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Public-Private Partnerships and Giving Voice to Communities for Improving Health and Education


Overview

 Outcomes
Details of the Program 
-Impact of contracting health services to improve maternal and child health
-Impact of financing and technical support for PPPs to improve access to quality schooling serving low-income communities
-Learning and Knowledge generation from IBRD countries’ experience
  
About Bank-Netherlands Partnership Program (BNPP)

Constraints on public budgets and human resources for health and education mean that governments need to find cost-effective ways of drawing on the private and non-profit sectors for the delivery of services and get the best performance out of publicly paid providers. Public-Private Partnerships (PPPs) in health and education policy play an important role in enhancing the supply as well as the quality of human capital. Also, PPPs have been successful in giving voice to the communities that they reach. PPPs in the social sectors can be described as partnerships between the public and private sector for the purpose of delivering a project or a service and may come in a variety of different legal or contractual forms (see Patrinos, Barrera-Osorio and Guaqueta 2009; and World Bank Global Monitoring Report 2009 for a detailed review).

The evidence base on how best to encourage the private sector and PPPs to play an expanded role in health and education service delivery in low-income countries is limited. This program covers ten projects in eight countries, five low-income and three middle-income for demonstration purposes, and aids them in implementing and evaluating alternative models of private involvement in education and health care services.

New evidence on the impact of PPPs in the delivery of health and education services can shed light on indicators of short term impacts of the programs to see what works best, how coverage can be scaled up most cost-effectively, and how quality and innovation can be improved. Special attention was given to promoting private involvement in schools and health centers catering to poor and marginalized groups, such as girls and orphans. The output of the activity led to preparation of analytical work and practical knowledge creation that can serve as inputs for Country Assistance Strategies (CAS) in different countries. Also, the activity created knowledge that will be used in project support to member countries.

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Outcomes
  • The program will result in reports on 11 substantive programs of public-private provision of health and education services on the basis of evaluations in 9 countries. There are four case studies on contracting of health services out to private and non-profit sectors to improve maternal and child health (Congo, Nigeria, Rwanda and Pakistan); four on the provision of financing and technical support to private schools and impact of provision of internet access by PPPs to low-income communities (Kenya, Pakistan, Philippines, and Mexico); and one case study of decentralization or giving voice to the communities in the provision of health services (Argentina).
  • One integrative report targeted to policymakers, summarizing the lessons learned from the 9 country level studies of 11 programs. The lessons learned would also be formulated as toolkit for use by task managers in future health and education projects.
  • Increase in number of low-income countries adopting public-private models in health and education which have drawn on the evidence base and policy recommendations derived from the proposed studies.
  • One regional evaluation workshop in each region with local counterparts of the proposed projects for capacity building on evaluation techniques and execution.

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Details of the Program

Component 1: Impact of contracting health services to improve maternal and child health

This component would support evaluation of performance-based contracting to improve maternal and child health. Cases would compare the outcomes achieved under interventions with the outcomes from other community level interventions:

  1. How different providers take up insecticide tested nets (ITN) approaches to roll back malaria in Rwanda, the Congo and Nigeria using random trials of interventions, some survey of providers, structural models for randomized trials for local specific conditions for scaling up interventions.
  2. Whether contracting with local NGOs to manage the first level of primary health care system is effective in Pakistan.

Expected Outputs/Results and Monitoring Indicators

  1. Process, outcome and impact evaluation of PPPs on improvements in health service delivery.
  2. A synthesis report on the impact of incentive schemes, performance-based contracting.
  3. National and regional workshops to disseminate results.

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Component 2: Impact of financing and technical support for PPPs to improve access to quality schooling serving low-income communities

The component would support evaluations of options for reducing service provider absenteeism, financial and technical support to expand private schooling provision for the poor, school financing facility, and technology in education. Cases would compare the outcomes achieved under interventions with the outcomes from other community-level interventions. The program would comprise the evaluation of:

  1. The Kenya School Financing Facility, which provides local currency financing to private K-12 schools.
  2. The voucher pilot in Pakistan aimed at expanding private schooling provision for the poor using survey techniques.
  3. The Balochistan education support project (BESP) in Pakistan to test small-scale models of PPPs in the delivery of primary education. A quasi-experimental design involving the use of matched control and project (beneficiary) groups will be used.

