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April Harding

World Bank, Health Global Practice, Department Member

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April Harding is a health systems expert in the World Bank's Health Global Practice, with 20+ years providing analytical and advisory support to World Bank clients. She leads the World Bank Institute's "Managing Markets for Health" initiative, which provides face-to-face and online courses on strategies for managing health markets to World Bank clients and partners.

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The University of Manchester

Kim Van der Borght

Vrije Universiteit Brussel

Hamad Bin Khalifa University

Université Paris 1 - Panthéon-Sorbonne

Akintunde K Otubu

University Of Lagos Akoka

Murdoch University

Dr. Madeline Taylor

The University of Sydney

University of Oregon

André M A I A G O M E S Lages

Universidade Federal de Alagoas

Juliana O Domingues

Universidade de São Paulo

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Papers by April Harding

Institutions Matter

by Edit Velenyi and April Harding

Staying the Course, 2013

Public-Private Partnerships And Public Hospital Performance In Sao Paulo, Brazil

Health Affairs, 2009

Public hospitals that are directly managed by government perform poorly in many developing countr... more Public hospitals that are directly managed by government perform poorly in many developing countries. Approaches to improving them through internal managerial reforms have failed, and effective alternatives are much needed. Policymakers are considering reforms through public-private partnerships (PPPs)-a promising but so far unevaluated approach. We present results of a successful reform in São Paulo, Brazil. The PPP model gave facility managers latitude to manage human resources-a factor critical to success. Given the prevalence of direct management of public hospitals in developing countries, the São Paulo experience has implications for policymakers seeking to improve hospital performance.

Private participation in health services handbook

Contracting for the delivery of community health services: a review of global experience

To achieve the health-related Millennium Development Goals, it will be necessary to improve the d... more To achieve the health-related Millennium Development Goals, it will be necessary to improve the delivery of health services, particularly to poor people. One proposed approach to improving both coverage and quality of care is to contract with NGOs or other non-state entities to deliver health services. This paper reviews experiences with contracting in which some coherent form of evaluation was carried out, using at least before and after, or controlled evaluation designs.

The economics of hospital reform from hierarchical to market-based incentives

by April Harding and Alexander Preker

World Hospitals and Health Services the Official Journal of the International Hospital Federation, Feb 1, 2005

Heavy investment over the past 30 years has made the hospital sector the largest expenditure cate... more Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. In most countries hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider 'of last resort' for the poor and critically ill. This article provides insights into recent hospital reforms undertaken throughout the world, with an emphasis on organisational changes such as increased management autonomy, corporatisation, and privatisation. It provides some insights about these popular reform modalities from a review of the literature, reform experiences in other sectors and empirical evidence from hospital sector itself. The material presented tries to answer three questions: (a) what problems did this type of reform try to address; (b) what are the core elements of their design, implementation and evaluation; and, (c) is there any evidence that this type of reform is successful in addressing problems for which they were intended? While this paper focuses on issues related to the design of the reforms, the paper also reports the findings from a larger study that examined the implementation and evaluation of such reforms so that they will be available to countries that are considering venturing down this reform path.

Private Sector Participation in Child Health A Review of World Bank Projects, 1993-2002

There is an increasing amount of evidence to support the view that the private sector significant... more There is an increasing amount of evidence to support the view that the private sector significantly influences child health and nutrition outcomes through both service provision and supply of health related goods. In this context, this paper analyzes World Bank projects in Health, Nutrition and Population between fiscal years 1993-2002. The paper identifies the range of approaches taken to involve the private sector in improving child health outcomes; the actors involved; the type of activities supported by the projects; and examples of successful private sector participation. The paper's conclusions and recommendations are outlined below.

A zebra or a painted horse? Are hospital PPPs infrastructure partnerships with stripes or a separate species?

