Illustrations Tables Introduction

Section A: Private Sector Health Care Innovation In Low- and Middle Income Countries Chapter 1: Innovative Health Service Delivery Models in Low- and Middle-Income Countries – What Can We Learn from the Private Sector? Chapter 2: Global Health Innovation: Exploring Program Practices and Strategies Chapter 3: The Future Of Health Care Access Chapter 4: For-Profit Health Care Providers at the Bottom of the Pyramid Chapter 5: Criteria to Assess Potential Reverse Innovations: Opportunities for Shared Learning Between High- and Low-Income Countries

Section B: Understanding The Contributions Of Private Sector Health Care Services Chapter 6: Assessing Health Program Performance in Low- and Middle-Income Countries: Building a Feasible, Credible, and Comprehensive Framework Chapter 7: Performance Measurement for Innovative Health Programs: Understanding Efficiency, Quality, and Scale Chapter 8: Trans-National Scale-Up of Services in Global Health

Section C: Vertical Cases – The Role Of The Private Sector In Addressing Major Diseases Chapter 9: Innovations in Tuberculosis Healthcare: Exploring the Evidence on Emerging Practices in Low- and Middle-Income Countries Chapter 10: Innovations in Malaria Healthcare: Exploring the Evidence on Emerging Practices in Low- and Middle-Income Countries Chapter 11: Innovative Practices in Global Health to Manage Diabetes Mellitus Chapter 12: Innovations in Global Mental Health Practice

Section D: Horizontal Cases – The Role Of The Private Sector In Generating Integrated Solutions Chapter 13: Innovations in Privately Delivered Maternal, Newborn and Child Health: Exploring the Evidence Behind Emerging Practices Chapter 14: Scaling Up Primary Care in Low- and Middle-Income Countries by Using Strategic Management Skills Chapter 15: Integrating Primary Care and Maternal, Newborn and Child Health in Low-and-Middle Income Countries Conclusion List Of Contributors

Low- and middle-income countries (LMICs) face daunting health care challenges. Patients in these countries experience not only a high incidence of infectious disease such as malaria and tuberculosis, but also must manage the rise of chronic conditions such as diabetes, cardiovascular disease, and respiratory disease (Nugent 2008). Organizations in these countries strive to address these complex health problems by engaging in novel approaches to counteract these trends. Because of resource constraints on public-sector health systems, most LMIC countries have many private sector providers (both formal and informal), whose performance must be better assessed to understand both their potential and limitations. This includes examining the ability of private sector organizations to help achieve universal health coverage (Lagomarsino et al. 2012) (Nishtar 2010). This book focuses on the subset of innovative private sector organizations that have developed promising new models to improve care for poor communities and examines their performance, scale, and sustainability.

This volume compiles and synthesizes a series of articles and reports produced over the last decade by the Toronto Health Organization Performance Evaluation (T-HOPE) team based at the University of Toronto. T-HOPE is an interdisciplinary research team composed of a diverse group of health, management, and social science experts studying global health innovations. The T-HOPE team includes a family physician and health services researcher, Onil Bhattacharyya; two professors of strategy and management, Anita McGahan and William Mitchell; and an anthropologist, Kathryn Mossman; as well as a team of research associates, MBA students, and medical students. This volume is divided into four broad sections, including an exploration of emerging models of health innovation, relevant health performance measures, innovations that target vertical health areas, and innovations specific to horizontal and integrated approaches in LMICs. This analysis highlights our efforts to identify successful innovations to improve health care quality and access, measure performance of private health care organizations, and define key strategies for scale up and sustainability of impactful health initiatives.

Private Sector Organizations in Global Health

The private sector in this context refers to non-state organizations that include for-profit and not-for profit entities (Hanson & Berman 1998), such as private clinics and hospitals, non-governmental organizations (NGOs), social enterprises, and private companies. “Innovation” refers to the performance of new ideas, or ideas perceived as new by the target population, to create value and drive change in health care (Kastelle & Steen 2011), (Weberg 2009). While the term “global health” has been used in a variety of ways, our use of the term refers to the study of health and health care with the priority of improving health for all (Koplan et al. 2009). While much of our research focuses on LMIC contexts, we also explore the connections and opportunities for learning between LMICs and HICs.

Innovation among private sector organizations in global health takes many forms. We found a subset of private sector organizations in global health that were early adopters of mobile devices, information technology, and social media. As described in Section A, we identify innovation in business models such as franchising, microfinance, and vouchers. Traditional management approaches including training, marketing, and financing are also applied in novel ways. The use of new delivery and management models to deliver high-quality medical care to disadvantaged groups is promising.

