Making the Case to Work in Health Market Systems

1. Futures Group and the World Bank Institute in collaboration with Abt Associates, O’Hanlon Health Consulting, University of California at San Francisco and Tropical Health LLP

2. SESSION 8Making the Case to Work in Health Market SystemsBarbara O’Hanlon Futures Group and the World Bank Institute in collaboration with Abt Associates, O’Hanlon Health Consulting, University of California at San Francisco and Tropical Health LLP

3. BASIC M4H TOOLS UNDERSTAND THE CONTEXT EXAMPLES OF FINDINGS MAKE THE CASE WRAP UP

4. Stages of an M4H Program Understand Intervene Assess • Select markets • Identify and test interventions • Assess and adapt market intervention • Assess market change and health output • Adapt and Scale-up interventions • Identify health /equity issues • Understand health market systems Intervening and Adapting to Markets Making the Case for a Market Approach Monitoring and Evaluating Results 1 2 3 4 5 6

5. Characteristics of a M4H Approach • Flexible • Depends on context • Alert to market diversity, complexity and dynamics • Market changes take time • Opportunistic • Promotes local ownership • Responsive to market players incentives and capacity • Risk management • Diversifies risk • Embraces failure • Catalytic • Starts small… builds on success • Leverages wider change … M4H is strongly process oriented

6. Implications of M4H Approach • Funders • Is the program design sufficiently flexible? • Is the program correctly positioned in country’s landscape? • Will the program fit within the Agency’s funding mechanisms? • Is there agreement on markets? On how to measure success? • Is the program timeline long enough to permit success? • Facilitators/Implementing Partners • Does the program design allow for flexibility? Failure? • Does the program offer tools (e.g. portfolio approach, measurement indicators) for successful implementation? • Is there agreement on markets? On how to measure success?

7. Tools of the Trade • Strategic Case - Rationale for a market intervention • Appraisal Case - Market potential and VfM Business Case Strategic Framework / Logframe • Define health / system objective • Define market objective • Define market/systematic change • Define broad strokes of intervention strategy Market Intervention • Understand the poor • Map specific market systems/ position to the poor • Identify underlying causes of market gaps • Design market interventions addressing gaps Results Chains • Monitor and manage for results

8. Analytical Approaches Overview Overview of Health System Health system assessment, partnership landscape assessment (PLA), Private sector assessment (PSA), other private sector research, consumer use/preference (DHS) Poor and their Health Context Socio-economic studies, census date, poverty assessments, livelihood analysis and consumer research Private actors and their Context Market studies, competitive analysis and provider research Health Markets Landscape and interviews of market actors

9. BASIC M4H TOOLS UNDERSTAND THE CONTEXT EXAMPLES OF FINDINGS MAKE THE CASE WRAP UP

10. 6 Stages of M4H Understand 1 2 3 4 5 6 Identify issues Understand market systems

11. Health Market System Analysis • Learn about the poor and their health context • How to define the poor • What is the poor’s health seeking behavior • Identify health market system gaps • Underperforming systems • Underserved health services / products • Understand and map market actors • Who are the key actors • What are their roles and responsibilities in the health market system • Learn about the private sector and their context • What is private sector capacity? Incentives? Constraints?

12. Analytical Approaches Overview Overview of Health System Health system assessment, partnership landscape assessment (PLA), Private sector assessment (PSA), other private sector research, consumer use (DHS) Poor and their Context Socio-economic studies, census date, poverty assessments, livelihood analysis and consumer research Private actors and their Context Market studies, competitive analysis and provider research Health Markets Landscape and interviews of market actors …Health Actors Supporting Functions Rules Partnerships ….. overview helps explains health priorities and system gaps …..PSA explains supply, demand and operating environment in the health sector

13. Health System Assessments (HSAs) Offers a rapid yet comprehensive assessment of a country's health system • HSAs developed by several USAID projects (Health Systems 20/20, Partners for Health Reformplus, Rational Pharmaceutical Management Plus and the Quality Assurance Project) • Conducted in over 30 countries in Asia, Africa, and the Caribbean • The approach covers key health systems functions and is organized around WHO’s six health system building blocks • Recommends strategies – primarily public sector centric – to strengthen health systems

