Public-Private Mix

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.

Competing for business? Improving hospital services in Zambia with market forces

Does competition improve hospital services? Do market forces in healthcare benefit the poorest members of society? Reforms which involve exposing hospitals to market forces are being introduced in many developing countries. However, very little is known about how these markets operate, particularly in developing countries. The University of Zambia, together with the London School of Hygiene and Tropical Medicine, considered the effect of competition among hospitals in Zambia. The study concludes that there is potential for competition in the hospital market to have beneficial effects in terms of prices, quality and efficiency. However, there is also the risk that faced with this competition, hospitals will be less able to charge private prices which allow them to cross-subsidise public patients.

Competing for business? Improving hospital services in Zambia with market forces

Does competition improve hospital services? Do market forces in healthcare benefit the poorest members of society? Reforms which involve exposing hospitals to market forces are being introduced in many developing countries. However, very little is known about how these markets operate, particularly in developing countries. The University of Zambia, together with the London School of Hygiene and Tropical Medicine, considered the effect of competition among hospitals in Zambia. The study examined hospitals in Lusaka, Central and Copperbelt provinces. Data on hospital use, revenues and expenditure, and charges for services were collected for the period 1996 to 1999 from each hospital using routine hospital records. In addition, a patient questionnaire was used in facilities to elicit patients’ views of the quality of services. As well as private for-profit and mine hospitals (facilities operated by the mining industry), "private" services included the private fee-paying services provided in government hospitals (known in Zambia as "high cost" services").

Competition Commission may probe healthcare
Visser A: Business Day, 30 December 2011

South Africa’s Competition Commission is considering initiating a market inquiry into the private healthcare industry reminiscent of its probe into the banking sector a few years ago, which recommended lower banking costs. Health Minister Aaron Motsoaledi has condemned high healthcare costs and accused the private health sector of engaging in "uncontrolled commercialism" and "destructive, unsustainable practices". Tembinkosi Bonakele, deputy commissioner of the Competition Commission, said that the commission was "likely" to commence with an inquiry because of growing concern about the high cost of private healthcare and the effect this had on the public healthcare system.

Conceptualising the impacts of dual practice on the retention of public sector specialists - evidence from South Africa
Ashmore J; Gilson L: Human Resources for Health 13(3), 2015,

‘Dual practice’, or multiple job holding, generally involves public sector-based health workers taking additional work in the private sector. This form of the practice is purported to help retain public health care workers in low and middle-income countries’ public sectors through additional wage incentives. There has been little conceptual or empirical development of the relationship between dual practice and retention. This article helps begin to fill this gap, drawing on empirical evidence from a qualitative study focusing on South African specialists. Fifty-one repeat, in-depth interviews were carried out with 28 doctors (predominantly specialists) with more than one job, in one public and one private urban hospital. Findings suggest dual practice can impact both positively and negatively on specialists’ intention to stay in the public sector. This is through multiple conceptual channels including those previously identified in the literature such as dual practice acting as a ‘stepping stone’ to private practice by reducing migration costs. Dual practice can also lead specialists to re-evaluate how they compare public and private jobs, and to overworking which can expedite decisions on whether to stay in the public sector or leave. Numerous respondents undertook dual practice without official permission. The idea that dual practice helps retain public specialists in South Africa may be overstated. Yet banning the practice may be ineffective, given many undertake it without permission in any case. Regulation should be better enforced to ensure dual practice is not abused. The conceptual framework developed in this article could form a basis for further qualitative and quantitative inquiry.

Conceptualizing the impacts of dual practice on the retention of public sector specialists - evidence from South Africa
Ashmore J, Gilson L: Human Resources for Health 13:3, 2015

Dual practice or multiple job holding, generally involves public sector-based health workers taking additional work in the private sector. This form of the practice is purported to help retain public health care workers in low and middle-income countries’ public sectors through additional wage incentives. There has been little conceptual or empirical development of the relationship between dual practice and retention. This article helps begin to fill this gap, drawing on empirical evidence from a qualitative study focusing on South African specialists. Fifty-one repeat, in-depth interviews were carried out with 28 doctors (predominantly specialists) with more than one job, in one public and one private urban hospital. Findings suggest dual practice can impact both positively and negatively on specialists’ intention to stay in the public sector. This is through multiple conceptual channels including those previously identified in the literature such as dual practice acting as a ‘stepping stone’ to private practice by reducing migration costs. Dual practice can also lead specialists to re-evaluate how they compare public and private jobs, and to overworking which can expedite decisions on whether to stay in the public sector or leave. Numerous respondents undertook dual practice without official permission. The idea that dual practice helps retain public specialists in South Africa may be overstated. Yet banning the practice may be ineffective, given many undertake it without permission in any case. Regulation should be better enforced to ensure dual practice is not abused. The conceptual framework developed in this article could form a basis for further qualitative and quantitative inquiry.