World hospitals and health services : the official journal of the International Hospital Federation, 2012

Public Private Partnerships (PPP) have been common in infrastructure for many years and are incre... more Public Private Partnerships (PPP) have been common in infrastructure for many years and are increasingly being considered as a means to finance, build, and manage hospitals. However, the growth of hospital PPPs in the past two decades has led to confusion about what sorts of contractual arrangements between public and private partners consititute a PPP, and what key differences distinguish public private partnership for hospitals from PPPs for infrastructure. Based on experiences from around the world we indentify six key areas where hospital PPPs differ from infrastructure partnerships. We draw upon the hospital partnerships that have been documented in OECD countries and a growing number of middle-income countries to identify four distinct types of hospital PPPs: service focused partnerships in which private partners manage operations within publicly constructed facilities; facilities and finance PPPs, focused on mobilizing capital and creating new hospitals; combined PPPs, involv...

Can developing countries achieve adequate improvements in child health outcomes without engaging the private sector?

Bulletin of the World Health Organization, 2003

The private sector exerts a significant and critical influence on child health outcomes in develo... more The private sector exerts a significant and critical influence on child health outcomes in developing countries, including the health of poor children. This article reviews the available evidence on private sector utilization and quality of care. It provides a framework for analysing the private sector's influence on child health outcomes. This influence goes beyond service provision by private providers and nongovernmental organizations (NGOs). Pharmacies, drug sellers, private suppliers, and food producers also have an impact on the health of children. Many governments are experimenting with strategies to engage the private sector to improve child health. The article analyses some of the most promising strategies, and suggests that a number of constraints make it hard for policy-makers to emulate these approaches. Few experiences are clearly described, monitored, and evaluated. The article suggests that improving the impact of child health programmes in developing countries re...

The economics of hospital reform: from hierarchical to market-based incentives

World hospitals and health services : the official journal of the International Hospital Federation, 2003

Heavy investment over the past 30 years has made the hospital sector the largest expenditure cate... more Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. Despite shifts in attention and emphasis toward primary care as a first point of contact for patients, in most countries, hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider "of last resort" for the poor and critically ill. Although, it is clear that hospitals play a critical role in ensuring delivery of health services there is much less agreement about how to improve the efficiency and quality of care provided. This article reviews recent hospital reforms undertaken throughout the world, with an emphasis on organizational changes such as increased management autonomy (often referred to as autonomization) and corporatization. It provides some insights about these popular reform modalities from a review of the literature, ref...

Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

PLoS ONE, 2011

Background: In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor count... more Background: In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.

Make or buy" decisions in the production of health care goods and services: new insights from institutional economics and organizational theory

Bulletin of the World Health Organization, 2000

A central theme of recent health care reforms has been a redefinition of the roles of the state a... more A central theme of recent health care reforms has been a redefinition of the roles of the state and private providers. With a view to helping governments to arrive at more rational "make or buy" decisions on health care goods and services, we propose a conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector. Empirical evidence from actual production modalities is also taken into consideration. We conclude that most inputs for the health sector, with the exception of human resources and knowledge, can be efficiently produced by and bought from the private sector. In the health services of low-income countries most dispersed production forms, e.g. ambulatory care, are already provided by the private sector (non-profit and for-profit). These valuable resources are often ignored by the public sector. The problems of measurability and contestability associated with ex...

Buying results? Contracting for health service delivery in developing countries

The Lancet, 2005

Building trust or buying results? – Authors' reply

The Lancet, 2005

Building trust or buying results? Authors&amp;#x27; reply. By - Benjamin Loevinsohn, April ... more

Private Sector Participation in Child Health: A Review of World Bank Projects, 1993-2002

There is an increasing amount of evidence to support the view that the private sector significant... more There is an increasing amount of evidence to support the view that the private sector significantly influences child health and nutrition outcomes through both service provision and supply of health related goods. In this context, this paper analyzes World Bank projects in Health, Nutrition and Population between fiscal years 1993-2002. The paper identifies the range of approaches taken to involve the private sector in improving child health outcomes; the actors involved; the type of activities supported by the projects; and examples of successful private sector participation. The paper's conclusions and recommendations are outlined below.

