Public-Private Mix

Contracting out: the case of primary care in South Africa

Contracts can be used to govern the relationship between the public and the private sectors where the private sector delivers services on behalf of the state. On occasion, this allows the state to offer services such as basic medical provision where public sector provision does not reach. Researchers examine the case of primary care in South Africa where such contracts are being utilised. They argue that understanding the relationship between client and contractor requires a thorough understanding of some of the factors that govern the relationship, such as the role played by individual motivation.

Council for Medical Schemes Annual Report 2012
South African Council for Medical Schemes: 2012

In this annual report, the South African Council for Medical Schemes details its support for the Department of Health in its efforts to strategically review the entire health system of South Africa. Council provided input to the technical sub-committees of the Ministerial Advisory Committee on the proposed National Health Insurance (NHI) system, and submitted a formal document on the NHI policy paper. Ever-escalating costs in the industry, which are driven by private hospitals and medical specialists, have always been one of Council’s concerns, and this financial year proved no different. This worrying trend of inflation-exceeding price increases in the private health sector has serious and negative implications for the well-being and sustainability of the entire health system. Council therefore continued to motivate for the establishment of a regulator to oversee the price determination of private healthcare provision. Council believes that a real need exists for a platform where medical schemes and healthcare providers can meet and negotiate prices for the benefit of all South African consumers. Private healthcare providers should also be regulated, specifically the hospitals and specialists. The practice where beneficiaries are exposed to unfair billing practices must be addressed.

Counting the cost of HIV in Southern Africa

Southern Africa is the region with the highest rates of HIV infection in the world. An estimated 9.4 million of the total population of 97 million were HIV-positive in 1999. What impact will the HIV/AIDS epidemic have on the provision of health services in the region? Is there any scope for improving access to highly active antiretroviral therapy (HAART) in low-income countries? A study by the International Monetary Fund warns that health services in southern Africa are already over-stretched. The current cost of providing health services to HIV patients accounts for a very large proportion of total health expenditure for most countries in the region. As the number of AIDS patients increases, the situation will deteriorate.

Criteria for evaluating evidence on public health interventions

Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.

Criteria for evaluating evidence on public health interventions

L Rychetnik, M Frommer, P Hawe and A Shiell
Public health interventions tend to be complex, programmatic, and context dependent. The evidence for their effectiveness must be sufficiently comprehensive to encompass that complexity. This paper asks whether and to what extent evaluative research on public health interventions can be adequately appraised by applying well established criteria for judging the quality of evidence in clinical practice. It is adduced that these criteria are useful in evaluating some aspects of evidence. However, there are other important aspects of evidence on public health interventions that are not covered by the established criteria. The evaluation of evidence must distinguish between the fidelity of the evaluation process in detecting the success or failure of an intervention, and the success or failure of the intervention itself. Moreover, if an intervention is unsuccessful, the evidence should help to determine whether the intervention was inherently faulty (that is, failure of intervention concept or theory), or just badly delivered (failure of implementation). Furthermore, proper interpretation of the evidence depends upon the availability of descriptive information on the intervention and its context, so that the transferability of the evidence can be determined. Study design alone is an inadequate marker of evidence quality in public health intervention evaluation.

Critique of Oxfam paper inaccurate, unconstructive and ideologically biased
Stocking B: 7 April 2009

A primary objective of Oxfam’s new paper ‘Blind optimism’ is to encourage and advance an evidence-based debate on the appropriate role of the private sector in health care delivery in poor countries. Montagu’s response detracts from this important debate by misrepresenting the paper. Oxfam advises against investing in risky and unproven private -sector approaches to expand health care in poor countries. It is not the same as advocating that all engagement with the private sector should cease. Unchallenged enthusiasm for private sector solutions is neither justified nor helpful. Based on the evidence available, there is an urgent need for more honesty about the significant risks to efficiency and equity associated with private sector growth in health care, and more openness about the paucity of comprehensive evaluations of private sector approaches and the lack of evidence that these approaches can be scaled up properly.