Concern over role of private sector in policy development
Conflict of Interest Coalition: February 2012

In this Statement of Concern, the Conflict of Interest Coalition calls for the development of a Code of Conduct and Ethical Framework to guide private sector involvement in public health policy development. The Coalition seeks clarity on the nature of recent government ‘partnerships’ with the private sector, and argues that public-private partnerships run the risk of counteracting efforts to protect and improve public health. The proposed framework should help protect the integrity of the United Nations’ public policy decision-making, to ensure it is transparent and to identify, safeguard against and manage potential conflicts of interest. The Statement argues that a clear distinction must be made between business-interest not-for-profit organisations (BINGOs) and public interest non-governmental organisations (PINGOs) and a clear differentiation between policy and norms and standards development and appropriate involvement in implementation. The Coalition calls on the World Health Organisation (WHO) to develop guidance for Member States to identify conflicts and eliminate those that are not permissible. WHO should perform thorough risk/benefit analyses on partnerships and provide surveillance on those considered acceptable.

Conflicts of interest and global health and nutrition governance - The illusion of robust principles
Richter J: BMJ, doi: http://dx.doi.org/10.1136/bmj.g5457, 2015

This is a response to a BMJ paper 'Do the solutions for global health lie in healthcare?' where in the run-up to the Second International Conference on Nutrition (ICN2), the author warned against downplaying the fundamental differences between the commercial interests of multinational food companies and those of public sector agencies. If public health officials do not acknowledge the divergent interests, he suggested, they risk harming their public health mission, institutional integrity and ultimately public trust. In the response, the author suggests that the current discourse ignores the problem of involving food transnational corporations in public decision-making processes, acceptance of funds and resources in the name of partnership or stakeholder engagement. The trend to increase such engagement reduces and almost eliminates public policy spaces without corporations. The author argues that that robust, comprehensive conflict of interest safeguards do not exist with respect to global food and nutrition governance. This obscures the fact that conflicts of interest are an important legal concept and that establishing conflict of interest policies are an integral part of UN agencies’ duty to establish the Rule of Law.

Conflicts of interest within philanthrocapitalism
Global Health Watch: 2012

This chapter from Global Health Watch 3 explores the origins of philanthrocapitalism and addresses its increasing influence on global health governance and decision-making. It examines the functioning and priorities of the Bill and Melinda Gates Foundation in order to explore how the alignment of corporate interests and philanthropic investment may be having adverse effects on health policy. It looks at the efforts of the proponents of philanthrocapitalism to challenge progressive tax measures that could generate government revenues earmarked for global health. Finally, the chapter suggests that a focus on conflicts of interest could be a useful starting point for the mobilisation of health specialists who are concerned about the influence of the Gates Foundation on health policy, but who have thus far had difficulty, as a result of the immense scale of the Foundation’s influence, in highlighting some of its controversial policies. Global Health Watch cautions against the new philanthropy’s core idea that private-sector investment fills the void left by cash-strapped governments. A key objective for health activists could be highlighting the ways in which government revenues are strapped through private-sector support and through a reluctance to embrace tax measures that are disparaged by philanthropists who purport to be operating outside the realm of politics.

Considering domestic manufacturing issues
Wanyanga, WO

This report - presented at the African Civil Society Meeting of the Intergovernmental Working Group on Intellectual Property, Innovation and Health in Nairobi, Kenya, 28-29 August 2007 - found that there are over 30 registered local manufacturers in Kenya and at least two others under construction (foreign investments). It also analysed seven private-private partnership (PPP) projects (six in Kenya & one in Tanzania). The first PPP project passed its first inspection in August 2007 and the others are due for inspection by the end of the project. The main outcome of the report was that intellectual property rights do not stimulate research and development for medicines for diseases prevalent in developing countries simply because the market in poor countries is considered to be too small or too uncertain.

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