The tool is divided in to three parts:
Part 1: Descriptive Information
Part 2: Numerical data, and
Part 3: Views, perspectives and opinions of key stakeholders.
Part 1
Would seek to compile information on country context (i.e. demographic and health status related background), organization and delivery of health care services both in public and the private sector, deployment of infrastructure and resources in the country’s health system with special reference to the private sector, characteristics and growth of the private health sector, legal, regulatory and administrative oversight related to the private health sector, popular image and perception about private health sector in the country, effect of private health sector on the health system and equitable access to affordable care to the population, and lessons from private sector engagement and public private partnership in health sector in the country. The tool also provides a broad outline for policy options towards private sector engagement in the country.
Part 2
Consists of numerical data in terms of health sector resources in the private sector and its growth over a time period, composition and proportion of services delivered by the private sector, details of health financing, details of health insurance coverage, and tariffs for clinical services in the private sector.
Part 3
Consists of a series of checklists containing interview questions for key stakeholders in health sector, seeking their views on private sector and public private partnership. The stakeholders include representatives from:
- senior policy makers and officials from both private sector and public sector,
- private sector health care providers (hospitals and clinics),
- private sector laboratories and diagnostic facilities,
- private sector professional associations and professional councils,
- not-for-profit health care providers,
- insurance companies,
- donors and international development partners, and
- patients. Some of the checklists are in the form of interview questions and some of them in the form of self-administered questionnaire.
Data collection and using the tool
A systematic approach towards private sector assessment requires:
adequate planning and preparation
desk review
field work, including analysis and triangulation of information
report writing, review and dissemination.
Ministries of health need to be willing to extend all necessary administrative support, including establishing dedicated research teams, allocating resources for salary and expenses, communication and logistics support.
Step 1
Establish a research team led by an experienced subject matter expert. Ideally, the team should consist of country level researchers. However, some individuals (in country nationals or international experts) may be co-opted to provide short-term technical support. Prepare terms of reference for the team with specific roles and responsibilities, timelines, reporting relationships, review and feedback mechanisms, quality control. The size and composition of the team may depend on the scope of work, country context, information from previous assessments. Allocate a sufficient budget, resources and logistical support for the research team. Empower them with sufficient authority to compile information and data from various sources. Scope of work, timelines, research team and budgetary support are inter-dependent on each other.
Step 2
Familiarise the team with the assessment tool and purpose of the assessment. The team must always bear in mind the shape of final report and how pieces of information and data that they gather will contribute in preparing the report. The team must be made aware of how the report will be used by the government, donor agencies, advocacy groups, private sector syndicates and other stakeholders. The team must also be made aware that the overall objective of this exercise is to explore opportunities for private sector engagement towards UHC. The scope of work may also indicate the (horizontal) coverage and (vertical) depth of assessment.
Step 3
The team should be asked to review of the tool within the team and with select stakeholders, and adapt the tool to the country context. The team will not alter the tool fundamentally but may modify the technical terms and concepts and make to tool operationally ready to be used in the local context.
Step 4
Identify and map the sources of information/ data according to the information categories in order optimise your data collection time. Identify the key stakeholders (as key informants/respondents) for in depth consultations and interviews. The stakeholders should be sufficiently representative in nature (sampling) in order to elicit a good spectrum of information. It may be useful to reach out to the stakeholders at this stage itself, in order create awareness and interest on the proposed assessment and may perhaps save time too.
Step 1
Identify sources of accessible documentation to be reviewed and prepare a list of these documents. Focus on the scope of the assessment, relevance of literature and expertise of team member in review. Create a spreadsheet indicating team members’ responsibilities, scope of their work, deliverables, timelines and access to al relevant documentation.
Step 2
The list of relevant literature/documents should be categorised according to the information categories listed in the tool (i.e. Part 1. Descriptive information). Once all relevant documents are acquired and is readily available, the research team should begin to analyse the literature in terms of data (e.g. number of hospitals in the private sector), factual information (e.g. regulatory provisions related to the private sector), and analysed information (e.g. study on quality of care in private sector hospitals). Make sure that all contents are properly cited and is verified by the team leader.
Step 3
The research team should prepare a ‘zero draft’ report, pooling together all their compiled data, information and review findings. The team lead must oversee the preparation of this zero draft.
Step 4
The research team, while reviewing the literature and while preparing the zero draft report, should identify the gaps in data and information and some of the unanswered questions. The reviewers should carefully list all the missing details so that such information/data could be compiled through personal discussion, field work or through other sources. The above task may be undertaken by individual team members in their respective review areas, but should be consolidated in to a single document. Before proceeding to seek the missing information from external sources, the team members should ask each other if the missing details are available in the literature they have been reviewing. It would be important to keep in mind what information is being sought for the purpose of the report, what information is available (from literature), and what pieces of information/data are missing or to be verified.
