72953 MAY 2012 ABOUT THE AUTHORS Informing the “Visible Hand��?1 CONNOR SPRENG is a Senior Economist in the Defining and Measuring What Governments Do— Investment Climate Depart- ment of the World Bank Group, joined the World Bank as a and Can Do—with Private Health Providers in Africa Young Professional in 2006. For the past three years, he has led the work on the Healthy Measures of the overall business environment have been around for many Partnerships Report as part of years, and the World Bank Group has been at the forefront—for example, the Health in Africa Initiative. Connor’s past work focused on with the Doing Business indicators. But it’s a different story when it comes the public-private interface in such sectors as health, to the environment for private businesses in the social sectors. Indeed, the education, banking/financial private sector’s role itself is somewhat controversial, making it all the more system, water/wastewater, and solid waste. important to develop a useful definition of effective policy and practice in this area. In 2011, the World Bank and IFC published a report, Healthy IFELAYO OJO is a medical doctor and public Partnerships: How Governments Can Engage the Private Sector to Improve health professional, has been a Consultant with the Health in Health in Africa, which represents a leap forward in our understanding of Africa Initiative for the past government performance toward the private health sector—and how to three years. He has practiced medicine in the public and measure and improve that performance. Part of the World Bank Group’s private sectors in Nigeria and conducted public health Health in Africa Initiative, the Healthy Partnerships Report presents a research across the Africa framework for defining, measuring, and reforming how the public and region and in South America. As a co-author of the Healthy private sectors work together. It makes the indicators not only relevant but Partnerships Report, Ifelayo participated in the analysis and also directly helpful to policymakers and to colleagues in the field. This writing as well as in the development of the conceptual SmartLesson shares insights gained while preparing the Report. foundations and the primary research. Background APPROVING MANAGER Cecile Fruman, Manager, The poor performance of many of Africa’s Private Participation in national health care systems is sobering. Less Infrastructure and Social Sectors, Investment Climate than 50 percent of all births in the region take Department, World Bank place in a health care facility, and only about Group. half the children with serious infections are treated in clinics or hospitals. The private sector is part of the answer, if only because of its size: private providers are responsible for delivering at least half the services—for the poor and the rich and for urban and rural populations alike. (See Figure 1.) The World Health Organization and others have identified improvements in the way governments interact with and make use of their private health sectors as one of the key ingredients to health systems improvements.2 1 “Visible hand��? is a play on Adam Smith’s “invisible hand.��? The term has come to refer to governments’ role in guiding and over- seeing markets to achieve ends for the public interest. 2 Information in this paragraph is from Healthy Partnerships: How Governments Can Engage the Private Sector to Improve Health in Africa (2011), World Bank Group, Washington, D.C. SMARTLESSONS — MAY 2012 1 Lesson 1: Start with enthusiasm—yours and your Figure 1: Source of Health Care by Wealth Quintile for Households team’s. in Sub-Saharan Africa Developing measures in a new and difficult area requires a lot of enthusiasm up front. The work is likely to be difficult and at times tedious, so you need to believe strongly in what you’re going to do. (For example, see Box 1.) Overcoming the challenges along the way is realistic only if you and your team are strongly committed at the outset. Therefore, enthusiasm for—and understanding of—the work should be a significant factor in the selection of the team. Doing this type of work within the World Bank Group presented its own distinctive set of challenges. The team acutely felt the reach and convening power of the World Bank Group as well as the difficulty of navigating the structures in Washington and in country offices. Although the former proved to be invaluable in securing key meetings, the latter tested our resolve and resilience many times. Source: Healthy Partnerships: How Governments Can Engage the Lesson 2: Seek to understand first what can—and what Private Sector to Improve Health in Africa (2011), World Bank should—be measured. Group, Washington, D.C. When developing indicators in a difficult area, it is a mistake to narrow the focus on particular measures too early. We Across the Africa region, many ministries of health are found ourselves repeatedly maneuvering between two actively seeking to increase the contributions of the private distinct opinions. On the one hand, public health experts health sector. However, relatively little is known about the were uncomfortable with the idea of quantifying details of engagement; that is, the roles and responsibilities governments’ performance toward the private health of the players and what works and what does not. There’s a sector. They kept telling us that there is too much context need for better understanding of the ways governments specificity, and therefore such comparative measures aren’t and the private health sector work together and how they possible. On the other hand, colleagues with experience in can work together more effectively. The publication of the measuring performance in a business environment, not Healthy Partnerships Report is a critical milestone in this specific to a certain sector, insisted