alaria2012 Malaria in the Asia-Pacific: The role of the private sector in ensuring equity and access to services Paper 5

alaria2012 Saving Lives in the Asia-Pacific Malaria in the Asia-Pacific: The role of the private sector in ensuring equity and access to services Paper 5

Malaria in the Asia-Pacific: The role of the private sector in ensuring equity and access to services Karen Bulsara Elizabeth Onyango Graham Root Montrose International October 2012

The Australian Government is hosting the Malaria 2012: Saving Lives in the Asia-Pacific conference in Sydney, Australia from 31 October to 2 November 2012. The conference aims to reinvigorate progress in malaria control and elimination in the Asia-Pacific region and to agree actions to urgently tackle resistance to artemisinin. The Australian Agency for International Development (AusAID) has commissioned five thematic papers to inform presentations and discussions during the conference. The analysis in these papers examines progress to, and efforts needed to achieve the goals set by the global malaria community including the long term aim of malaria elimination. The papers look at how and what is needed to accelerate progress to achieve a 75 per cent reduction in malaria deaths and cases by 2015 over a 2000 baseline, agreed by the World Health Assembly in 2005 and re-confirmed in 2007. The five papers in the series are: 1. Malaria in the Asia-Pacific: burden, success and challenges which summarises the current burden, successes and challenges in malaria control and elimination in the Asia-Pacific region and discusses the major policy implications for countries and regional development partners. 2. Malaria in the Asia-Pacific: Challenges and opportunities for sustainable financing describes some of the challenges facing the region as it moves towards greater regional self-sufficiency in financing malaria control and elimination. 3. Malaria in the Asia-Pacific: Challenges and opportunities for access to quality malaria medicines and other technologies summarises the key issues and challenges to improving quality and access to malaria medicines and commodities in the Asia-Pacific region, and highlights reducing the risk of artemisinin resistance. 4. Malaria in the Asia-Pacific: Modelling the current and potential impact of artemisinin resistance and its containment describes the global impact of artemisinin resistance should artemisinin combination therapies and artemisinin monotherapies lose their effectiveness. The paper also focuses on the health, economic and development impact of increased levels of artemisinin resistance in the Asia-Pacific region. 5. Malaria in the Asia-Pacific: The role of the private sector in ensuring equity and access to services provides an overview of the private sector operating in malaria in the Asia-Pacific region and describes key challenges and opportunities for engaging the private sector, including best practice from the region and elsewhere. This paper has been produced as a background paper for the Malaria 2012: Saving Lives in the Asia-Pacific Conference by the AusAID Health Resource Facility (HRF) managed by Mott MacDonald Australia Limited. The content does not necessarily reflect Australian Government policy. The views expressed in this publication are those of the author(s) and not necessarily those of the Commonwealth of Australia. The Commonwealth of Australia and Mott MacDonald Australia Limited accept no responsibility for any loss, damage or injury resulting from reliance on any of the information or views contained in this publication.

Contents Acronyms Executive Summary ii iv 1. Introduction 1 2.1 Private sector categories 2 2. Definitions and brief overview of the private sector in the Asia-Pacific region 2 2.2 Brief overview of the private sector in the Asia-Pacific region 3 3. Target populations 5 4. Private sector malaria interventions 6 5. Challenges and opportunities for engaging the private sector 16 5.1 Weak regulation 16 5.2 Supply chain analysis 17 5.3 Greater utilisation of non-state funding sources to improve the sustainability of malaria financing 18 5.4 Establishing PPPs with the natural resource and agricultural industries for malaria control 18 5.5 Insufficient research 19 5.6 Regional collaboration 20 6. Conclusion 22 Annex 1: Case Studies 24 Annex 2: Target group table 31 Annex 3: Status of tariffs on antimalarial commodities (Aug. 2010) 34 Annex 4: Extractive industry provided health care diagram 35 Annex 5: Illustrative diagram for a Value Chain Analysis 36 References 37 Notes 43

ii Acronyms ACT Artemisinin-based combination IDP Internally displaced people therapy IEC Information, Education and AMFm Affordable Medicines Facility for Communication malaria IMCI Integrated Management of AMT Artemisinin-based monotherapy Childhood Illness ANC Antenatal Care INGO International non-governmental APMEN Asia-Pacific Malaria Elimination organisation Network IRS Indoor Residual Spraying AusAID Australian Agency for ITNs Insecticide Treated Nets International Development LLIHN Long lasting insecticide treated BCC Behaviour change hammock nets communication LLINs Long lasting insecticide treated BMGF Bill and Melinda Gates Foundation nets BP British Petroleum LLITKs Long Lasting Insecticide CBO Community based organisation Treatment Kits (for nets) CSO Civil society organisation M-TAP Malaria Taxes and Tariffs DALY Disability adjusted life year Advocacy Project DFID UK Department for International M4P Making markets work for the Development poor DHS Demographic and Household MMA Myanmar Medical Association Survey MMV Medicines for Malaria Venture EAP East Asia-Pacific region NDOH National Department of Health EPI Expanded Program on NGO Non-governmental organisation Immunization NMCP National Malaria Control Program FBO Faith-based organisation OOP Out of pocket expenses FHI Family Health International PacMI Pacific Malaria Initiative FMCG Fast-Moving Consumer Good PacMISC Pacific Malaria Initiative Support GFATM The Global Fund to Fight AIDS, Centre Tuberculosis and Malaria PDP Product Development GMAP Global Malaria Action Plan Partnership GP General Practitioner PNG Papua New Guinea GPARC Global Plan for Artemisinin PPP Public Private Partnership Resistance Containment PR Principal Recipient HIV Human Immunodeficiency Virus PSI Population Services International