Contracting for the delivery of community health services: a review of global experience

To achieve the health-related Millennium Development Goals, it will be necessary to improve the d... more To achieve the health-related Millennium Development Goals, it will be necessary to improve the delivery of health services, particularly to poor people. One proposed approach to improving both coverage and quality of care is to contract with NGOs or other non-state entities to deliver health services. This paper reviews experiences with contracting in which some coherent form of evaluation was carried out, using at least before and after, or controlled evaluation designs.

The economics of Public and Private Roles in Health care

The introduction of market force in public hospitals sector: from new public sector management to organizational reform

by Loraine Hawkins, April Harding, and Jones M

This Discussion Paper was prepared as a background document for the Hospital Reform Module of the... more This Discussion Paper was prepared as a background document for the Hospital Reform Module of the Joint Harvard/World Bank Institute Flagship Course on Health Sector Reform and Sustainable Financing. The Flagship course provides an practical review and update of current issues in health systems reform and financing for senior policy makers from developing countries. Since its inception, the Flagship course has reached more than 3,000 participants from over 50 countries. Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. Despite shifts in attention and emphasis toward primary care as a first point of contact for patients, in most countries, hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider "of last resort" for the poor and critically ill. Although, it is clear that hospitals play a critical role in ensuring delivery of health services there is much less agreement about how to improve the efficiency and quality of care provided. This Discussion Paper provides insights into recent hospital reforms undertaken throughout the world, with an emphasis on organizational changes such as increased management autonomy, corporatization, and privatization. It provides some insights about these popular reform modalities from a review of the literature, reform experiences in other sectors and empirical evidence from hospital sector itself. The material presented tries to answer three questions: (a) what problems did this type of reform try to address; (b) what are the core elements of their design, implementation and evaluation; and, (c) is there any evidence that this type of reform is successful in addressing problems for which they were intended? While this paper focuses on issues related to the design of the reforms, the paper also reports the findings from a larger study that examined the implementation and evaluation of such reforms so that they will be available to countries that are considering venturing down this reform path.

Institutions Matter

by Edit Velenyi and April Harding

Staying the Course, 2013

Public-Private Partnerships And Public Hospital Performance In Sao Paulo, Brazil

Health Affairs, 2009

Public hospitals that are directly managed by government perform poorly in many developing countr... more Public hospitals that are directly managed by government perform poorly in many developing countries. Approaches to improving them through internal managerial reforms have failed, and effective alternatives are much needed. Policymakers are considering reforms through public-private partnerships (PPPs)-a promising but so far unevaluated approach. We present results of a successful reform in São Paulo, Brazil. The PPP model gave facility managers latitude to manage human resources-a factor critical to success. Given the prevalence of direct management of public hospitals in developing countries, the São Paulo experience has implications for policymakers seeking to improve hospital performance.

Private participation in health services handbook

Contracting for the delivery of community health services: a review of global experience

To achieve the health-related Millennium Development Goals, it will be necessary to improve the d... more To achieve the health-related Millennium Development Goals, it will be necessary to improve the delivery of health services, particularly to poor people. One proposed approach to improving both coverage and quality of care is to contract with NGOs or other non-state entities to deliver health services. This paper reviews experiences with contracting in which some coherent form of evaluation was carried out, using at least before and after, or controlled evaluation designs.