CSOs voice concerns over corporate takeover of WHO
Raja K: Third World Resurgence, 298/299, 35-37, 2015

At the World Health Assembly in May, civil society organisations criticised the rich countries for refusing an increase in their assessed contributions to WHO and opposing actions by the agency which would be contrary to the interests of their corporations. THE Framework for Engagement with Non-State Actors (FENSA), initiated to safeguard the independence, integrity and credibility of the World Health Organisation (WHO), now seems to bear the threat of facilitating and legitimising corporate capture of the organisation, civil society groups have charged. 'Many proposals by rich countries in draft FENSA text [are] promoting corporate capture of WHO in the name of promotion of engagements without discussion on any comprehensive mechanism to avoid conflict of interest. These proposals, if accepted, would institutionalise the undue corporate influence on WHO,' said Lida Lhotska of the International Baby Food Action Network (IBFAN) in a press release. Over the last 20 years, the proportion of WHO's budget which is met through mandatory assessed contributions has fallen from 75% to 20%. This is a consequence of continuing new functions being added to the organisation and a continuing freeze on assessed contributions. The remaining 80% is met by voluntary donations, including from the rich countries, the World Bank and the Bill & Melinda Gates Foundation.

Current climate and prospects in Africa for Private-Public Partnerships in Health
Kistnasamy B: Network for Africa: Public-Private Linkages for Health, 7-10 May 2008

It is a myth that health in Africa is financed primarily by the public sector. About 36% of funding in Africa is from out-of-pocket payments, with 7% from other private sources and 27% from donors. Only 30% of African health care funding is public funding. In addition, 32% of healthcare access for rural Africans comes from the private sector, and 46% of doctors in sub-Saharan Africa work in the private sector. The for-profit private sector provides significant care for sub-Saharan Africans, across income groups, and this is expected to double by 2016. Since there are not enough resources in the public sector and governments cannot rely forever on development partners (donors) funds, Public/private partnership can help expand the pool of human resources.

Davos calls for greater investment in disease prevention for children
World Economic Forum: January 2011

During a World Economic Forum held from 26-29 January 2011 in Davos, Switzerland a panel discussion was held on children’s health, the first in the history of the Forum. The panel included World Health Organization Director-General, Margaret Chan, who called for universal access to vaccines for preventable diseases, insecticide-treated bed nets for all children living in malaria zones and proper and balanced nutrition for children. It also included Melinda Gates from the Gates Foundation, who called for greater investment in women and frontline health workers, such as community health workers, as well as universal vaccine access for all children. The panel included a number of speakers from the private sector, such as Muhtar A. Kent, Chairman of the Board and Chief Executive Officer, Coca-Cola Company, USA; Lars Rebien Sorensen, President and Chief Executive Officer, Novo Nordisk, Denmark who raised some examples of how product innovation can respond to health needs. While there was pressure for private sector involvement in improving child health globally, there was also critique of insufficient product innovation to make food and other products less harmful to child health; that industry voice and influence in political circles is stronger than that of people working with child health; that cuts to financing of social services are having a negative effect on child health; and the question was asked: "Can we have healthy children without healthy labour conditions and healthy wages?"

Defend the World Health Organization from corporate takeover
People’s Health Movement, 18 May 2015

Ahead of the first meeting of the drafting group on Framework for Engagement with Non – State Actors (FENSA), Civil Society Organisations and Social Movements expressed their deep concern on perceived attempts to facilitate a corporate takeover of WHO. The joint statement signed by over 40 organisations called on WHO member states to take such time as is necessary to achieve a robust framework for engagement with non-state actors, to protect the WHO from undue influence. Further, the statement also called on member states to support the director general's proposals to increase the assessed contributions. The framework was initiated to safeguard the independence, integrity and credibility of WHO, but the organisations have a strong apprehension that the negotiations on FENSA may fundamentally alter the influence of the private sector and philanthropic foundations and NGOS sponsored by the private sector in a manner that compromises the credibility of WHO.

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