A desk review, however systematic, tends to provide an analysis of the current status, which is inadequate for a comprehensive private sector assessment. The desk review of literature and its synthesis should be supplemented with in-depth discussion/consultation with key stakeholders (key informants), as well as onsite visits, which will provide greater insight into the current role of private sector in the country’s health system and opportunities for an enhanced role. These interviews may help to address any information gaps or validate already gathered information on private health sector, understand their perceptions and opinions on role of private sector in the country’s health system, and explore the potential for private sector engagement and public-private partnership.
Step 1
Before commencing field work conduct in depth interviews with key stakeholders or conduct on site visits to private providers, depending on country context. There are a multitude of stakeholders in a country’s health system.
Once the categories of key stakeholders are identified, list the names of the organizations (or their representatives) and individuals as potential respondents for interviews. The selection of potential respondents should be based on a purposive sampling to enable more informed views from individuals who have most knowledge about the private sector. Attempts should be made to include as many key stakeholders as possible. Some may even be interviewed through telephone calls or ‘skype’. If needed snowball sampling may be used to increase the number of respondents and improve the quality of information.
Selection of respondents should be judicious keeping in view the geographical (rural and urban) and private sector density (low and high density). Care must be taken not to miss out a key stakeholder or compile inadequate information from a respondent.
Step 2
Members of the research team should be made thoroughly familiar with the checklist (and the questions). It may be useful to prepare a guidebook on each checklist in terms of the meaning/depth of the question, expected responses, further questions. Members of the research team may also be trained on interview skills by allowing them to conduct mock interviews of pilot testing of their interviewing skills using the checklist. Research team members may be assigned a specific category of stakeholders with whom they will conduct the interviews.
Step 3
Inform potential respondents/organizations of the assessment and invite them to participate. Fix a date and time to conduct the interview and send a copy of the checklist to the respondent prior to their interview.
Use the checklist to guide the interviews.
Wherever the questionnaire method is useful, for example for patients, consider modifying the checklist into a self-administered questionnaire.
The tool contains checklists for stakeholders/respondents:
senior policy makers and officials from both private sector and public sector
private health care providers (hospitals and clinics)
private sector laboratories and diagnostic facilities
private sector professional associations and professional councils
not-for-profit health care providers
insurance companies
donors and international development partners
patients.
The researchers may include additional stakeholders or exclude some of the stakeholders depending on the country context.
Step 4
Once interviews with key stakeholders have been conducted, debrief the respondent by providing a written report or a bulleted list of the preliminary observations in order to verify and validate the interpretations and findings. Team members may also debrief each other.
Snowball sampling is a special nonprobability method used when the desired sample characteristic is rare or difficult to locate. Snowball sampling relies on referrals from initial subjects to generate additional subjects. While this technique can dramatically lower search costs, it comes at the expense of introducing bias because the technique itself reduces the likelihood that the sample will represent a good cross section from the population. http://www.statpac.com/surveys/sampling.htm
Based on the data and information compiled through desk review, and views and opinions compiled through in depth consultations with the key stakeholders, the research team should organize the findings in the form of a draft report. A possible outline of the report is presented in the tool document. The draft report is subject to verification, triangulation and quality review.
Consider the following when preparing the draft report:
Define the private sector and the scope of health services assessed, by which providers
Describe the private sector and licensing/regulatory provisions
Analyse the data by conducting inferential analysis based on compiled data ‘the pattern of growth of the private sector’; and systematic review of scientific information “quality of clinical services in private sector”; and evaluate opinions and views of stakeholders “issues and challenges in private sector engagement”
Identify the possible impact of private investment in the health sector
Recommend potential areas for private sector engagement and appropriate models of private sector engagement.
Before submitting a final report to external reviewers, the draft report should be subject to internal review by the research team for verification, validation, reference check, presentation (flow and style), technical editing, coherence and checking that the recommendations are based on adequately compiled evidence.
The report typically has the following format:
Executive summary
Introduction or background that includes country context, overview of the health system and its performance, role of the private sector and the growth of the private sector, health financing and health expenditure, issues and opportunities in the health system with reference to the private health sector
Objectives of the assessment and methodology
Analysis and findings, which includes a description of the private sector and its role, analysis and inferences of the evidence, and key findings from the analysis.
Recommendations and policy options, which include identifying opportunities and priority areas for private sector engagement, proposing strategies to mobilize the private sector and identifying options available to policy-makers
References
Annexes.
Before finalizing the report and/or sending it to external reviewers, the research team may consider organizing a dissemination workshop with a broad set of stakeholders. During the workshop the research team may present the draft report and seek comments, feedback and additional input.