that only through highly process. It is only a first step, and more work is needed. But focused case studies could measurements become credible. the positive response from policymakers and colleagues in the field confirm that it is an important step. The hitch is that indicators make sense only with regard to the data they describe. As long as you don’t know what the The Report developed a new framework to assess the level data say, you cannot be confident that you’re choosing the of engagement between the public health authorities and appropriate measures. Ideally, this would be a sequential private sector providers. A team of researchers collected process. But since we didn’t have that kind of time, we did data through interviews, supplemented by desk research, in the process in parallel: gathering data and narrowing the 45 Sub-Saharan African countries. We conducted more than focus as our understanding of the data grew. 750 in-person interviews, covering each country’s key stakeholders, such as senior government officials, private A good example of this process is our attempt to define an sector representatives (including practicing doctors and indicator: “time it takes to open a clinic.��? Since the “opening nurses), and independent experts. The results highlight a business��? indicator is one of the most prominent and those places where public-private collaboration is working most readily accessible indicators for Doing Business, we well and those where it is not. The framework and its sought to develop an analogous indicator for health indicators also suggest strategies to enhance contributions providers. As it turns out, however, such an indicator cannot by the private health sector. be defined for health with the same methodology, because the specific case of a clinic cannot be specified in a way that Lessons Learned makes sense for a majority of countries. The procedures and the legal structures or legal understanding are vastly different from one country to another. “Measurement is the first step that leads to control and eventu- ally to improvement. If you can’t measure something, you can’t The lesson we draw from this experience is that indicators understand it. If you can’t understand it, you can’t control it. If derived in the first round of such groundbreaking efforts you can’t control it, you can’t improve it.��? can be ambitious, while at the same time limited in scope to —H. James Harrington, American author, engineer, entrepre- what is useful and comparable. Our contribution lies neur, and performance-improvement pioneer therefore partly in the degree to which our initial round of 2 SMARTLESSONS — MAY 2012 outcomes such as access and quality). As the positive feedback Box 1: Persevere! (And Maybe Pack a Lunch) during data collection confirmed, the framework appealed to decision makers’ intuition and their way of thinking about policies and practices. However, this framework works a bit less well for analyzing the indicators and their impact. Feedback from academics showed that the way we did it isn’t necessarily an optimal way of organizing the measures. But policy relevance reliably trumps such considerations, so the value of our choice has been thoroughly confirmed. Similarly, we insisted throughout the project that covering all countries in Sub-Saharan Africa was an important element of our work. We ultimately scrapped the outright country rankings as a result of internal reviews, because we wanted to avoid having the exercise hijacked by the confrontational or potentially incendiary headlines that country rankings can Given the diversity of Sub-Saharan Africa, our determination to sometimes produce. cover all the countries in the region provided plenty of opportunities—some of them quite unexpected—to show our However, keeping the intended audience in mind is important perseverance. Take for instance our flight from South Sudan to in setting the tone for the Report. There is no use in Khartoum on a puddle jumper that belonged to the World Food sugarcoating the comparative nature of the exercise. In fact, Program. that is the part that many of our clients find most compelling: We went straight to the airport from a series of meetings and “How are our neighbors doing? Why are we falling behind interviews. Then, true to the rule of “hurry up and wait,��? we sat them in certain categories, and what do we need to do to on the runway in Juba, sweating profusely in our business attire. catch up?��? But it did get cooler during the flight—when clouds seemed to invade the cabin as moist air was sucked in through the holes in In the end, the importance of the political process cannot the floor and walls. During the flight, we developed a fatalistic calm. After a stopover at Malakal airport, the pilot requested clearance to take off, but “The findings and recommendations of the IFC-World Bank the control tower did not respond. Finally, we overheard the pilot Healthy Partnerships report will allow the public and private sec- say to the copilot, in a resigned, matter-of-fact tone, “These guys tors to continue collaborating, not only on sector-specific reforms never answer.��? Then he accelerated the prop plane down the needed to improve health outcomes in Kenya but also to identify runway for takeoff. economywide issues also covered in the report.��? We arrived in a sweltering Khartoum at dusk, thankful to continue —Rt. Hon. Raila A. Odinga, EGH., MP., our quest to learn how governments engage the private sector in Prime Minister, Republic of Kenya Sudan. But we were tired, thirsty, and—ironically—hungry; during the five-hour flight on the World Food Program plane, we “The Healthy Partnerships Report has greatly improved and con- didn’t even get a snack! firmed our understanding of the context for private health service provision in Sub-Saharan Africa. Based on the enlightenment we have gained, we will continue to expand our networks of perma- data collection and indicator development will be able to nent primary care clinics in Ghana and Sub-Saharan Africa.