The public-private health advisory platform would advise governments on policies, regulations, institutions, supervision, and quality control in the for-profit and non-profit private sectors of health systems. The platform would help governments identify, develop, and implement Public-Private Partnership
(PPP) transactions and other mechanisms to engage the private sector, such as vouchers, franchising, and pay-for-performance contracting. It could be a multi-donor institution providing on- demand technical and implementation advice.
The platform could be modeled on elements taken, variously, from two existing structures: (i) The Private Infrastructure Development Group (PIDG) and specifically the affiliated DEVCO facility.lxxv PIDG was established in 2002 with the aim of increasing private sector investment in the infrastructure of developing countries. DEVCO was established in 2003 specifically to address the major obstacle to increasing sustainable private sector investment in public health, which continues to be the thin pipeline of well articulated, “bankable” PPP projects contracted out by governments in a transparent fashion.lxxvi A facility modeled after DEVCO would, as one part of the proposed platform, advise governments about implementing PPPs. (ii) The Public-Private Infrastructure Advisory Facility (PPIAF), launched in 1999. A facility modeled after PPIAF would, as another part of the proposed platform, advise governments about upstream policy and regulatory issues.lxxvii The platform could provide assistance with preparing and structuring PPP projects, promoting opportunities to potential investors, drafting PPP contracts and tender documents, carrying out the tender process, and negotiating with winning bidders and their lenders up until financial close. It could help governments enhance the business environment within the health sector, improve health-services contracting, and incentivize and regulate health insurance through strategies such as risk pooling.
Value added: Increasing the efficiency and effectiveness of health
expenditures by (i) strengthening the interface between state and non-state sectors;lxxviii (ii) mobilizing private investment; and (iii) increasing investment flows to the private sector.
Experience: The proposed mechanism draws on experience from
DEVCO and PPIAF. Using donor funding totalling about US$20 million, DEVCO projects to date are expected to leverage private investment of about US$1.675 billion, yield US$713 million in fiscal benefits for client governments,lxxix and expand access or improve services for about 7.23 million people. DEVCO’s pilot projects in the health sector indicate higher success rates. Since its inception, PPIAF has implemented 379 activities. Positive impact of 286 of these – three-quarters of the total, which together account for about 87% of funding – has been documented.lxxx
Technical feasibility: IFC mandates have led to health-oriented
PPPs in several countries and have proven their technical feasibility. PPIAF experience has proven the feasibility of an advisory facility, although PPIAF does not specifically target the health sector.
Political sponsors: The Center for Global Development; the World
Timeframe for implementation: Setting up new facilities to provide
upstream policy and regulatory advice and to support transaction mandates is expected to take six to 15 months. The World Bank and IFC could implement an advisory platform immediately, through two existing mechanisms. A joint Bank-IFC advisory unit already operates in Africa and could be easily expanded to other regions. And the IFC already provides transaction advisory services for health PPPs in several countries. Because the IFC has several potential projects in IDA/IHP+ countries already in preparation, IFC advisory services could be expanded swiftly if additional funds became available.
Realized flows: DEVCO has utilized donor funding totalling about
US$20 million since its inception. Since its inception, PPIAF has implemented 379 activities, whose expenditures total about US$80 million in total funding.
Potential flows: Based on sponsor experience and projections,
the demand for contributions to facilities that implement policy and transaction projects is expected to be about US$70 to 150 million for three to five years.
Costs (set-up and running costs): Set-up and running costs are
estimated to be comparable to those of conventional World Bank Group multi-donor partnership arrangements.
Additionality: PPPs and private-health-sector policy improvements
exhibit moderate additionality, depending on which part of the private sector is involved. IFC expects that PPP advisory services costing US$20 million could trigger up to US$500 million in private sector investments. However, new investments in PPPs might crowd out some foreign direct investment that would have gone to health systems in any case.
Sustainability: The sustainability of financing depends on the
source. The IFC reports that the sustainability of PPPs in emerging markets is high, even in difficult financial times. The number of PPP deals cancelled has been consistently low across countries and sectors, including the health sector. The sustainability of advisory services is enhanced when governments receiving these services themselves make significant contributions to the Platform’s cost, as some governments participating in DEVCO advisory programmes have done.