iii QDSTM Quality Diagnosis and Standard SPH Sun Primary Health Treatment of Malaria by Private SQH Sun Quality Health General Medical Practitioners STI Sexually transmitted infection R&D Research and Development TB Tuberculosis RBM Roll Back Malaria THE Total Health Expenditure RDT Rapid Diagnostic Tests UNICEF United Nations Children s Fund SE Asia South East Asia US$ United States dollars SEARO WHO South East Asia regional URC University Research Company office VMW Village Malaria Worker SP Sulfadoxine-pyrimethamine WHO World Health Organization

iv Executive Summary Key messages 1. Strong and sustained engagement with the private sector is essential to reach the target of a 75 per cent reduction in cases and deaths by 2015. The private sector already makes a significant contribution to malaria prevention, diagnosis and treatment in the Asia-Pacific region, and will continue to be an important partner in malaria control efforts in the future. 2. In South Asia, around 80 per cent of health care for poor people is provided by the private sector. 1 Partnerships between the public and private sectors have helped to reduce the cost of essential malaria medicines. Companies engaged in forestry and mining often have direct access to mobile and migrant populations at high-risk of contracting malaria, who are often beyond the reach of the public sector. 3. Engaging the private sector is not without its challenges. The cost of private care may deter the poor from seeking treatment, or impoverish them if they do. In countries where the capacity to regulate medicines supply is poor, many private providers sell low-quality medicines, or treatments such as artemisinin monotherapies, which are banned in some countries. Prescribing practices may also be poor. This contributes to emerging resistance to malaria medicines in the region. 4. More strategic engagement with the private sector is therefore needed. This should aim to tap new resources and optimise private sector strengths such are reaching remote markets. Increasing the affordability and quality of services provided in the private sector is also important. 5. To achieve this, governments need to: Regulate the private sector better, more efficiently and consistently, to improve access to quality malaria products and services. Build the evidence base on where the private sector has been effective and delivered results in malaria control. This will allow malaria programs to select the most appropriate strategies for engaging the private sector in their context. Harness private sector financing for malaria, particularly in the Asia region. It is crucial, however, that governments have the capacity to regulate and manage these resources. Capitalise on opportunities to establish public-private partnerships, for example with natural resource and agricultural industries, to implement malaria control programs. Such partnerships should engage and support local health authorities, and be carefully planned in order to remain sustainable. Bring the private sector into regional fora. This is key to increasing engagement between public and private sectors and building trust. It should also help to better define the role of the 1 AusAID Thematic Strategies: Sustainable Economic Development - Private Sector Development, AusAID 2012.

v private sector in key areas, such as reaching remote and mobile populations and combatting the sale of sub-standard medicines. countries. However, since private sector data is rarely included in official statistics, there is limited evidence of the exact scale of its contribution. Overview This paper looks at the significant role that the private sector plays in malaria control in the Asia- Pacific region, and how it can be better harnessed to achieve increased and more equitable access to malaria services. The term private sector is used to include a diverse range of health care providers: from formal groups of health professionals and commercial companies of various sizes; large healthcare and workplace programs run by major corporations; to civil society groups and informal providers such as unqualified medicine sellers and shopkeepers. A range of strategies for engaging the private sector have been implemented in the region, and successes have been documented. For example, market-based incentives, such as subsidising the costs of long lasting insecticide treated nets, have been applied to keep the cost of essential malaria commodities affordable, thereby stimulating demand. Formal provider associations have been successfully encouraged to self-regulate. Publicprivate partnerships have helped to bring innovations in malaria medicines and other technologies to the market. Consumer empowerment initiatives and behaviour change communication campaigns have been implemented. The role of the private sector In the Asia-Pacific region, the private sector health market is large and vibrant. Despite having to pay, many people choose to access malaria services through the private sector. This is due to, for example, a greater variety of providers, better availability of products, and a perception that goods and services are of higher quality compared to the public sector. Yet, while the private sector can improve access to services, particularly where the public sector is weak, it is no magic bullet. Paying for health care can impoverish households. Key populations at-risk of malaria may remain neglected. Also, the quality of services, medicines and other technologies provided in the private sector can be poor. To address these issues, governments need to engage more strategically with the sector. The capacity and reach of the private sector is not uniform across the region. It plays a particularly large role in providing services to the general population in Southeast Asia, Central Asia, and India, but has a mixed or more limited role in other Challenges To harness the full potential of the private sector, a number of crucial challenges must be addressed. A key issue is that governments have had limited capacity (or will) to regulate private sector markets. This is urgently needed to address, for example, the patchy availability of quality medicines for malaria, the proliferation of substandard or fake medicines, poor prescribing practices and high prices in the private sector. National malaria control programs need to better understand the nature, role and scale of the private sector s (potential) contribution. There are knowledge gaps on how private markets work, which make decision-making difficult. For example, the cost-effectiveness of interventions delivered by the private sector is under-researched, and malaria treatment practices by informal providers are not fully understood. Little is known about how supplier behaviour affects prices for the consumer, despite the evidence that retailers have an important influence on the availability, quality and price of malaria products. 2 This will require 2 Patouillard, E. et al., Retail sector distribution chains for malaria treatment in the developing world: a review of the literature Malaria Journal, 2010.