The economics of hospital reform from hierarchical to market-based incentives

by April Harding and Alexander Preker

World Hospitals and Health Services the Official Journal of the International Hospital Federation, Feb 1, 2005

Heavy investment over the past 30 years has made the hospital sector the largest expenditure cate... more Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. In most countries hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider 'of last resort' for the poor and critically ill. This article provides insights into recent hospital reforms undertaken throughout the world, with an emphasis on organisational changes such as increased management autonomy, corporatisation, and privatisation. It provides some insights about these popular reform modalities from a review of the literature, reform experiences in other sectors and empirical evidence from hospital sector itself. The material presented tries to answer three questions: (a) what problems did this type of reform try to address; (b) what are the core elements of their design, implementation and evaluation; and, (c) is there any evidence that this type of reform is successful in addressing problems for which they were intended? While this paper focuses on issues related to the design of the reforms, the paper also reports the findings from a larger study that examined the implementation and evaluation of such reforms so that they will be available to countries that are considering venturing down this reform path.

Private Sector Participation in Child Health A Review of World Bank Projects, 1993-2002

There is an increasing amount of evidence to support the view that the private sector significant... more There is an increasing amount of evidence to support the view that the private sector significantly influences child health and nutrition outcomes through both service provision and supply of health related goods. In this context, this paper analyzes World Bank projects in Health, Nutrition and Population between fiscal years 1993-2002. The paper identifies the range of approaches taken to involve the private sector in improving child health outcomes; the actors involved; the type of activities supported by the projects; and examples of successful private sector participation. The paper's conclusions and recommendations are outlined below.

A zebra or a painted horse? Are hospital PPPs infrastructure partnerships with stripes or a separate species?

World hospitals and health services : the official journal of the International Hospital Federation, 2012

Public Private Partnerships (PPP) have been common in infrastructure for many years and are incre... more Public Private Partnerships (PPP) have been common in infrastructure for many years and are increasingly being considered as a means to finance, build, and manage hospitals. However, the growth of hospital PPPs in the past two decades has led to confusion about what sorts of contractual arrangements between public and private partners consititute a PPP, and what key differences distinguish public private partnership for hospitals from PPPs for infrastructure. Based on experiences from around the world we indentify six key areas where hospital PPPs differ from infrastructure partnerships. We draw upon the hospital partnerships that have been documented in OECD countries and a growing number of middle-income countries to identify four distinct types of hospital PPPs: service focused partnerships in which private partners manage operations within publicly constructed facilities; facilities and finance PPPs, focused on mobilizing capital and creating new hospitals; combined PPPs, involv...

Can developing countries achieve adequate improvements in child health outcomes without engaging the private sector?

Bulletin of the World Health Organization, 2003

The private sector exerts a significant and critical influence on child health outcomes in develo... more The private sector exerts a significant and critical influence on child health outcomes in developing countries, including the health of poor children. This article reviews the available evidence on private sector utilization and quality of care. It provides a framework for analysing the private sector's influence on child health outcomes. This influence goes beyond service provision by private providers and nongovernmental organizations (NGOs). Pharmacies, drug sellers, private suppliers, and food producers also have an impact on the health of children. Many governments are experimenting with strategies to engage the private sector to improve child health. The article analyses some of the most promising strategies, and suggests that a number of constraints make it hard for policy-makers to emulate these approaches. Few experiences are clearly described, monitored, and evaluated. The article suggests that improving the impact of child health programmes in developing countries re...

The economics of hospital reform: from hierarchical to market-based incentives

World hospitals and health services : the official journal of the International Hospital Federation, 2003

Heavy investment over the past 30 years has made the hospital sector the largest expenditure cate... more Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. Despite shifts in attention and emphasis toward primary care as a first point of contact for patients, in most countries, hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider "of last resort" for the poor and critically ill. Although, it is clear that hospitals play a critical role in ensuring delivery of health services there is much less agreement about how to improve the efficiency and quality of care provided. This article reviews recent hospital reforms undertaken throughout the world, with an emphasis on organizational changes such as increased management autonomy (often referred to as autonomization) and corporatization. It provides some insights about these popular reform modalities from a review of the literature, ref...

Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

PLoS ONE, 2011

Background: In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor count... more Background: In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home.