ODA: It is expected that concessional funds used for the proposed
Platform will qualify as ODA. Aid effectiveness criteria
Country ownership: Positive. The Advisory Platform would (i)
operate on an on-demand basis, and (ii) support countries in the context of their own health systems and policy priorities. Contributions to programme costs by recipient governments can enhance country ownership, as experience has proven.
Predictability: The predictability of financing depends on the source
of funds and on donors’ long-term commitment.
Impact on aid architecture for health and harmonization: The
Platform could be designed within the existing aid architecture for health – for example, it could be established within an existing multilateral entity.lxxxi If established as an independent new entity, it might add to the complexity of the aid architecture.
Alignment: An Advisory Platform would help a government align
the private sector with country systems.
Synergies and externalities: An Advisory Platform could potentially
generate substantial synergies with existing aid flows and public health expenditures.
Results: An Advisory Platform would not directly link financing
to results but impact has been documented in the past (see “experience”).
Accountability: Does not directly depend on the financing
mechanism. An Advisory Platform could increase the accountability of the private sector.
Pro poor: Does not depend on financing but on the mechanism’s
policies and programmes. Delineating pro-poor from broader benefits may be difficult in policy-advisory work. An Advisory Platform could support the pro-poorness of the private sector
and public-private partnerships by helping governments identify and implement pro-poor engagement strategies, such as issuing vouchers to poor woman for attended deliveries, and contracting for delivery of health services in underserved areas. Advice about structuring PPPs can focus on expanding services to the poor. Summary and overall evaluation
The main value added of a Public-Private Health Advisory Platform would be to create an interface between state and non-state sectors, mobilize private investment, and enable PPPs to strengthen health systems and achieve specific health goals. Support would be provided to governments on demand. The Platform would support other private sector mechanisms discussed in this report. It is expected that it could effect change at a relatively modest cost. A recent survey of policymakers in developing countries (conducted by the Center for Global Development) indicates that a low technical capacity to engage the private health sector is seen as a serious constraint on meeting priority health goals and increasing the effectiveness of health spending.
Further information Information: www.ppiaf.org/ www.cgdev.org/section/initiatives/_active/ghprn/workinggroups/psaf www.pidg.org www.ifc.org/HealthinAfrica www.ifc.org/advisory www.ifc.org/ifcext/psa.nsf/Content/DevCo
Reading: (Preker and Harding 2000; Harding and Preker 2003;
Marek, Eichler et al. 2004; Preker and Langenbruner 2004; International Finance Corporation 2007; Preker, Baris et al. 2007)
Results-Based Financing (RBF)
This mechanism would scale up the use of Results-Based Financing (RBF) in health systems. RBF is an umbrella term embracing several mechanisms designed to increase the quality of services provided. It includes output-based aid, provider-payment incentives, performance-based inter-fiscal transfers, conditional cash transfers, and incentives for households to adopt health- promoting behaviours. Payment is made in cash or goods in response to measurable actions taken or performance targets achieved. Depending on country objectives and challenges, RBF can be designed as supply-side mechanisms, such as output- based aid and pay-for-performance, that provide subsidies or incentives to health workers, or as demand-side mechanisms targeting communities and consumers and aimed at reducing or eliminating hidden costs that constrain the use of services. A multi-donor trust fund could be established to fund new RBF interventions in health systems. Alternatively, the existing Health Results Innovation Trust Fund, currently financed by Norway, could be expanded to include other donors, while IHP+ institutions could access the fund and channel resources according to RBF principles. General criteria
Value added: Increasing effectiveness of the delivery and use of
funds because of high incentives to achieve results.
Experience: New RBF mechanisms could build on the experience
of the Health Results Innovation Trust Fund. This provides financing to support national plans; build learning and evidence based on innovative mechanisms to strengthen health systems and build
national capacity. For further description of existing experience, see Working Group 1’s report.
Technical feasibility: The Health Results Innovative Trust Fund
is implementing pilot RBF programmes in several countries. Past experience with RBF and RBF-like mechanisms includes successful and unsuccessful examples. Unsuccessful programmes have shown that feasibility depends on concrete implementation and on countries’ readiness. Prior to implementation, countries must have or build the capacity to detect and prevent gaming, misreporting, and leakage of benefits, including conditional cash transfers. They also need the means of avoiding unintended effects – for example, providers doing only what is measured and dropping other activities. And they must have accounting systems capable of paying out the incentives.