vi collecting data nationally, analysing distribution chains in all sectors, as well as taking into account consumer demand. Sustainable financing is another important issue. There are a wide range of non-state funding sources that can be better tapped for malaria control in the region, including global funding mechanisms. But making these work in a sustainable manner relies on sustained political engagement, as well as the capacity of institutions (locally, nationally and regionally) to regulate and manage financing partnerships effectively. Opportunities While these challenges are not unique to the region, opportunities related to the potential contribution of the private sector are. Asia, in particular, has a burgeoning private sector whose resources remain largely untapped. The presence of natural and energy resources in the region also presents an opportunity. Companies in these industries often operate in remote locations, which are beyond the reach of public services. They are therefore well placed operationally, logistically and financially to extend the health care they provide to employees and their families, who represent some of the most vulnerable groups at risk of malaria. This is already happening in some countries with established natural resource industries. Experience suggests that developing positive relationships with communities and governments is key to success and sustainability. Existing regional malaria efforts and fora provide further opportunities to pool resources for the procurement of medicines and technologies, and share knowledge. New regional efforts could focus specifically on best practices for engaging the private sector in malaria control. In conclusion, in a climate of limited funding, strategic engagement with the private sector provides malaria control programs with both an opportunity and an obligation. There is an opportunity to widen access, improve quality and reduce costs of malaria interventions, through a variety of approaches. However, the private sector cannot be considered a panacea. There is also an obligation to actively engage with the private sector at sub-national, national and regional level to plan and design programs which ensure equity for poor and marginalised communities across the Asia-Pacific region.

1 1. Introduction In recent years, increasing attention has been paid to researching the cost-efficiency and equity of health services delivered by the private sector. Much of this research indicates that while the role and function of the private sector varies substantially from country to country, and even within a single country, in the Asia-Pacific region, private providers typically play a significant role in malaria prevention, diagnosis and treatment. In Cambodia for example, first treatment was sought from private sector providers in 90 per cent of fever cases, while in Lao, initial treatment was sought in the private sector in 63 per cent of fever cases. 3,4 To increase and sustain the substantial gains made in malaria control in the Asia-Pacific region, malaria control programs need to understand the nature, role and scale that the private sector can and in many cases does play. The comparative advantage of using the public, private or civil society channels for delivering malaria control activities need to be considered by malaria program managers. Whilst private sector providers can improve access to services, particularly where the public sector is weak, it offers no magic bullet. Many individuals, strategic engagement with the private sector. This paper considers various strategies to engage with private sector stakeholders for malaria control, providing examples of such programs in the Asia- Pacific region in order to highlight key issues, challenges and opportunities. Montrose International was commissioned by the Australian Agency for International Development (AusAID) to undertake a desk-based literature review. Published papers, project evaluations and other program documentation were sourced through search engines and author-gathered project reports. It should be noted that the review only considers examples within the Asia-Pacific region, and not sub-saharan Africa. The report is structured as follows: Section 2 provides definitions and a brief overview of the private sector in the Asia- Pacific region; Section 3 considers priority target groups and how the private sector can contribute to serving them; Section 4 presents possible and existing private sector engagement strategies; Section 5 considers key issues, challenges and opportunities in engaging the private sector and Section 6 concludes the report. particularly the poor, make out-of-pocket (OOP) payments on health care as a result of illness, which can be an important determinant of household impoverishment. 5 This is a situation which has obvious negative consequences on equity and which can be addressed through 3 Yeung, S. et al., Access to artemisinin combination therapy for malaria in remote areas of Cambodia, Malaria Journal, 2008. 4 Nonaka, D. et al., Public and private sector treatment of malaria in Lao PDR. Acta Trop, 2009. 5 Montagu, D. et al., The Private Sector and Health Services Delivery in the EAP Region. (UNICEF Report, 2010).