Overall, many private sector organizations innovating in global health are understudied and poorly understood outside the local context. The range of

private sector organizations in health care is extensive: traditional healers, midwives, street dentists, multinational corporations, small entrepreneurial companies, local pharmaceutical companies, private hospitals, specialty clinics, non-governmental organizations that seek to provide care to the public, humanitarian aid agencies, privately practicing physicians, IT companies, and a range of others. Despite the preponderance of a range of engaged organizations, few studies address the activities of a broad cross section of private sector organizations engaged in health care. There is limited evidence on which private health sector approaches work best under various circumstances in low-income countries (Mills, Brugha, Hanson, & McPake 2002). Indeed, it is essential that we develop a better understanding of the effectiveness, scale, and scope of the private health sector in LMICs, given that evaluation of such initiatives is lacking (Hanson et al. 2008).

While a large literature has developed on the measurement of affordability, accessibility, and impact in global health, these criteria are difficult to

implement in practice in resource-limited settings. We know of no organization that organizes itself around these criteria. To address this problem, the Center for Health Market Innovations (CHMI), an initiative of the Results for Development Institute (R4D), developed a database in an effort to track the performance of a large number of health market innovations in developing countries. We formed a partnership with CHMI to analyse this data, and have relied on the CHMI database as a starting point for evaluating organizations on criteria that are both relevant and theoretically robust. We found that the gap between theory and practice was greater than in almost any other area of study that we have encountered, especially given the wide variety of organizational models and services provided. Indeed, because organizations adopt different strategies, assessing their contributions requires a more complex assessment than simply focusing on access, cost, and quality. Measuring impact effectively requires both management and health care criteria, which we built into our framework assessment tool, described in Section B. Having developed this tool, we then sought to develop insights from the application of these criteria and explore the emerging models and their evidence in both vertical health areas – either disease or demographic groups – in Section C, and horizontal health areas like primary care in Section D. Our assessments focused particularly on smaller organizations rather than large multinational corporations.

Most health care in LMICs is delivered by a mixed health care system, where service delivery and financing of care is predominantly provided by private actors alongside publicly funded government health provisions (Nishtar 2007; Nishtar 2010). These private actors are a common source of health services and essential to addressing certain health conditions in many low-income countries (World Bank 2008). However, some have voiced concerns about their ability to serve the poorest, the quality of the care they provide, and the often limited regulation of their activities (Basu, Andrews, Kishore, Panjabi, & Stuckler 2012; Bennett 1992; Patouillard, Goodman, Hanson, & Mills 2007; Brugha & Zwi 1998; Mills et al. 2002). These are significant concerns and they raise important questions about the limits of this sector. However, we have found that some private sector organizations are particularly adept at tailoring approaches to particular contexts and enabling specialized care. For example, some have found that while private sector health care in LMICs is not necessarily more medically effective, accountable, or efficient than the public sector, it may be superior in the areas of patient experience and timeliness of care (Basu et al. 2012), and have better availability of medications and equipment (Basu et al. 2012). Some private sector programs have also been shown to provide very high-quality care to LMIC patients, such as Narayana Hrudayalaya Hospital in India. Its high-volume, low-cost model for heart surgery has resulted in average mortality rate of 1.4 per cent within 30 days of coronary artery bypass graft surgery, a lower rate than the 1.9 per cent average reported in the US in 2008 (Anand 2009; Center for Health Market Innovations 2017). Private sector programs may also have useful strategies for managing staff, which could provide lessons for the public sector, given that attracting and retaining health workers, such as nurses and doctors, is a major challenge in some LMICs due to poor management, lack of recognition

or promotion, inadequate training, and problems with remuneration (Kober & Van Damme 2006; Chimwaza et al. 2014). Thus, we have found that there are opportunities for the public and private sector to learn from each other and, in fact, private sector organizations may complement public sector approaches. For example, through public-private partnerships, Karuna Trust, a charitable trust in India, manages state-owned primary care centres in remote and rural areas that were performing poorly. It has improved both patient satisfaction and health outcomes at a lower cost, and reaches more than one million people through 68 primary care centres in seven Indian states (Karuna Trust 2017). In addition, the public sectors in some LMICs have invested in and supported innovation through collaborations with the private sector. This includes the Rwandan Ministry of Health’s support of scaling up RapidSMS with a variety of private sector partners. This open-source mobile SMS platform helps community health workers monitor pregnant women and babies, saving hundreds of thousands of lives (Ngabo et al. 2012; World Health Organization 2013).