Throughout the developing world, most health systems are characterized by mixed public and private financing and delivery of care. In many countries, private providers--including a plethora of different types of formal and informal, for profit and not for profit organizations and individuals—are more numerous than their government counterparts. Health expenditure data show that, although the public-private mix varies significantly by country (and information to accurately quantify this mix is scarce), more than half of total health spending is private out-of pocket in at least 19 countries in Asia and 15 countries in Africa, including many of the world’s most populous nations (China, India, Pakistan, Bangladesh, Nigeria). Private providers, and the health markets that they operate in, have the potential to both harm and improve the health of the poor. In order to ensure that health markets and private providers contribute to national health and financial protection goals, governments must play an important stewardship role of their whole health systems, including the part that they don’t directly operate, by better regulating, managing, and incentivizing the “non-state” part of the health sector. Meanwhile, innovative private health delivery and financing models that show promise for improving health and financial protection can be better nurtured.

In January 2008, the Rockefeller Foundation asked the Results for Development Institute (R4D) to lead an effort to better understand the role of the private sector in health systems in developing countries. In partnership with the International Health Policy Program of the Thai Ministry of Public Health and other health policy research organizations, R4D has worked to identify opportunities to strengthen public/private health systems through the collection, analysis, and dissemination of information and evidence on non-state health care providers and funders, and on public stewardship mechanisms designed to better harness these private actors. This effort, drawing on the work of a wide range of academic, think tank, and consulting partners, included the following activities:

• Analysis of Demographic and Health Survey data on where people seek care for various health issues.

• Cataloguing and analysis of private sector health delivery and financing models that some have characterized as “innovative.”

• A global scan and survey of countries about their regulatory models.

• A web-based survey and in-depth interviews of attitudes toward the private health sector.

• Analysis of how purchasing and contracting models can support health systems goals.

• New thinking on stewardship and how to make health markets work better for the poor.

• Macroeconomic analysis of national public and private health spending

• An analysis of the potential of the private sector to enhance health product supply chains.

This work has resulted in 2 synthesis reports by the Results for Development Institute and 13 technical papers by various institutions. Please visit our Products page to access all reports, or click on the links in the Related Products box to the side.

Building upon the findings of the Private Sector in Health Systems effort, R4D has continued to work with the Rockefeller Foundation on the Foundation’s new initiative, Transforming Health Systems (THS).