2 2. Definitions and brief overview of the private sector in the Asia-Pacific region The private sector plays an important role in the prevention, diagnosis and treatment of malaria in many countries in the Asia-Pacific region. Despite having to pay OOP, many choose to access malaria services through the private sector for a variety of reasons. These include a greater variety and availability of providers; lower financial and opportunity costs; greater flexibility and a perception of higher quality than in the public sector. 2.1 Private sector categories The private sector is diverse and complex. Furthermore, the boundary between the public and private sectors is not always clear and there can be significant overlap between them, in some cases leading to a marketisation of health services. 6 The Chinese government, for example, charges fees to users at health facilities, and uses profits to augment health worker income. This dual practice can create close connections between the two sectors and may provide opportunities for reaching private sector providers while ensuring public health priorities are understood. The main categories of private sector stakeholders involved in malaria control are: Formal private health care providers providing a range of malaria treatment services. This group includes large and small commercial companies and groups of health professionals. Services they provide include hospitals; maternity homes; clinics run by doctors, nurses, midwives and paramedical workers; diagnostic facilities and pharmacies. These providers are often located in urban or peri-urban areas. Informal private health care and general private retailers providing limited malaria diagnosis, a variety of treatment options and bed nets. They include unqualified static and itinerant medicine sellers, drugstores, traditional healers, shop keepers, market stallholders, mobile hawkers and general stores. They are often located more widely in peri-urban and some rural locations and therefore have a wider reach than the formal private sector. Civil society groups provide services in addition to acting as intermediaries between government and private sector providers, acting in a monitoring and accountability role for the selling of nets and artemisinin-based combination therapies (ACTs), for example. Some non-governmental organisations (NGOs) have variable geographical coverage. However, social marketing and social franchising programs, providing subsidised malaria products and services through private sector providers and retailers, have a much wider geographical reach. Private sector companies investment in health care and workplace health programs by major corporations, particularly the natural resource and agricultural industries. These companies provide malaria interventions for 6 Mills, A. et al., What can be done about the private health sector in low-income countries. Bulletin of the World Health Organization, 2002.

3 staff within the company, as well as frequently for communities in surrounding areas. These are often located in areas of high malaria transmission and so serve at-risk population groups, including outdoor mobile workers. 2.2 Brief overview of the private sector in the Asia- Pacific region The capacity and role of the private sector is not uniform across the Asia-Pacific region. Whilst there is insufficient data measuring the total number of private providers, national health surveys which capture data by surveying users, although limited, is considered the best information available to measure the significance of the private sector in the provision of health care. 7 The proportion that countries spend on health through the private sector as a percentage of total health expenditure (THE) varies greatly (see Table 1). The increased use of cost sharing mechanisms, the marketisation of health care and the rise of private practice have led to a shift in the proportion of health care costs paid for by citizens. The difference in OOPs between countries can be seen in Table 1. Because of the large burden of health care costs on families, especially in a number of countries in South and South East Asia, there is a need to ensure that the private sector is providing quality services at affordable costs in order to ensure equity. Table 1: Total Health Expenditure (THE) in selected countries in the Asia-Pacific region 8 THE as % of GDP Govt Exp as % of THE Ext Res as % of THE Pvt Exp as % of THE OOP as % of Pvt Exp OOP as % of THE Afghanistan 8 12 32 88 94 83 Bangladesh 4 34 8 66 97 63 Bhutan 5 87 11 13 91 12 Cambodia 6 37 24 63 64 40 China 5 54 < 46 79 37 India 4 29 1 71 86 61 Indonesia 3 49 1 51 75 38 Lao PDR 4 33 15 67 77 51 Myanmar 2 12 9 88 92 81 Nepal 5 65 12 65 83 48 Pakistan 2 38 5 62 82 50 Papua New Guinea 1 72 24 28 56 16 Philippines 1 35 1 65 84 54 Solomon Islands 9 93 32 7 54 4 Sri Lanka 3 15 3 55 81 45 Thailand 1 75 < 25 56 14 Timor Leste 9 56 34 44 26 11 Vanuatu 5 91 23 9 57 5 Vietnam 7 38 3 62 93 58 Key: THE= Total Health Expenditure; Ext Res= External Resources; Pvt Exp=Private Expenditure (which is money spent on health by sources other than the government or donors); OOP=Out of Pocket Expenditure. 7 Montagu, D. et al., The Private Sector and Health Services Delivery in the EAP Region, UNICEF Report, 2010. 8 WHO, National Health Accounts (WHO, 2010).

4 Figure 1: Out of pocket payments as a percentage of Total Health Expenditure 9 The countries of the Asia-Pacific region have been categorised into five groups, with varying roles for the private sector: Group 1 - South East Asian countries - Large role for the private sector Cambodia, Indonesia, Lao PDR, Myanmar, Philippines, Thailand, Vietnam. The private sector typically provides the majority of all health services. Health care provision by the for-profit private sector is much larger than by NGOs. Myanmar s OOPs are by far the highest in the region. Group 2 - Central Asian countries - Large role Afghanistan and Pakistan. The private sector is used extensively in these fragile states. In Afghanistan, the private sector expanded rapidly during a time of conflict and is largely responsible for the very high OOPs. These services are generally concentrated in urban areas, not well organised, largely unregulated, and providing poor-quality care. 10 Group 3 - South Asian Countries - Mixed role Bangladesh, Bhutan, India, Nepal and Sri Lanka. The private sector certainly has a large role in India and Bangladesh, but Bhutan s OOPs are low and reflect lesser use of the private sector. Group 4 - Pacific Island Countries - Small role Papua New Guinea (PNG), Solomon Islands, East Timor, Vanuatu. The private sector is small, providing less than half of health services, the bulk of which is provided by NGOs (particularly faith-based organisations [FBOs]). OOP as a percentage of THE is low. Corporate provision of health care tends to occur in the context of social investment programs and is particularly notable in PNG with regards to the mining and oil and gas industries. Group 5 - North East Asian Countries - Limited role China. The private sector exists in specialty areas such as dental care and private hospitals. These are mainly in commercial cities and within structural arrangements where the government is an active partner. 9 WHO, National Health Accounts (WHO, 2010). 10 Sabri, B. et al., Towards sustainable delivery of health services in Afghanistan: options for the future, WHO Bulletin, September 2007.

