Public-Private Mix

Delivering on the Global Partnership to achieve the Millennium Development Goals
MDG Gap Task Force, 2008

The UN Secretary-General’s report ‘Delivering on the Global Partnerships for Achieving the Millennium Development Goals’ highlights large gaps in the availability of medicines in the public and private sectors, as well as a wide variation in prices which render essential medicines unaffordable to poor people. The report describes progress towards achieving MDG8 (develop a global partnership for development) and its related targets in the areas of essential medicines, official development assistance, trade, external debt and technology. In cooperation with pharmaceutical companies, access to affordable essential medicines in developing countries was measured using nine indicators and data collected by WHO and its partners. The report found that, in the public sector, generic medicines are only available in 34.9% of facilities, at on average cost 250% more than the international reference price. In the private sector, those same medicines are available in 63.2% of facilities, but cost about 650% more than the international reference price. While policies that promote access such as generic substitution are in place in many countries, more national and international effort is needed to improve the availability and affordability of medicines.

Developing countries and the private sector: What chances for improving child health?

The private sector exerts a significant and critical influence on child health outcomes in developing countries. This article in the Bulletin of the World Health Organisation reviews the available evidence on private sector utilisation and quality of care. It provides a framework for analysing the private sector's influence, extending its analysis to include nongovernmental organisations (NGOs), pharmacies, drug sellers, private suppliers, and food producers. The article analyses some of the most promising strategies for improving child health, and suggests a number of possible constraints to emulating these approaches more widely. The article suggests that improving the impact of child health programmes in developing countries requires a more systematic analysis of the presence and potential of the private sector, including actors such as professional associations, producer organisations, community groups, and patients' organisations.

Diamond mining giant faces challenges to its voluntary counselling and testing (VCT) programme
PlusNews: 7 November 2008

On paper, South Africa has some of the world's best HIV workplace programmes, but on the ground they just aren't adding up. Diamond mining giant De Beers has long boasted that 86% of employees at its six mines have been tested by its voluntary counselling and testing (VCT) programme. The company estimates that 10% of its workforce is HIV-positive, but markedly fewer access the antiretroviral (ARV) treatment programme. Workers' fears about confidentiality, a preference for traditional medicine and poor patient-doctor communication were all cited as challenges to raising treatment numbers, according to an ongoing study by De Beers. The research was presented by the company and the University of KwaZulu-Natal (UKZN) on 6 November at the Private Sector Conference on HIV and AIDS, hosted by the South African Business Coalition on HIV and AIDS (SABCOHA).

Differences in essential newborn care at birth between private and public health facilities in eastern Uganda
Waiswa P; Akuze J; Peterson S; Kerber K; Tetui M; Forsberg BC; Hanson C: Global Health Action 8(10), March 2015, doi: 10.3402/gha.v8.24251

In Uganda and elsewhere, the private sector provides an increasing and significant proportion of maternal and child health services. However, little is known whether private care results in better quality services and improved outcomes compared to the public sector, especially regarding care at the time of birth. This study described the characteristics of care-seekers and assess newborn care practices and services received at public and private facilities in rural eastern Uganda. The authors collected data from mothers with infants at baseline and endline using a structured questionnaire among private and public health facilities. Private health facilities did not perform significantly better than public health facilities in terms of coverage of any essential newborn care interventions, and babies were more likely to receive thermal care practices in public facilities compared to private (68% compared to 60%). Babies born at public health facilities received an average of 7.0 essential newborn care interventions compared to 6.2 at private facilities. Women delivering in private facilities were more likely to have higher parity, lower socio-economic status, less education, to seek antenatal care later in pregnancy, and to have a normal delivery compared to women delivering in public facilities. In this setting, private health facilities serve a vulnerable population and provide access to service for those who might not otherwise have it. However, provision of essential newborn care practices was slightly lower in private compared to public facilities, calling for quality improvement in both private and public sector facilities, and a greater emphasis on tracking access to and quality of care in private sector facilities.

Disintegrated care: The Achilles heel of international health policies in low and middle-income countries
Unger J-P, De Paepe P, Ghilbert P, et al: Journal of Integrated Care 6, 2006

Current international aid policy is largely neoliberal in its promotion of commoditization and privatisation. This paper reviews this policy's responsibility for the lack of effectiveness in disease control and poor access to care in low and middle-income countries. The paper documents how health care privatisation has led to the pool of patients being cut off from public disease control interventions—causing health care disintegration—which in turn resulted in substandard performance of disease control. Privatisation of health care also resulted in poor access. Our analysis consists of three steps. Pilot local contracting-out experiments are scrutinized; national health care records of Colombia and Chile, two countries having adopted contracting-out as a basis for health care delivery, are critically examined against Costa Rica; and specific failure mechanisms of the policy in low and middle-income countries are explored. The paper concludes by arguing that the negative impact of neoliberal health policy on disease control and health care in low and middle-income countries justifies an alternative aid policy to improve both disease control and health care.

