gaps in governments’ capacity to contract out health services?

What are the gaps in governments’ capacity to contract out health services and how does widespread contracting of services affect governments’ capacity and role?

10 What are the tools available to monitor the non-state sector’ activities and improve services quality and affordability (regulations, licensing, accreditation, etc). How should those tools be used and in which context?

How best can licensing and accreditation schemes be implemented? What impact can such schemes have on improving the quality and / or coverage of services?

11 What is the role of the consumers/patients defense associations?

What is the role of the consumers / patients defense associations?

12 Under what conditions can regulation improve health systems outcomes?

Under what conditions can regulation improve health systems outcomes?

13 How to build better collaboration, e.g. trust, between state and non-state sectors?

How to build better collaboration, e.g. trust, between state and non-state sectors?

14 What is the impact of dual practice? Are regulations on dual practice required, and if so how should they be designed and implemented?

What is the impact of dual practice? Are regulations on dual practice required, and if so how should they be designed and implemented?

15 How should/could government integrate non-state sector into national strategic planning and policy?

How should/could government integrate the non-state sector into national strategic planning and policy?

16 How can the government create a better environment to foster the growth of quality and affordable non-state actors that would complement state sector activities? How can government foster effective competition among non-state actors?

How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes that would complement state sector activities?

17 How best to capture data about private sector providers on a routine basis, for example through including them in HMIS?

How best to capture data about private sector providers on a routine basis, for example through including them in HMIS?

18 What is the impact of health tourism on the quality and affordability of health systems? Should the government provide incentives to the non-state sector to develop health tourism?

What is the impact of health tourism on the quality and affordability of health systems? Should the government provide incentives to the non-state sector to develop health tourism?

38

Annex 9: Changes to the research questions made at the workshop Presented at workshop Changed to:

1 What are the role, magnitude and capacity of the non-state sector in the provision of health care?

What are the role, magnitude, capacity and utilisation of different types of non-state sector providers in the provision of health care and how do these change over time?

2 To what extent can the non-state sector increase the quality and / or coverage of health care services for the general population?

What is the quality and / or coverage of health care services provided by the non-state sector for the general population?

3 To what extent can the non-state sector increase the quality and / or coverage of health care services for the poor?

What is the quality and / or coverage of health care services provided by the non-state sector for the poor?

4 What are the levels of client satisfaction among those who access non-state providers and how can client satisfaction be improved?

What are the levels of client satisfaction among those who access non-state providers?

5 What are the costs of the private sector interventions? Are they are less expensive than public sector alternatives?

What are the costs and affordability of the non-state sector goods and services relative to the state sector? And to whom?

6 What is the role of PPPs and how can their performance be strengthened?

What is the nature, form and effectiveness of organised forms of interaction between public and private sectors and how can these interactions be strengthened?

7 Is contracting out of services an efficient way to expand coverage of services?

Is contracting out of services an efficient way to expand coverage of services?

8 Can contracting for services help improve service quality in the private sector, and if so under what conditions?

Can contracting for services improve service quality and if so under what conditions?

9 What are the gaps in governments’ capacity to contract out health services and how does widespread contracting of services affect governments’ capacity and role?

What are the gaps in governments’ capacity to contract out health services and how does contracting of services affect governments’ capacity and role?

10 How best can licensing and accreditation schemes be implemented? What impact can such schemes have on improving the quality and / or coverage of services?

How best can licensing and accreditation schemes be implemented? What impact can such schemes have on improving the quality and / or coverage of services?

11 What is the role of the consumers / patients defense associations?

How to do consumers’ / patients’ associations impact on access and quality of care?

12 Under what conditions can regulation improve health systems outcomes?

What types of regulation can improve health systems outcomes, and under what conditions?

13 How to build better collaboration, e.g. trust, between state and non-state sectors?

How to build better collaboration, e.g. trust and mutual understanding, between state and non-state actors?

14 What is the impact of dual practice? Are regulations on dual practice required, and if so how should they be designed and implemented?

What is the impact of dual practice? Are regulations on dual practice required, and if so how should they be designed and implemented?

15 How should/could government integrate the non-state sector into national strategic planning and policy?

Should/could government integrate the non-state sector into national strategic planning and policy and if so how?

16 How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes that would complement state sector activities?

How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes?

17 How best to capture data about private sector providers on a routine basis, for example through including them in HMIS?

How best to capture data and trends about private sector providers on a routine basis?

18 What is the impact of health tourism on the quality and affordability of health systems? Should the government provide incentives to the non-state sector to develop health tourism?

What is the impact of medical tourism on the quality, access and affordability of health services? Should the government provide incentives to the non-state sector to develop medical tourism?

39

Annex 8: List of top 10 ranked priorities with mean score and range

Rank Question (with original number) Score Range

1 16) How can the government create a better environment to foster non-state providers in the achievement of health systems outcomes?

16.67 12-20

2 3) What is the quality and / or coverage of health care services provided by the non-state sector for the poor?

16.56 13-19

3 12) What types of regulation can improve health systems outcomes, and under what conditions?

16.11 13-19

4 17) How best to capture data and trends about private sector providers on a routine basis?

16.00 12-20

5 5) What are the costs and affordability of the non-state sector goods and services relative to the state sector? And to whom?

15.89 14-18

6 1) What are the role, magnitude, capacity and utilisation of different types of non-state sector providers in the provision of health care and how do these change over time?

15.67 11-20

7 10) How best can licensing and accreditation schemes be implemented? What impact can such schemes have on improving the quality and / or coverage of services?

15.22 12-18

7 2) What is the quality and / or coverage of health care services provided by the non-state sector for the general population?

15.22 12-18

9 15) Should/could government integrate the non-state sector into national strategic planning and policy and if so how?

14.89 10-20

10 9) What are the gaps in governments’ capacity to contract out health services and how does contracting of services affect governments’ capacity and role?

14.63 (n=8)

9-19