Expected Outputs/Results and Monitoring Indicators

  1. Expanded analysis of ongoing interventions to analyze long-term access to quality schooling, with repeat surveys and analyses.
  2. A synthesis report on the impact of financial and technical support to foster PPPs in education.
  3. National and regional workshops to disseminate results.

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Component 3: Learning and Knowledge generation from IBRD countries’ experience

There are three experiences that fall under components 1 and 2 above in two IBRD countries that are quite unique and will generate a wealth of knowledge which will be extremely useful for IDA countries since very little information of such experiences exist in the IDA countries. In particular this component will focus on knowledge and data generation useful for low income countries from the experience of IBRD countries. These include:

  • The Gearing up Internet Literacy and Access for Students initiative in the Philippines where a consortium of NGOs and private firms will provide computers and internet access to secondary schools to improve the quality of instruction. The use of computers and the internet has grown rapidly in developing countries. Between 2000 and 2005, the number of internet users in these countries grew by a quarter of a billion people. For this reason, this project can give very useful lessons in the relationship between computers and learning outcomes for other countries that are implementing similar type of programs. The methodology will focus on randomization into key components of the program. The program will help to build the technical capacity of the countries through a process of 'learning-by-doing' of the methodology of impact evaluation.
  • Argentina’s program to decentralize the management of health service delivery to a pilot set of provinces and to compare these pilot provinces to other provinces where health services remain centrally managed.
  • Mexico’s Parental Empowerment through Public-Private Partnership aims to enhance the existing rural school-based management program by increasing the amount of resources parents associations manage in a randomized treatment and control experiment. Half of the money comes from the Ministry of Education through its usual support to these schools – all eligible schools will already be beneficiaries of the compensatory program. The other half is provided by the private sector as a public-private partnership. The private sector partners include Cinepolis, Deutsche Bank Mexico, Fundación Televisa, Lazos Foundation and Western Union. Supervision of the overall experiment is supported by the NGO Investing in Education Foundation.

Expected Outputs/Results and Monitoring Indicators

  1. Process, outcome and impact evaluation of PPPs on improvements in health and education service delivery.
  2. A synthesis report on the impact of decentralization on health outcomes.
  3. A synthesis report on the impact of ICT on Education.
  4. National and regional workshops to disseminate results.

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Projects

This program is organized into three main components that reflect the sector of focus of the PPP program (education or health) and the income level of recipient countries (low income or middle income).

Component 1: Impact of contracting health services to improve maternal and child health

Component 2: Impact of financing and technical support for PPPs to improve access to quality schooling serving low-income communities

Component 3: Learning and Knowledge generation from IBRD countries’ experience

 

Component 1: Impact of contracting health services to improve maternal and child health

Rwanda’s Performance-Based Financing (PBF) scheme:
The Rwandan national Performance-Based Financing (PBF) scheme provides bonus payments to government and faith-based primary care facilities based on the provision of various types of services and the quality of those services. The Government of Rwanda (GoR) adopted the idea in 2005 and, through a collaborative process with development partners, designed and implemented a national model in the first half of 2006.The formula used to determine the payment to a participating facility in a given period of time is a function of a measure of an output unit, the number of patients that received the output, and a quality index of the service provided. The quality of care enters the payment formula through a multiplicative factor that raises or lowers the payment for all outputs. The quality index component of the payment formula is a function of both structural and process measures of quality of care that are identified using the Rwandan clinical practice guidelines. There are 14 maternal and child health PBF output indicators, each with an associated per unit payment rate. The first 7 indicators capture the utilization of key services, including curative care, prenatal care, family planning, institutional delivery, and child preventive visits. The second set of 7 indicators capture aspects of the clinical content of the care provided during visits and serve as measures for the process quality of care. PBF payments go directly to facilities, which decide how to use the funds, without restrictions. The overall amount of PBF payments is large in comparison to the facilities’ budgets.