��? inform continued research, and the possible establishment —Sanford World Clinics Development Team of such an indicator in later iterations of our work. Lesson 3: Remember that the clients are the audience for be overstated. Sophisticated and technically appropriate and users of your work. Keep it relevant to their needs. solutions are useless if they are not translated into concrete action by the stakeholders. Indeed, the application of the When developing indicators and an analytical framework to framework, along with the implementation of changes in organize them, it is tempting to get caught up in the technical policy and practice, is to a significant degree a political details of the measures. Analytical rigor and elegance can be challenge rather than a technical one. important, but they aren’t substitutes for relevance to policymakers. Lesson 4: Consult widely, but rely on your own team. Over objections from the academic experts on the project Broad-based consultations were a central element of our team, we chose a framework to be compatible with the way work from the start. This turned out to be beneficial for policymakers think. We organized the indicators along the our understanding of the background or history of the lines of the tools of the state (overall policy, information issues. It was important for us to get a broad range of exchange, regulation, financing, production) rather than opinions. However, early consultations did not in any way along lines that would make health systems evaluation easier insulate us from later criticism about decisions that (for example, by aligning them with intermediate health emerged from those consultations. We learned that you SMARTLESSONS — MAY 2012 3 don’t get credit for early consultations, not only to develop but also to truly believe beyond the reward of the quality of the and “own��? the elevator speech about the work itself. Consulting internal and external work. Effective communication is not from experts can help, though it cannot prevent the perspective of what we did or what we having the very same discussions later in the think the work is about, but rather from the process, during reviews. perspective of what the work can mean for others and what they can take away from it. When we embarked on the final analysis During media training just prior to the and writing of the Report, bringing the Report’s launch, we developed a tagline for indicators and all of our analytical work it: “The Power of Two.��? As part of this effort, together, we expected to rely on top experts we reshaped our message away from in this area to do much of the writing and to frameworks and indicators toward find the right language and balance. But overarching conclusions and end results. In instead, we ended up doing much of the retrospect, the writing of the Report itself writing ourselves. The input from experts would have benefited even more had we was necessary but in no way sufficient to embarked earlier on this type of focused create the final product. effort to shape the message. Lesson 5: Invest heavily in effective Internal communication also matters a great communication—internally and externally. deal. Not only in the development of the Report, keeping all relevant parties involved It has been said many times before, but it still and engaged, but also in making sure the bears repeating: internal and external Report is not a one-off exercise, and that it communication—before, during, and after gets properly integrated. In many ways this the project—is absolutely central to its work is just a first step; it has to be further success. developed. It takes persistent follow-up to retain management buy-in and ensure Communication can be especially challenging integration of the approach into World Bank when working in a new area that may not fit projects. neatly into established organizational boxes. For investment climate work in the health Conclusion sector, this is certainly the case. But the novel, frontier element of the work makes Improving the way we define and measure communication all the more important. performance when it comes to public policy and practice toward the private sector— External communication requires particular especially in health—is a critical and ongoing care in shaping the message. It is necessary challenge. Pushing the limits of this knowledge requires enthusiasm, confidence, attention to the core issues, and a consistent focus on the client. It also demands that we pay particular attention to communicating results both internally and externally. We anticipate that the work we have done here in developing indicators—the methodology as well as the broader approach to measuring government performance with regard to oversight of DISCLAIMER private delivery of social services—will be SmartLessons is an awards relevant to other development work, beyond program to share lessons learned in development-oriented advisory the health sector and beyond Africa. services and investment operations. The findings, interpretations, and conclusions expressed in this paper are those of the author(s) and do not necessarily reflect the views of IFC or its partner organizations, the Executive Directors of The World Bank or the governments they represent. IFC does not assume any responsibility for the completeness or accuracy of the information contained in this This is about “The Power of Two��?—public and document. Please see the terms private sectors working hand-in-hand. and conditions at www.ifc.org/ smartlessons or contact the program at smartlessons@ifc.org. 4 SMARTLESSONS — MAY 2012