Political sponsors: The pilot – the Health Results Innovation Trust
Fund – is supported by the World Bank and Norway.
Timeframe for implementation: An expanded RBF Multi-Donor
Trust Fund could be set up relatively quickly (in nine to 12 months) assuming there is political support and funding. It could be used for new pilots and/or for scaled up RBF.
Realized flows: US$100 million in the Health Results Innovation
Potential flows: RBF support to health systems could potentially
reach several billion USD a year. The World Bank estimates that it could channel up to US$2 billion a year in grants to governments through a scaled-up Health Results Innovation Trust Fund. Both international and domestic funds could be channeled through RBF.
Costs (set-up and running costs): Costs of providing financing:
Estimated to be in the range of conventional concessional loans and grants to developing countries. Costs to the World Bank are estimated to be comparable to those of its conventional operations. Cost within countries of establishing necessary support systems: Estimates are not available. It is expected that RBF is more costly to implement than traditional input-focused financing mechanisms. It requires more detailed specification of the goods and services to be provided, of performance indicators, and in general of the duties of those involved. It also requires more sophisticated monitoring and evaluation, including systems that prevent gaming.
Additionality: RBF does not raise additional funds.
Sustainability: Depends on ongoing donor commitment and
funding. Successful RBF programmes may over time exhibit more sustainability than conventional programmes, since donors are rewarding proven results.
ODA: It is expected that RBF interventions for strengthening health
systems in low-income countries would qualify as ODA if financing comes from public sources (for example, a country’s general development budget or a Solidarity Levy).
Aid effectiveness criteria
Country ownership: RBF is designed to strengthen country systems
and channel funds through them. Country ownership would be high as long as projects are country-driven in practice.
Predictability: Predictability can be viewed as potentially low, and
thus a disadvantage, in that flows depend on results. It can also be viewed as potentially high, in that recipients can to some degree control the flow of funds by their own actions.
Alignment: Varies by countries. Ultimately, depends on whether
country systems can accommodate the monitoring and evaluation systems RBF requires.
Synergies and externalities: Possible improvements in data
collected and in monitoring and evaluation; also an increased motivation to report. However, if systems are poorly designed, incentives for misreporting and gaming could increase.
Impact on aid architecture for health and harmonization: None.
No new organization would have to be created. Existing players could implement the mechanism, and processes could be aligned with and coordinated by IHP+.
Results: One of the most important potential benefits of RBF as
compared with other funding mechanisms is its orientation toward measurable, verified results (rather than inputs and processes). Anecdotal evidence of RBF’s ability to achieve positive results (for example, from the Health Results Innovative Trust Fund pilot programme in Rwanda) is promising. For a more detailed discussion, see Working Group 1’s paper.
Accountability: Provides a framework for accountability, since
disbursement of funds is tied to specified results. RBF necessarily focuses on improved governance (changing the relationship between public and private stakeholders and increasing accountability and transparency) in order to prevent misreporting and gaming. However, accountability depends on successful implementation.
Pro poor: RBF can be targeted toward pro-poor interventions
by linking financing to results that especially benefit the poor. Ultimately depends on the chosen results indicators. Summary and overall evaluation
The value added of RBF is to create incentives within recipient countries to deliver results. RBF is a relatively flexible approach that could be supported though a multi-donor trust fund, as suggested here. Several billion dollars annually could be channeled through RBF. Potential disadvantages include upfront costs, including the need for carefully designed programmes to avoid the creation of inappropriate incentives, and the fact that funding would have to come from conventional ODA or from one or more of the other financing mechanisms in this paper. Ultimately, RBF’s success would depend on well-designed programmes that take into consideration country systems and capacity for implementation. If properly implemented, RBF could score high on aid effectiveness criteria. It is designed to support strong results and could be used to target funding to the poor. Since RBF channels funds through country systems, funding is expected to be well aligned with country priorities. Positive externalities could arise from the additional data collected, the high motivation to report, and monitoring and evaluation requirements.
Predictability may be viewed either as a disadvantage (in that flows depend on results) or as an advantage (in that recipients can to some degree control the flow of funds by their own actions). Further information
Reading: (Loevinsohn and Harding ; Barder and Birdsall 2006;
Ivanova 2006; Oxman and Fretheim 2008; Fiszbein, Schady et al. 2009)