Pakistan’s contracting the provision of Primary Health Care:
The Bank has been supporting the Government of North West Frontier Province (NWFP), Pakistan in carrying out reforms in health, education and social protection through a Development Policy Credit (DPC). As part of a DPC, health reforms envisaged improving the performance of the Primary Health Care (PHC) Services using different management models including contracting. In NWFP, the provincial government wanted to pilot several different models of contracting. A clear set of health service targets were included in the contracts. Emphasis was placed on both rehabilitation of Basic Health Units (BHUs) and on improving health service coverage. Service coverage targets included maternal and child health; preventive services; tuberculosis; and curative care. Health camps and health education were specifically targeted to improve preventive care utilization (Heard et al 2008). While the contracting in model has been widely used in Pakistan, Districts in NWFP will be allocated, not randomly, to either i) contracting in, ii) increased autonomy for existing public sector managers, iii) increased autonomy plus a performance-based bonus, or iv) a control group. Household data will be taken from the Pakistan Social and Living Standards Measurement (PSLSM) survey carried out by the federal government every few years which is representative at the district level.

Nigeria’s Malaria Booster Control Project (MBCP)
To alleviate bottlenecks in Nigeria’s current health system that impede service delivery in malaria prevention and case management, one northern and two southern Nigerian states are participating in a country-led initiative to explore innovative community-directed interventions and public-private partnerships for malaria control. These service delivery channels will be introduced in a phased manner across the states and will work to reduce demand and supply-side impediments to the access and proper use of life-saving long-lasting insecticidal nets (LLINs) and treatment of uncomplicated malaria with ACT, the recommended first-line anti-malarial. These channels are: i) community-directed interventions (CDIs) involving community directed distributors (CDDs); and ii) public-private partnerships (PPPs) with patent medicine vendors (PMVs).

Democratic Republic of Congo’s Evaluating the Impact of Communication Methods to Increase ITN Use in the Kinshasa Province
Malaria-related morbidity and all cause child mortality are significantly reduced by the proper use of insecticide-treated bed nets (ITNs) in households. The Democratic Republic of Congo (DRC) has recently launched a massive scale-up of free ITN distribution in the Kinshasa province, delivering two million ITNs to a population of over seven million people at the rate of two ITNs per household, by the end of 2008. However, the impact of ITNs on preventing malaria morbidity and mortality will be minimized if they are not properly and consistently used, especially among children and pregnant women. The goal of the study is to provide public health scientists and officials with an effective intervention to optimize ITN uptake and use especially among children and pregnant women as they become widely available through the scale-up of national distribution programs. It is hypothesized that a community-based interpersonal communication (IPC) as well as multi-channel communication intervention will increase ITN use among households already possessing them within the context of a provincial ITN distribution program.

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Component 2: Impact of financing and technical support for PPPs to improve access to quality schooling serving low-income communities

Pakistan’s voucher pilot aimed at expanding private schooling provision for the poor (Foundation Assisted Schools – FAS)
The Foundation Assisted Schools (FAS) program is essentially a public subsidy program to low-cost private schools in the province of Punjab, Pakistan. It is administered by the Punjab Education Foundation (PEF), a publicly-funded semi-autonomous statutory organization established in 1991 which serves as the main institutional mechanism for public-private partnership programs in education in Punjab. The FAS program offers a monthly per-student subsidy of PKR300 (US$4.3) to low-cost private schools conditional on, among others, (1) maintaining a minimum enrollment size of 100 students; (2) offering free education to all students; and (3) achieving a minimum student pass rate of 67% in a written, curriculum-based test prepared by PEF and administered semi-annually by contracted independent organizations (this test is called the Quality Assurance Test or QAT by PEF). In addition, the program offers (1) annual individual bonuses of PKR10,000 (US$143) to groups of teachers in program schools which achieve a 90% student pass rate in the QAT and (2) an annual competitive bonus of PKR50,000 (US$714) to the program school that attains the highest student pass rate in the QAT in each district where FAS program schools are present. The FAS program was initiated in November 2005 on a pilot basis in 54 schools in 5 districts. Since then, the program has been rapidly expanded in phases to cover additional low-cost private schools and districts. As of June 2008, the program had completed four entry phases and covered 1,082 private primary, middle, and secondary schools in 18 districts; 87% of these schools are located in seven districts.