5 3. Target populations As seen in Section 2, the private sector is mainly accessed by the general population in the countries in groups 1, 2 and 3, with a more limited role for the private sectors in the countries in groups 4 and 5. When considering how to engage most effectively with the private sector in these countries, consideration of the most relevant target groups is also necessary. Due to the epidemiology of malaria in the Asia-Pacific region, containment and elimination requires a focus on those most likely to be exposed to mosquitoes which rest and bite outdoors. This requires an analysis of the behavioural risk factors which affect specific population groups in the high transmission forest and border areas, most notably outdoor workers and migrants. This is a particular problem in South East Asia where around two million people are estimated to be migrating annually. 11 The precise mapping and quantification of different target audiences in each region will help to determine which private sector interventions are most costeffective in reaching them. The private sector may not always be the most cost-effective way to deliver malaria services. Retail channels optimally cover as large a geographic area as possible in order to generate economies of scale whilst also being commercially viable. Therefore targeting only certain parts of a country (for example, only border areas), as required by some malaria programs, may be less efficient through private sector retailers was a finding that emerged from the project in Cambodia which implemented a net bundling strategy (see Annex 1, Case Study 3). In addition, new prevention product development is essential; since long lasting insecticide treated nets (LLINs) only offer indoor protection, alternative prevention tools, such as hammock nets and repellents, must also be considered for these mobile groups. A review of the target groups most at risk of malaria (see Annex 2), including both stable and mobile groups, highlights the groups that can be reached by private sector interventions. The mobile groups which can be reached by the private sector are classified as: employer-affiliated groups of semi-mobile employees, extractive industry and seasonal farm workers; government-affiliated groups made up of the police, soldiers and border guards; and the most difficult to reach non-affiliated groups of labourers, new settlers, migrants and highly mobile workers. Private sector strategies targeting employeraffiliated groups, such as semi-mobile employees working in the extractive industries and seasonal farm workers, offer high potential for public-private partnerships (PPPs), particularly in mining, oil and gas industries, infrastructure projects such as hydroelectric dam building and agriculture, such as rubber and palm oil plantations. than through national distribution channels. This 11 WHO Report, Second International Task Force Meeting for the Strategy for the Containment of Artemisinin Tolerant Malaria Parasites in the South-East Asia Project, (WHO, 2010a).

6 4. Private sector malaria interventions Having identified a role for the private sector in reaching specific target groups, an assessment can be made of the strategies available, in order to determine those which would be most effective in a given context. Many private sector strategies have been, and are being, implemented in the Asia-Pacific region, making valuable contributions to accelerate progress towards the global target of a 75 per cent reduction in malaria cases and deaths by 2015. However, the available evidence on the scale of this contribution is scant and unrepresentative because private sector data is rarely included in national censuses or statistics. 12 A framework table summarising private sector engagement strategies is adapted in Table 2. This table is based on two analyses and has been adapted to be of relevance to malaria programming. 13 This framework can be used as a planning tool to assist decision-makers in establishing the extent of private sector engagement at the national level. The framework includes examples from the region, while Annex 1 contains further details on the case studies cited. The strategies are divided into four primary approaches: 1. Market-based approaches, including marketbased incentives; marketing mechanisms; and organisational collaboration. Civil society organisations (CSOs), such as those involved in social marketing play an important role, acting as intermediaries between public and private sectors in order to harness the private sector s retail capacity. Opportunities exist for regional PPPs to target high risk mobile populations across borders as exemplified, for example, with the Gates Foundation-funded, multi-partner Containment Project which is taking place on the border between Cambodia and Thailand. 14 Extractive industries are present in most countries and have significant potential for major transformational impact. In order to leverage this potential effectively and equitably, it is important that appropriate public financial management and regulatory and legal frameworks are designed and enforced. Fostering pro-poor business models, such as the making markets work for the poor (M4P) approach, which has been utilised in Thailand and Vietnam for agricultural supply chains but not yet for health in the Asia-Pacific region. M4P is an example of an overarching approach that guides the assessment of market systems, planning for the future and acting to bring about change. These approaches can drive economic development in a way that contributes to poverty alleviation and achievement of malaria control targets. 12 Ahmed, S. et al., Analysing relationship between the state and non-state health care providers, Asia and the Pacific, (Health Policy & Health Finance Hub. University of Melbourne, 2011). 13 Ahmed, S. et al., Analysing relationship between the state and non-state health care providers, Asia and the Pacific, (Health Policy & Health Finance Hub. University of Melbourne, 2011), and Montagu, D. et al., The Private Sector and Health Services Delivery in the EAP Region. (UNICEF Report, 2010). 14 WHO, Artemisinin-Resistance Containment Project, WHO [web page] <http://www.who.int/malaria/diagnosis_treatment/arcp/en/index. html>.