14. Partnership Landscape Analysis A participatory process to foster public private cooperation… • PLA is a participatory process that paves the way for improved public private cooperation • Broader than health – education and water • The study provides a firm basis for serious and joint cooperation between the sectors • Implemented PLAs in the health sector: Kenya (2010), Tanzania (2011), Ghana (2012)

15. Private Sector Assessment Key Features of PSA Approach • Flexibleallowing counterparts to shape focus • Comprehensivepulling together data from multiple sources • “Snap shot”of private sector activities at one point in time • Participatoryinvolving all stakeholders with a focus on commercial sector • Action oriented recommending policy reforms and PPPs Engage the Private Sector through Public-Private Dialogue Assess the Private Sector Involve All Stakeholders

16. Other Private Sector Analyses Private Sector Mapping In Malawi, the survey identified training needs by location Private Health Facility Census After an initial survey in Lagos, a 2nd more intensive survey was conducted in a sample of 30 (out of 853) randomly selected facilities

17. BASIC M4H TOOLS UNDERSTAND THE CONTEXT EXAMPLES OF FINDINGS MAKE THE CASE WRAP UP

18. Examples of Findings: Health Sector Landscaping

19. Examples of Findings: Sources of Health Finances Kenya 2005/6 NHA 100% = 20.7 billion ksh

20. Examples of Findings: Description of Public/Private Mix Private Sector Stakeholder Groups • Public/Private Mix of Health Professionals • 3 out of 4 doctors • 3 of out 4 nurses • 4 out 5 pharmacists • work in the private sector Public/Private Mix of Health Infrastructure

21. Examples of Findings: Donor Mapping USAID DFID KFW WB/HIA FP/RH USAID PEPFAR GFTAM Supply Chain GFTAM USAID PMI CHAI Malaria

22. Examples of Key Findings:Public/Private Mix: Deliveries Deliveries by Source Source of Delivery by Income Group Type of Private Sector Facilities Used for Deliveries

23. BASIC M4H TOOLS UNDERSTAND THE CONTEXT EXAMPLES OF FINDINGS MAKE THE CASE WRAP UP

24. Preliminary Analyses / Make the Case Data Collected Offers  Strategic Case • Identifies preliminary health needs and underserved population group’s needs • Prioritizes health areas and/or system gaps where the private health sector can play a role • Anticipates expected outcomes from working with the private health sector • Proposes several market areas for consideration

25. (New?) Concepts in the Design Phase Who are the poor? • Do traditional approaches work to define the poor? • Is the group appropriate for private sector response? Who is the private health sector? • Commercial sector only? What about social entrepreneurs? • Or do we also include FBOs/NGOs? Where to intervene? • Intervene/avoid where donors operate? How long? • Longer time horizon for market changes compared to direct interventions?

26. Organizing Findings into a Strategic Framework Define equitable health outcome: What is the anticipated health outcome? Who is the target group? Define market change: How can the market address the poor’s health needs? What changes are needed in the health market and enabling environment to better serve the poor? Define broad thrusts: What actions can facilitate the changes in the market and/or operating environment? Equitable Health Outcome Health Market Change Strategic Intervention(s)

27. BASIC M4H TOOLS UNDERSTAND THE CONTEXT LEARN ABOUT THE POOR MAKE THE BUSINESS CASE WRAP UP

28. Examples of Key Findings:Public/Private Mix in FP FP Methods by Source Source of FP Methods by Income Group Type of Private Sector Facility Used for FP Method

29. Doing M4H — Three Phases Funders • Stop, learn, and design • Be entrepreneurial / go with opportunities Implementing Partners • Conduct more analysis • Stop, learn, and design • Be entrepreneurial / go with opportunities Intervene Understand Assess Funders • Be flexible • Open to new results measurements Implementing Partners • Make deals • Establish partner relationships • Co-implement • “Nudge” the partners • Assess and learn • Make pro-active changes in course Funders / Implementing Partners • Be a neutral observer • Report accurately • Learn to improve • Be open and honest Business Case Market Intervention Result Chains