Table 2.

Status of the private health sector arrangements in the six countries and feasibility of engagement in the implementation of EPHS

Political situation and stability	Afghanistan	Ethiopia	Pakistan	Somalia	Sudan	Zanzibar
	Fragile and conflict affected	Fragile and conflict affected	Politically volatile	Fragile and conflict affected	Post conflict, politically volatile	Political stable
Types of private providers and policy framework towards PHS
Types of PHS providers and their contribution to delivery of services	Benefit packages provided by NGOs through contracting out to some not-for-profit hospitals Unqualified and underqualified providers mainly in rural areas Limited corporate commercial hospital sector	Formally registered providers, corporate commercial sector and some practitioners of traditional medicine	Private providers include qualified GPs, secondary and tertiary hospital, unqualified or underqualified, providers Some private hospitals empanelled and implement national health insurance packages	NGOs are the largest service providers Large number of unqualified providers, faith-based healers Small to medium secondary and tertiary hospitals exist mainly in urban areas	Many qualified small-to-medium private facilities Corporate sector has presence in cities Faith healers, herbal medicine sellers, traditional healers also provide services Many health facilities run by charities and not-for-profits	Most providers are registered, licensed, and monitored Some unqualified practitioners work as traditional healers. Private health facilities empanelled with national health insurance programme implement benefit packages
Policy framework towards the PHS	National policy on PHS exists There is a PHS oversight authority in the MOPH	Policy and legal framework for PHS exists and enforced by regulatory agency Licensing and registration system present for providers	PHS included in various policies Common regulatory framework for public and PHS facilities and providers implemented by licensing and registration bodies	No specific policy for the PHS, general law governs commercial sector National health sector strategy recognises PHS, no regulatory authority	No national policy framework or regulatory body for PHS Registration and licensing systems exist under different boards or bodies	Policy exists but no legal framework for PHS Private Hospital Advisory Board and professional bodies register facilities and providers
Current level of relationship/partnership between the public and PHS	PPP policy on health is managed by Ministry of Finance BPHS/EPHS are provided countrywide by NGOs via a contracting out model	Policy on engaging PHS for service delivery in cities PHS provides some services included in the EPHS but not obliged to do so Some pilot and small-scale PPPs and PHS engagement unit in exist in MoH	Some provinces and programmes have PPP policies for service develop and facility management through contracting to NGOs Contracts not always done through open competition or tied to results-based investments	Strategy exists for contracting service delivery to NGOs, private hospitals All NGOs required to deliver EPHS regardless of who contracts them MOH capacity to manage contracts is limited	No existing policy for PHS engagement, currently being developed by the federal MOH	MOH has a policy on PHS engagement for service delivery and some programmes and NGOs have PPP policies for health Private Hospital Advisory Board acts as the link between the MoH and the private sector
Financial and service contribution of the PHS to the delivery of services
Private expenditure as % of THE	75% (2009) 77% (2019)	–	56.8%*	–	70.3%†	–
Out-of-pocket as % of THE	77%‡	–	51.9%*	47%	66.95%†	16%
Prepaid plans+social security as % of THE	Negligible	–	0.9%*	2%	SHI as % of THE=6.43%; SHI as % of GGHE 24.62%†
PHS % annual total outpatient visits	NA	–	75%–80% mainly curative services	60% services provided by the PHS	NA	47% services by PHS mainly is curative
PHS % of inpatient episodes or hospital visits (year)	NA	–	NA; Bed density in PHS<3/10 000; public sector 6/10 000	–	NA
Policies and interventions used or piloted to engage the PHS in delivering health services and/or essential packages of health services
Outsourcing/contracting out	Delivery of BPHS and EPHS	None	Provinces contract out for delivery of primary and secondary services Provincial EPHS exist, role of contracting not defined	Private-for-profit sector provides more services not included in EPHS particularly in curative and rehabilitative care	NHIF contracts with private facilities to deliver listed services Newly defined EPHS co-developed by NHIF and FMoH and will be linked	NHIF, Jubilee and Strategies insurance company contracts with private facilities to deliver services
Social marketing or franchising	Limited vertical projects on family planning, iodised salt, ORS, iron and folic acid	Some	Mainly in family planning through donor funding	Not included in the health benefit package	Role of social marketing and franchising included in benefit package	NA
Social (health) insurance	NA	No	Sehat Sahulat programme (health insurance programme) covers selected inpatient tertiary and secondary services	Not included in the health benefit package	SHI covers >82% population with own list of services and medicines§	NA
Demand side interventions (vouchers or cash transfers)	Pilot projects for RMNCH services in two provinces	No	Limited and mainly from NGOs, mostly through direct donor financing	Not included in the health benefit package	With support from WB and EU, cash transfers done interruptedly in some areas	NA

*National Health Accounts 2017–2018.

†Sudan System of Health Accounts 2018.

‡National Health Accounts 2019.

§National Health Insurance Annual Report 2021.

BPHS, benefit package of health services; EPHS, essential package of health services; EU, European Union; FMoH, Federal Ministry of Health; GGHE, general government health expenditure; GPs, General Practitioners; MOH, Ministry of Health; MOPH, Ministry of Public Health; NA, not available; NGOs, non-governmental organisations; NHIF, National Health Insurance Fund; ORS, oral rehydration salts; PHS, private health sector; PPP, public–private partnership; RMNCH, reproductive, maternal, newborn and child health; SHI, social health insurance; THE, total health expenditure; WB, World Bank.