7 2. Legal and administrative approaches, including regulation and training. Engaging the private sector can facilitate a more inclusive and comprehensive approach to malaria control and strengthen existing health services, but not unless there is recognition at the highest political levels that the private sector is a vital partner in malaria control. Advocacy is needed at both the international and national levels to create, resolve and promote awareness of the potential gains from greater private sector engagement. Social franchising has shown itself to play a vital role in improving quality standards and treatment practices through medical detailing and training amongst its private provider networks. These approaches have significant potential, since governments are unable to regulate the informal sector, and can therefore act to fill an immediate gap. 3. Public empowerment approaches, including information dissemination and participation. Behaviour change communication (BCC) is essential and goes beyond simply product advertising and awareness, which is usually undertaken in the private sector. The private sector can be encouraged to co-fund investment in this area and certainly benefit from CSOs BCC campaigns. 4. Product innovation approaches, including product development partnerships (PDPs). PDPs promise treatment and insecticide innovation, which can be brought to market by making greater use of financial incentives such as grants, subsidies, tax incentives, manufacturer-based subsidies and in-kind support to influence private provision. The framework in Table 2 identifies the range of strategies for engaging with the private sector, their objectives and some examples of where they have been applied in the Asia-Pacific region. The nature of the engagement of governments or other stakeholders varies from strategy to strategy, and some will require higher levels of technical capacity within government bodies, prior to undertaking such an approach. 15 Some strategies, such as contracting, social marketing, training and information dissemination, involve lower levels of risk for governments, and therefore require lower levels of technical capacity, while others, such as financial incentives, strategic market development, PPPs and accreditation/licensing, are more complex and require a greater level of planning, coordination and development of technical capacity prior to implementation. 15 Montagu, D. et al., The Private Sector and Health Services Delivery in the EAP Region. (UNICEF Report, 2010).

8 Table 2: Framework summarising private sector engagement strategies PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES 1. Market-based approaches To ensure: Coverage, Quality, Cost* a. Financing mechanisms To facilitate equitable market functioning Social Insurance. Equitable levels of funding for stipulated health care. Generate provision for malaria diagnosis and treatment to defined population. Vietnam s Health Care Fund for Poor, Indonesia s Jamkesmas for vulnerable groups and Philippines PhilHealth tuberculosis (TB) are all examples of pro-poor financing mechanisms which are usually applied in lower middle income countries. 17 Implementation depends on the level of socio-economic development, financial sector development and employment conditions, especially the existence of a larger proportion of formal sector organised establishments. Financial incentives. Use of grants, subsidies, tax incentives and in-kind support to influence private provision. Also includes manufacturer-based product subsidies. Stimulate private providers to deliver ACTs, LLINs to a defined population. Vouchers schemes can link supply to retail provision. In PNG, taxes and tariffs on malaria commodities were removed to reduce costs and improve access (Case Study 1). In Cambodia, the Affordable Medicines Facility for malaria (AMFm), is an example of a manufacturer-based product subsidy, which is negotiated directly with medicine manufacturers. Importers pay 80 per cent less for ACTs and these lower costs can be passed to the consumer (Case Study 2). Contracting. Purchasing services from private providers, applying benchmarks for services, quality of care, health outcomes. Increase range of choice and encourage higher quality services. In Afghanistan, the government contracts primary health care out to NGOs to directly supply services as the public sector is severely weakened by conflict. 18 Purchasing. Buying goods and services for limited time, from private providers - lower risk and commitment than contracting. Increase value for money to public sector by expanding range and increasing efficiency through competition. In Cambodia, Myanmar and Laos, the government purchases LLINs for free distribution to specific high-risk populations. While this has the potential to improve equitable coverage, it does also have the potential to crowd-out the existing private sector net retailers. 17 Ahmed, S. et al., Analysing relationship between the state and non-state health care providers, Asia and the Pacific (Health Policy & Health Finance Hub. University of Melbourne, 2011). (Examples are not specific to malaria). 18 Sabri, B. et al., Towards sustainable delivery of health services in Afghanistan: options for the future, WHO Bulletin, September 2007.