Make or buy" decisions in the production of health care goods and services: new insights from institutional economics and organizational theory

Bulletin of the World Health Organization, 2000

A central theme of recent health care reforms has been a redefinition of the roles of the state a... more A central theme of recent health care reforms has been a redefinition of the roles of the state and private providers. With a view to helping governments to arrive at more rational "make or buy" decisions on health care goods and services, we propose a conceptual framework in which a combination of institutional economics and organizational theory is used to examine the core production activities in the health sector. Empirical evidence from actual production modalities is also taken into consideration. We conclude that most inputs for the health sector, with the exception of human resources and knowledge, can be efficiently produced by and bought from the private sector. In the health services of low-income countries most dispersed production forms, e.g. ambulatory care, are already provided by the private sector (non-profit and for-profit). These valuable resources are often ignored by the public sector. The problems of measurability and contestability associated with ex...

Buying results? Contracting for health service delivery in developing countries

The Lancet, 2005

Building trust or buying results? – Authors' reply

The Lancet, 2005

Building trust or buying results? Authors&amp;#x27; reply. By - Benjamin Loevinsohn, April ... more

Private Sector Participation in Child Health: A Review of World Bank Projects, 1993-2002

There is an increasing amount of evidence to support the view that the private sector significant... more There is an increasing amount of evidence to support the view that the private sector significantly influences child health and nutrition outcomes through both service provision and supply of health related goods. In this context, this paper analyzes World Bank projects in Health, Nutrition and Population between fiscal years 1993-2002. The paper identifies the range of approaches taken to involve the private sector in improving child health outcomes; the actors involved; the type of activities supported by the projects; and examples of successful private sector participation. The paper's conclusions and recommendations are outlined below.

Contracting for the delivery of community health services: a review of global experience

To achieve the health-related Millennium Development Goals, it will be necessary to improve the d... more To achieve the health-related Millennium Development Goals, it will be necessary to improve the delivery of health services, particularly to poor people. One proposed approach to improving both coverage and quality of care is to contract with NGOs or other non-state entities to deliver health services. This paper reviews experiences with contracting in which some coherent form of evaluation was carried out, using at least before and after, or controlled evaluation designs.

The economics of Public and Private Roles in Health care

The introduction of market force in public hospitals sector: from new public sector management to organizational reform

by Loraine Hawkins, April Harding, and Jones M

This Discussion Paper was prepared as a background document for the Hospital Reform Module of the... more This Discussion Paper was prepared as a background document for the Hospital Reform Module of the Joint Harvard/World Bank Institute Flagship Course on Health Sector Reform and Sustainable Financing. The Flagship course provides an practical review and update of current issues in health systems reform and financing for senior policy makers from developing countries. Since its inception, the Flagship course has reached more than 3,000 participants from over 50 countries. Heavy investment over the past 30 years has made the hospital sector the largest expenditure category of the health system in most developed and developing countries. Despite shifts in attention and emphasis toward primary care as a first point of contact for patients, in most countries, hospitals remain a critical link to health care, providing both advanced and basic care for the population. Often, they are the provider "of last resort" for the poor and critically ill. Although, it is clear that hospitals play a critical role in ensuring delivery of health services there is much less agreement about how to improve the efficiency and quality of care provided. This Discussion Paper provides insights into recent hospital reforms undertaken throughout the world, with an emphasis on organizational changes such as increased management autonomy, corporatization, and privatization. It provides some insights about these popular reform modalities from a review of the literature, reform experiences in other sectors and empirical evidence from hospital sector itself. The material presented tries to answer three questions: (a) what problems did this type of reform try to address; (b) what are the core elements of their design, implementation and evaluation; and, (c) is there any evidence that this type of reform is successful in addressing problems for which they were intended? While this paper focuses on issues related to the design of the reforms, the paper also reports the findings from a larger study that examined the implementation and evaluation of such reforms so that they will be available to countries that are considering venturing down this reform path.