Do financial contributions from ‘pharma’ violate WHO Guidelines?
Gopakumar K: Third World Network (TWN) Info Service on Health Issues Dec 15(01), December 2015

Millions of dollars given by major pharmaceutical companies to the World Health Organisation (WHO) raise questions of compliance with the organisation’s guidelines on interactions with commercial enterprises. Currently, WHO’s relations with commercial enterprises are guided by the “Guidelines on interaction with commercial enterprises to achieve health outcomes” . The 107th Session of the Executive Board in 2001 “noted” the Guidelines that cover cash donations, contributions in kind, seconded personnel, collaboration for product development, collaboration for meetings etc. Compliance with the Guidelines has essentially been left to the Secretariat. According to paragraph 11 of the Guidelines, “Commercial enterprises working with WHO will be expected to conform to WHO public health policies in the areas of food safety, chemical safety, ethical promotion of medicinal drug products, tobacco control, and others”. It is notable that the draft Framework of Engagement with Non-State Actors (FENSA) currently being finalised by WHO Member States does not contain a provision that requires a commercial enterprise to conform to WHO’s polices, norms and standard. In the absence of such a clear provision FENSA could legitimise engagement with the private sector, which does not follow WHO’s policies in the areas of food safety, chemical safety, ethical promotion of medicinal drug products, tobacco control, and others. WHO Member States at the resumed session of the Open Ended Intergovernmental Meeting (OEIGM) on FENSA is expected to look at the regulation of WHO’s engagement with the private sector. The experience with the implementation of the Guidelines on interaction with commercial enterprises to achieve health outcomes would be useful for the consideration of Member States. In 2014, WHO received USD 6,158,153 from GlaxoSmithKline (GSK). It received USD 5,785,000 and USD 8,266,284 in 2012 and 2013 respectively from GSK. GSK Biologics paid USD 17,000. Novartis AG donated USD 5,300,000 in 2014 and USD 4,500,000 in 2013. Hoffmann-La Roche donated USD 6,158,153 in 2014 and USD 4,806,492 in 2013. The purposes of those donations were not disclosed.

Does anti-malarial drug knowledge predict anti-malarial dispensing practice in drug outlets? A survey of medicine retailers in western Kenya
Rusk A, Smith N, Menya D, Obala A, Simiyu C, Khwa-Otsyula B and O'Meara W: Malaria Journal 11:263, 6 August 2012

To investigate medicine retailer knowledge about anti-malarials and their dispensing practices, a survey was conducted of all retail drug outlets that sell anti-malarial medications and serve residents of the Webuye Health and Demographic Surveillance Site in the Bungoma East District of western Kenya. Results indicated that most (65%) of the medicine retailers surveyed were able to identify artemether-lumefantrine (AL) as first-line anti-malarial therapy for uncomplicated malaria recommended by the Kenyan Ministry of Health. Retailers who correctly identified this treatment were also more likely to recommend AL to adult and paediatric customers. Retailer training and education were found to be correlated with anti-malarial drug knowledge, which in turn was correlated with dispensing practices. While the Kenya Ministry of Health (MoH) guidelines were found to influence retailer drug stocking and dispensing behaviours, the authors argue that knowing the MoH recommended anti-malarial medication does not always ensure it is recommended or dispensed to customers. Retailer training and education are both areas that could be improved. Considering the influence that patient demand has on retailer behaviour, future interventions focusing on community education may positively influence appropriate dispensing of anti-malarials.

Does contracting-out improve health services?

This paper, produced by Partnerships for Health Sector Reform/plus, discusses the effectiveness of contracting out primary care services as a tool for health reform. The paper provides a short history of contracting out, a discussion of its advantages and disadvantages, and a review of the available literature on the impact of contracting out. The authors note that there is a lack of evaluation research on the success of contracting-out, and a lack of conclusive evidence that contracting out improves overall health sector efficiency.

Does duty call? Contracts and GPs in South Africa

Some experts argue that private healthcare providers are preferred by service-users, or are more efficient or accessible than the public sector, and hence that government should contract out services to them. However, factors such as institutional capacity to write and manage contracts and market competition affect how contracts with private providers function. This has major implications for contracting in low and middle-income countries (LMICs). Research by the London School of Hygiene and Tropical Medicine explored the operation of a long-standing contract with private GPs in South Africa.

Does Ownership Matter? An Overview of Systematic Reviews of the Performance of Private For-Profit, Private Not-For-Profit and Public Healthcare Providers
Herrera CA, Rada G, Kuhn-Barrientos L, Barrios X: PLoS ONE 9(12), 1 December 2014

Ownership of healthcare providers has been considered as one factor that might influence their health and healthcare related performance. The authors provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers -namely public, private non-for-profit (PNFP) and private for-profit (PFP)- based on the findings of systematic reviews (SR). Of the 5918 references reviewed, fifteen SR were included, but six of them were rated as having major limitations, so they weren't incorporated in the analyses. According to the nine analysed SR, ownership does seem to have an effect on health and healthcare related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of mortality of patients and payments to facilities have been found, both being higher in PFP facilities. In terms of quality and economic indicators such as efficiency, there are no conclusive results. When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found. PFP providers seem to have worst results than their PNFP counterparts, but there are still important evidence gaps in the literature that needs to be covered, including the comparison between public and both PFP and PNFP providers. More research is needed in low and middle income countries to understand the impact on and development of healthcare delivery systems.