Kenya’s Private Schools Financing and Technical Assistance Program
The Kenya Private Schools Financing and Technical Assistance Program is a program of the International Finance Corporation (IFC) to provide local currency financing and technical assistance (TA) to private K-12 institutions in Kenya. The IFC signed a risk-sharing agreement with K-Rep Bank (K-Rep) of up to 120 million Kenyan shillings ($1.7 million equivalent) on loans extended to eligible private schools in Kenya. Under this agreement, the IFC shares 50 percent of the risk on the pool of loans made to schools after an initial 5 percent first loss taken by K-Rep. Schools will use these loans to finance construction projects, purchase educational materials, including computers, and cover other capital expenditures. To support the risk-sharing agreement, a comprehensive technical assistance (TA) will be delivered to schools individually and through workshops, and will cover the following areas: school self-diagnostics, strategic planning, business plan development, educational management information systems, human resource training and management, accounting and financial management, curriculum and learning management, and quality assurance. The program’s target areas are Nyeri (Central), El Doret and Nukuru (Rift), Mombassa (Coast), and Nairobi (Nairobi). The vast majority of schools will be located in urban areas.

Pakistan’s Transport Subsidy in the Balochistan Education Support Project (BESP)
The BESP project supports education service delivery models through partnerships with non-government and low-cost private sector providers, under the umbrella of the Balochistan Education Foundation (BEF). Under its first component, the project is establishing new community schools in rural areas (US$13.9 million) with the objective to provide access to quality primary education to school-aged children, where the community is able to enroll at least 20 students in a school, and there is no girls school within a 2-km radius. These schools will provide formal primary education, with the assistance of eligible partner NGOs, under the supervision of the BEF. Each community school under the project must have a Parent Education Committee (PEC), legally registered and trained in management and finance. The evaluation aimed at measuring the impact of a transport subsidy that was offered to encourage children from remote rural communities to enroll into existing nearby government schools or in new community schools within the community.

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Component 3: Learning and Knowledge generation from IBRD countries’ experience

Mexico’s school-based management financed jointly by the public and the private sectors (AGE’s)
Mexico’s compensatory education program began in the early 1990s. It is now implemented by the National Council for Educational Development (CONAFE), a division of the Secretariat of Public Education. The school-based management (SBM) component, or AGEs, started in 1996 and consists of monetary support and training to Parent Associations (APFs). The APF can spend the money on the educational purpose of their choosing although spending is limited to small civil works and infrastructure improvements. AGEs increase school autonomy through improved mechanisms for participation of directors, teachers and parent associations in the management of schools. The AGEs financial support consists of quarterly transfers to APF school accounts, averaging $600 per year according to school size. An expansion of AGEs is being implemented through an experiment in four states. Participating schools receive double the usual amount. The project is implemented in 125 schools. Half of the money is financed by government through its usual support to these schools, all of which are already beneficiaries of the compensatory program. The other half is provided by the private sector, including Cinepolis, Deutsche Bank Mexico, Fundación Televisa, Lazos and Western Union. Supervision of the overall experiment is supported by the NGO Investing in Education Foundation. The World Bank supported these programs since the early 1990s.

Philippines’s Gearing up Internet Literacy and Access for Students initiative (GILAS)
The Gearing up Internet Literacy and Access for Students initiative in the Philippines where a consortium of NGOs and private firms will provide computers and internet access to secondary schools to improve the quality of instruction. The use of computers and the internet has grown rapidly in developing countries. Between 2000 and 2005, the number of internet users in these countries grew by a quarter of a billion people. For this reason, this project can give very useful lessons in the relationship between computers and learning outcomes for other countries that are implementing similar type of programs. The methodology will focus on randomization into key components of the program. The program will help to build the technical capacity of the countries through a process of 'learning-by-doing' of the methodology of impact evaluation.