9 PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES b. Marketing mechanisms To create new sources of supply and demand Social Marketing. Using commercial channels, techniques and communication to market products with public health benefit. INGO/NGO managed operations. Increase population coverage; ensure supply of subsidised product to wide geographical area. In Cambodia, the Bundling Strategy implemented by Population Services International (PSI) provided long lasting insecticide treatment kits (LLITKs) which were bundled free with untreated nets. This innovative strategy prevented crowding-out of existing untreated net market and leveraged the cost efficiencies of the existing retail channels to supply LLITKs. (Case Study 3); PSI also implemented the social marketing of a case management initiative which was successful in supplying subsidised ACT s through private sector formal and informal channels. 19 In Afghanistan, the social marketing of insecticide treated nets (ITNs) by HealthNet International is an example of this approach being used in a conflict situation. ITNs were sold through a network of clinics run by NGOs. Sufficient revenues were generated to restock nets within 2 years and the same approach was applied in refugee camps. 20 This approach also has potential for new product introduction, allowing technologies such as hammock nets and repellents to be widely distributed to those who need them. Social Franchising. Using commercial channel, techniques and communication approaches to market networks of service providers. Managed by INGO/NGOs. Substantially increase reach and assure quality standards. Myanmar s Sun Quality Health program implemented by PSI is a social franchising initiative using enlisted formal private providers in urban areas. Reach and health impact were strengthened considerably by adding a second tier of informal providers, the Sun Primary Health Network who were linked to these formal providers. This extended coverage of care into rural areas. (Case Study 4). 18 Littrel, M. et al., Case Management of malaria fever in Cambodia: results from national anti-malarial outlet and household surveys, Malaria Journal, 2011. 19 Rowland, R. et al., Prevention of malaria in Afghanistan through social marketing of insecticide-treated nets: evaluation of coverage and effective cross-sectional surveys and passive surveillance. Tropical Medicine & International Health, 2002.

10 PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES Strategic Market Development. Detailed analysis of overall existing commodity retail market and comparative advantage of all stakeholders. Enabling/financing market growth e.g. through regulation, technology transfer, improving supply chains etc. Creation of a self-sustaining market mechanism for increased supply of essential health products e.g. ITNs, LLINs etc. Use of M4P, Value Chain Analysis etc. In Cambodia, ACTwatch was set up to address the gap in data on antimalarial medicines. Studies collect data from shops and health facilities in order to investigate malaria treatment seeking behaviour in the community, and analyse the functioning of the supply chain. This example highlights that evidence can inform policy discussions and provide critical insights into the private sector s role. 21 Social entrepreneurship programs. Establishing training and support of networks of individuals to provide goods and services. Substantially increase commercially viable reach of goods and services. Enterprise Challenge Funds (ECFs) are an instrument by which donors can directly encourage pro-poor outcomes from private sector activity. ECFs can improve the business enabling environment, focusing on access to finance, agribusiness and aspects of supply chain management. They also have the potential for strategic market development activities, such as net production and retail. c. Organisational collaboration Change market conditions to increase participation by private providers in malaria programs Alliances among providers. Establishing and encouraging formal links and collaboration among providers. Increase private sector contribution by creating groups with economies of scale for more efficient public-private collaboration. Myanmar Medical Association (MMA) is a professional association of formal private health providers (Case Study 5). This example shows the importance of finding the right balance between incentives and regulation to enable better use of self-regulating professional organisations in order to improve the quality of care among formal providers. 20 www.actwatch.info

11 PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES Coordination/alliances between public and private sectors. Establishing and encouraging formal links and collaboration between public and private sectors PPPs. Foster actions by private sector that promote health objectives and increase private sector participation e.g. major corporations workplace health care. In Indonesia and PNG, the extractive industries malaria control programs provide reach and coverage of large numbers of vulnerable mobile populations in high malaria transmission areas, with weak public health infrastructures. ExxonMobil (PNG), Newcrest Mining (PNG) and Newmont (Indonesia) carried out comprehensive malaria control workforce programs and extended programs for surrounding communities. (Case Studies 6, 7, 8). In the Philippines, the Shell Foundation is working with government to implement a social investment program which established and trained staff for village laboratories and held community sensitisation malaria meetings (Case Study 9). In PNG, OilSearch undertook the training of community malaria workers for rapid diagnostic tests (RDTs) which was sustainably financed through charging of user fee (Case Study 10). In Indonesia and Philippines, EpiSurveyor, a free mobile phone and web-based data collection system showed the potential for PPPs to use mobile phone technology. The initiative included private sector foundations, with partners: Datadyne; UN Foundation; Vodafone Foundation and Knight Foundation. (Case Study 11). In Cambodia, a LLIN Loan Scheme implemented by University Research Company (URC) and Family Health International (FHI) allowed farm owners in high risk areas who employ large numbers of temporary mobile workers to protect their migrant workers by providing LLINs (Case Study 12).

