Public-Private Mix

Changes in utilization of health services among poor and rural residents in Uganda: Are reforms benefitting the poor?
Pariyo GW, Ekirapa-Kiracho E, Okui O, Rahman MH, Peterson S, Bishai DM, Lucas H and Peters DH: International Journal for Equity in Health 8(39), 12 November 2009

This paper describes the changes in utilisation of health services that occurred among the poor and those in rural areas in Uganda between 2002/3 and 2005/6 and associated factors. Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset-based index derived from principal components analysis (PCA). The study found that the rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access. The risk of not seeking care due to high costs did not change significantly. Poor people, females, rural residents and those from elderly headed households were more likely to use public facilities relative to private for-profit (PFP) providers. Although overall utilisation of public and private not-for-profit (PNFP) services by rural and poor populations had increased, PFP providers remained the major source of care. Policy makers should consider targeting subsidies to the poor and rural populations. Public-private partnerships should be broadened to increase access to health services among the vulnerable.

Changing roles - responding to health sector transformation in developing countries

Many low and middle-income countries (LMICs) have experienced changes in the provision of healthcare services. Services are now provided by a variety of sources under market conditions. In response to this shift, how have the roles of healthcare providers changed? How have households adapted to these changes in order to meet their health needs? What should governments do to provide good healthcare in these conditions? Research by the UK's Institute of Development Studies highlights that over the last few decades there have been profound changes in the ways that health goods are produced and consumed in LMICs. This change is due to economic and political factors, such as crises in public sector financing and governance, that have reduced governments’ capacity to fund infrastructure, supplies and salaries and competently manage healthcare. The result in many countries is that it is difficult to maintain the distinction between public and private in the health sector.

Civil society health caucus at the WSSD

The Civil society health caucus at the WSSD Global Forum hosted a Commission to discuss the Role of the of the state and water, sanitation and primary health care in the context of globalisation. The discussion included analysis of the situation which raised the following points.

• Debt and globalisation impact negatively on the distribution of all resources, including environment and health through their destruction and privatization.
• Environmental degradation increases the burden of ill health
• Lack of knowledge about environment and health and hygiene are sorely lacking amongst many citizens, especially children.
• Environmental services are a basic right which every citizen should enjoy
• Privatisation of services, including through public private partnerships, has been a very negative experience for many poor people, especially women and children, in countries as diverse as the UK and Argentina
• War and military occupation both severely restrict access to health and basic services, and conflict and psychological stress are also increasingly a result of struggles for access to these services.

Further details: /newsletter/id/29330
Clinical social franchising: An annual compendium of programmes, 2009
Global Health Group: 2009

Social franchising is argued to be a way of rapidly scaling up clinical health interventions in developing countries. Building upon existing expertise in poor and isolated communities, social franchising organisations engage private medical practitioners to add new services to the range of services they already offer. Specific examples are provided, such as the Confiance programme in the Democratic Republic of the Congo that provides a toll-free hotline for answering family planning-related questions and making referrals. It is reported to have been effective in addressing family planning concerns raised by men. This paper argues that standardisation, quality monitoring and scalability make social franchising one platform for the expansion and improvement of a wide range of medical services.

Closing the access barrier for effective antimalarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study
Talisuna AO, Daumerie P, Balyeku A, Egan T, Piot B, Coghlan R et al:Malaria Journal 11(356), 29 October 2012

Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to artemisinin-based combination therapy (ACT) for malaria in the private sector could be improved through the provision of a high level supply chain subsidy. Four intervention districts were purposefully selected to receive branded subsidised medicines, while the fifth district acted as the control. Researchers analysed the intervention's impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial. At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, it accounted for 69 % of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8 % at baseline to 26.2 % at evaluation in the intervention districts. These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.

Combatting Substandard and Falsified Medicines: A View from Rwanda
Binagwaho A, Bate R, Gasana M, Karema C, Mucyo Y, Mwesigye JP et al: PLOS Medicine 10(1371), 2 July 2013

Substandard and falsified medicines are major global health challenges that cause unnecessary morbidity and mortality around the world and threaten to undermine recent progress against infectious diseases by facilitating the emergence of drug resistance. According to this study, Rwanda has the lowest prevalence of poor quality tuberculosis drugs among African countries. This positive finding may be associated with Rwanda's efforts to ban the sale of monotherapies, ensure that private sellers of important medicines are qualified, and prioritise the prevention of falsified medicines entering the country, the authors argue. As policymakers in, and researchers of, Rwanda's health sector, they argue that the improvement of the country's supply chain and drug surveillance systems, combined with equity-oriented strategies for increasing geographic and financial access to high quality drugs through the public sector, has played an important role in the country's steep declines in mortality due to tuberculosis and malaria. In scaling up pharmacovigilance for malaria and tuberculosis, they call for a global treaty and leadership by the World Health Organisation to address manufacturing and trade in substandard and falsified medicines.

Commercialisation and Globalisation of Health Care: Lessons from UNRISD Research
United Nations Research Institute for Social Development, Social Policy and Development, December 2007

Using market mechanisms in the provision of health services and seeing health care as a private good are approaches that have featured prominently in health sector reforms across the world. The UNRISD research on global and local experiences of health care commercialization challenges this framework. It calls for reclaiming public policies that promote the purposes that health systems are set up to serve: population health and the provision of care for all according to need.

Commission hears data on WHO report on high price of hospital care in SA
Pitso R: BusinessDay, August 2016

The South African Competition Commission’s healthcare market enquiry on Tuesday convened a special session in Pretoria, at which stakeholders were due to give oral presentations in response to a report by the World Health Organisation (WHO). The report, contested by the private actors, concluded that the cost of hospital care in SA was high when measured against GDP per capita and that the driving forces were in-house hospital and specialist fees. The Organisation for Economic Co-operation and Development (OECD) collected the data and conducted the study, which compared the prices of South African private hospitals to those of 20 OECD countries. The health market inquiry was established to determine why medical inflation has historically risen faster than consumer price inflation, and whether there are barriers to effective competition in the private healthcare sector. The public hearings aim to explore the relationships among different players.

Common Declaration for Responsible Partnerships
International Forum on Public-Private Partnerships for Sustainable Development, December 2015

In the context of the 2015 Paris Climate Conference, COP 21, an International Forum on Public-Private Partnerships (PPPs) for Sustainable Development has been held in Annemasse. Within this framework and in view of the Sustainable Development Goals defined by the UN, the Cité de la Solidarité Internationale organised on October 30 2015 a collective intelligence workshop gathering representatives from the civil society as well as public and private stakeholders. The assembly called for PPPs that guarantee access for all to common goods and the respect of Human Rights to foster an economy of human dimension. They recommended to: Include the civil society in the entire process of public-private partnerships, upstream to downstream, by identifying the genuine needs, promoting the general interest as the final goal and avoiding conflict of interest and controlling the services of which they are the main beneficiaries. They argued that it is necessary to create a legal framework and appropriate tools to strengthen civil society legitimacy, to guarantee co-construction of equal win partnerships with general interest as a common objective to avoid an unbalanced or competitive approach and to consider alternative approaches and initiatives of collaboration (such as social and solidarity-based economy) as an evolution towards more balanced and inclusive partnerships favouring a participatory democracy.

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?
Shah NM, Wang W and Bishai DM: Health Policy and Planning 26:163–171, March 2011

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. The authors of this paper propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. They applied this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing independent private sector providers; social franchises of private providers; non-government organisation (NGO) providers; and government providers on these three factors. They found that franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. These results suggest that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific, the authors conclude.

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