Argentina’s Plan Nacer
During the 2001 economic crisis there was a drop in the basic health indicators, including an increase in child mortality in 2002. In this context, the National Ministry of Health began the Plan Nacer program as part of its Federal Health Plan. Plan Nacer is a public health insurance strategy for pregnant women and children under six who have no health coverage. The program focuses on the provision of basic health services for the poor and makes structural changes to improve efficiency in the health system, aimed at reducing morbidity and child-mother mortality in Argentina. Through the Plan Nacer program, the national government transfers additional financial resources to the provinces to promote child-mother health; transfers are linked to the results that the participating provinces achieve: i) 60% of the transfer is linked to the identification and registration of eligible population; ii) 40% of the transfer for the fulfillment of health goals on eligible (uninsured) population. Plan Nacer began to operate in late 2005 in the nine provinces in the North of the country (which have the highest child mortality), and was extended to the rest of the country in 2007.

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Synthesis Reports

Education
KenyaKenya’s Private Schools Financing and Technical Assistance Program

pdf Baseline Description
pdf Evaluation Strategy, Main Outcomes and Next Steps 
MexicoMexico’s school-based management financed jointly by the public and the private sectors (AGE’s)

pdf Synthesis Report
pdf Evaluation Strategy, Main Outcomes and Next Steps 

PakistanPakistan’s voucher pilot aimed at expanding private schooling provision for the poor (Foundation Assisted Schools – FAS)

pdf Summary Note | Regression-discontinuity evidence
pdf Evaluation Strategy, Main Outcomes and Next Steps 
PakistanPakistan’s Transport Subsidy in the Balochistan Education Support Project (BESP)

pdf Synthesis Report
pdf Evaluation Strategy, Main Outcomes and Next Steps 
PhillipinesPhilippines’s Gearing up Internet Literacy and Access for Students initiative (GILAS)

The Internet and Youth: Evaluating the GILAS program in the Philippines 
pdf Evaluation Strategy, Main Outcomes and Next Steps 
Health
ArgentinaArgentina’s Plan Nacer
 
pdf Synthesis Report
pdf Evaluation Strategy, Main Outcomes and Next Steps 
CongoDemocratic Republic of Congo’s Evaluating the Impact of Communication Methods to Increase ITN Use in the Kinshasa Province

pdf Evaluation Strategy, Main Outcomes and Next Steps 
NigeriaNigeria’s Malaria Booster Control Project (MBCP)

pdf Synthesis Report
pdf Evaluation Strategy, Main Outcomes and Next Steps 
PakistanPakistan’s contracting the provision of Primary Health Care

pdf Synthesis Report
pdf Evaluation Strategy, Main Outcomes and Next Steps 
RwandaRwanda’s Performance-Based Financing (PBF) scheme

pdf Synthesis Report
pdf Evaluation Strategy, Main Outcomes and Next Steps 

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Pictures & Videos

Mexico (Education) - Mexico’s Support to School Management (AGEs) 
http://www.investingineducation.org/100_ages_Videos.phpp 

Pakistan (Education)

  

Rwanda (Health) - Performance Based Contracting (PBC) for General Health Services in Rwanda

    

Presentations

Session Title: Innovative Service Delivery through PPPs in Health and Education - Impact Evaluation Preliminary Findings
World Bank Human Development Week 2008

Session Description

Evidence is emerging from impact evaluations of nine highly innovative Public-Private Partnerships (PPP) on Health and Education in seven low- and middle-income countries funded in cooperation with the Dutch Government through the BNPP Trust Fund. In this half-a-day learning event, innovative forms of service delivery through public-private partnerships will be described and preliminary findings from ongoing impact evaluations will be presented. This course will begin with the launch of the 2008 report on "The Role of Public-Private Partnerships in Education" and the presentation of the PPP continuum as a tool to assess and analyze a country's engagement with the private sector for service delivery.

Key issues to be addressed in this event include:

  • Based on preliminary results, are PPP programs successful in broadening access to quality services to marginalized populations? Are these PPP programs and lessons learned "extrapolable" to other countries?
  • What are the implications of successful PPP programs in the general education system?
  • What are the challenges of incorporating PPP programs into national educational systems?

Last updated: 2009-07-21




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