What is the non-state sector?

The Centre for Systematic Review at ICDDR,B is tasked with addressing non-state sector issues in health policy and systems in low- and middle-income countries. However, there is much discussion among the uninitiated about what exactly we mean by ’non-state sector’ and the reasons that this area is worthy of research.

An often used approach to thinking about the non-state sector is that it encompasses everything outside of the public health system, meaning that these providers and services fall outside of the realm of the national or local government’s direct structure for the provision of health services. However the line is not often clear, with providers working both in the public sector and also maintaining their own practices, perhaps introducing perverse incentives. Further, public sector activities like hospitals may host a private pay ward  (Mills et al. 2002, Patouillard 2007).  There is also a range of classifications for those outside the public sector and the non-state sector can be looked at in terms of for-profit, not-for-profit, faith-based organizations, and more.

At the individual level the non-state sector includes both formal and informal providers, but rather than there being a strict dichotomy or bifurcated structure, the range of providers can be viewed along a continuum. In this continuum the most highly trained providers in the formal sector would be physicians and specialty physicians who would encompass the greatest scope of practice as well as set-ups in which to practice. There would also be nurses and trained midwives. At the other end of the continuum would be a range of informal providers who encompass a large range of possible members but their scope of practice would be limited. They can be traditional birth attendants, shamans, lay health workers or unlicensed local wise-men and drug vendors.
 

Why does the non-state sector matter?

With an expansive and active non-state sector in many countries, there is an accompanying need or call for governments and donors to move beyond the planning and delivery of public health services and develop means of successfully engaging the non-state provider (Bennett et al. 2005). In many low- and middle-income countries, upward of three-fourths of care is provided in the non-state sector (WHO/USAID  2007; USAID-India 2006; Bustreo et al. 2006; Mills et al 2002). In India, more than 80% of qualified doctors practice in the private sector (Batley 2006). Because of the ambitious health objectives established by the Millennium Development Goals with its rapidly approaching deadline, a sense of urgency is added to the necessity of non-state sector engagement (Working with the Non-State Sector  2006; UN Millennium Project 2005).

References

Batley R (2006) Engaged or divorced? Cross service findings on government relations with non-state service-providers, Public Admin Development, 26: 241-51.

Bennett S, Hanson K, Kadama P, Montagu D (2005) Working with the Non-State Sector to Achieve Public Health Goals. Making Health Systems Work: Working Paper No. 2. WHO.

Bustreo F, Hardin A, Axelsson H (2003) Can developing countries achieve adequate improvements in child health outcomes without engaging the private sector? Bulletin of the World Heath Organization 81 (12): 886-894.

Mills A, Brugha R, Hanson K, McPake B (2002) What can be done about the private health sector in low-income countries? Bulletin  of the World Health Organization, 80(4) 325-330

Patouillard E, Goodman C, Hanson K, Mills A (2007) Can working with the for profit sector improve utilization of quality health services by the poor? A systematic review of the literature. International Journal for Equity in Health, 6 (17) Accessed online: http://www.equityhealthj.com/content/6/1/17

USAID-India (2006) International Workshop on Social Franchising in the Health Sector, Workshop Proceedings.

WHO and USAID (2007) Public Policy and Franchising Reproductive Health: Current Evidence and Future directions, Guidance from a Technical Consultation Meeting. Unpublished.

Working with the Non-State Sector to Achieve Public Health Goals Consualtion on Priorities and Actions. (2006) Chateau de Penthes, Pregny, Geneva 20-21 February 2006. Background paper.