12 PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES d. Policy dialogue Policy dialogue. Engaging private sector in discussions - may extend to consultation in development of legislation, standards, regulatory and facilitation systems. Foster private sector adherence to policy. The Novartis Foundation for Sustainable Development holds an annual international symposium to strengthen the development policy dialogue between the private sector, NGOs, research institutions and state bodies. Malaria is a focus area. 22 2. Legal/administrative approaches To ensure: Quality, Cost a. Regulation Accreditation/certification. Setting and enforcing standards among organisations. Raise standards of care, health outcomes, and efficiency by enabling empirical basis for judging quality. In India and Thailand, accreditation schemes are in place which highlight that they are more successful in middle income than low income countries. This is due to low income countries having a lack of guaranteed government funding or private financial payment mechanisms which make participation valuable to the facilities targeted for accreditation. This strategy is unlikely to be a core part of quality improvement for malaria in low income countries where social franchising is a better tool to enforce quality standards. 23 Licensing. Setting and enforcing standards for individual providers. Raising standards of individual practitioners by setting and enforcing criteria for practice. In Myanmar, a Monotherapy Replacement Project implemented by PSI, will raise standards by actively supporting the national ban on the sale of monotherapies in the private sector and encouraging the public to demand a quality assured ACT from the drug sellers with communication campaigns. 24 This project, which is still in its early stages, will demonstrate that innovative approaches to raising standards, for example by actively working to enforce bans of monotherapies, can be as effective as issuing licenses. (Case Study 13). 22 Novartis Foundation for Sustainable Development [web page] <http://www.novartisfoundation.org/page/content/index.asp?menuid=268&id=609&menu=3&item=45.9>. 23 Ahmed, S. et al., Analysing relationship between the state and non-state health care providers, Asia and the Pacific (Health Policy & Health Finance Hub. University of Melbourne, 2011). and Private Healthcare in Developing Countries, Accreditation [web page] <http://ps4h.org/accreditation.html>. 24 This activity, while not necessarily issuing licenses, is the best proxy for licensing in the context of enforcing standards and criteria for practice.

13 PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES Pricing mechanisms. Setting, monitoring and enforcing prices of medicines, devices, consultations. State monitors and enforces price of essential medicines and other technology. In India, the National Pharmaceutical Pricing Authority (NPPA) is an example of a body which can fix/revise the prices of controlled bulk medicines and formulations and enforce prices and availability of medicines. 25 They can also recover amounts overcharged by manufacturers for controlled medicines and monitor prices of decontrolled medicines in order to keep them at reasonable levels. Technology regulation. Formal state approval and reimbursement structures, process and enforcement. State controls safety, efficacy and cost of health care by regulating availability/sale of pharmaceuticals and LLINs. In some countries, the stipulation to supply only WHO pesticide evaluation scheme (WHOPES) approved LLINs is being implemented. This has standardised the production of LLINs and created an international export market for 10 manufacturers (four of whom are in the Asia-Pacific region). While the protective quality of nets has been improved, local LLIN producing markets in developing countries have been crowded out in some cases. Market regulation. Includes anti-monopoly/ competition laws, consumer protection mechanisms and enforcement. State protects citizens from (high) monopoly pricing. In Cambodia, China, Indonesia, Laos, Myanmar, Singapore, Thailand and Vietnam, Operation Storm was implemented in partnership with INTERPOL. This example showed the importance of regional, multi-sectoral collaboration for the enforcement of medicine policy and the seizure of fake medicines. This intervention demonstrated that the problem of counterfeit medical products should be managed beyond health sectors and borders, as it is a criminal action requiring the involvement of all in the criminal justice system such as police, justice, customs and national regulatory authorities. (Case Study 14). 25 WHO Member states and Medicines Price Information.

14 PRIVATE SECTOR STRATEGIES OBJECTIVES EXAMPLES b. Training Provider training. Educating and supporting private providers. Improving standard of care of private providers. In Myanmar, the Monotherapy Replacement Project implemented by PSI (Case Study 13) is one whereby the dominant supplier of monotherapy which supplies 70-80 per cent of all artemisinin-based monotherapies (AMTs) in the country has agreed to supply ACTs instead, buying them from PSI at a subsidised rate. The project will also seek to educate to increase demand for ACTs. Although the project looks promising, it is in its early stages and so the impact is yet to be recognised. In Cambodia, the Bundling Strategy (Case Study 3) is another example of provision of training to ensure adherence to treatment protocols and quality of care, particularly in the informal private sector. 3. Public empowerment To ensure: Quality, Coverage Information dissemination. Information, education and communication (IEC) campaigns to promote healthy behaviours and health service use. Implemented by NGOs and social marketing organisations. Communication with/educating the public about malaria prevention, diagnosis, and early treatment. Signposting to private providers. In Cambodia, the Taxi Drivers Scheme run by URC and FHI involved drivers sharing malaria education with migrant passengers while also acting as referral sources in remote areas (Case Study 15). PSI also provides ACT treatment, multi-media BCC campaigns, including consumer campaigns and training (Case Study 2). Participation. Establishing formal opportunities for the pubic to communicate their opinions about services and service providers. Provide opportunities for public opinion input. In Vanuatu, community participation for elimination in the context of low transmission (Tafea Province) showed continued IEC/BCC is essential to maintain preventive (and treatment seeking) practices. 25 26 Atkinson, J. et al., Community participation for malaria elimination in the Tafea Province, Vanuatu Malaria Journal, 2010.