Public-Private Mix

Investing in health R&D: where we are, what limits us, and how to make progress in Africa
Simpkin V; Namubiru-Mwaura E; Clarke L; et al: BMJ Global Health 4(2), doi:, 2019

Global research and development (R&D) pipelines for diseases that disproportionately affect African countries appear to be inadequate, with governments struggling to prioritise investment in R&D. This article provides insights into the sources of investment in health science research, available research capacity and level of research output in Africa. Africa has 15% of the world’s population, yet only accounted for 1.1% of global investments in R&D in 2016. There were substantial disparities within the continent, with Egypt, Nigeria and South Africa contributing 65.7% of the total R&D spending. In most countries of the Organisation for Economic Co-operation and Development, the largest source of R&D funding is the private sector. R&D in Africa is mainly funded by the public sector, with significant proportions of financing in many countries coming from international funding. Challenges that limit private sector investment include unstable political environments and poor governance practices. Evidence suggests various research output and research capacity limitations in Africa in terms of university rankings, number of researchers, number of publications, clinical trials networks and pharmaceutical manufacturing capacity and substantial regional disparities within the continent. The authors propose that incentivising investment is crucial to foster current and future research output and research capacity. This paper outlines some of the initiatives under way for this, including through innovative and collaborative financing mechanisms that stimulate further investment.

New dispensing structure 'needs attention'
IOL, 16 May 2006

Aspects of the proposed new dispensing-fee structure for pharmacists need more attention, the Pharmaceutical Stakeholders Forum (PSF) said on Tuesday. These included the recent impact analysis of the proposed dispensing fee on community pharmacies, said PSF coordinator Ivan Kotze. The PSF made the comment in a submission on Monday to the Pricing Committee - appointed by Health Minister Manto Tshabalala-Msimang under the Medicines and Related Substances Control Amendment Act to help bring about a more transparent pricing system for medicines in South Africa.

New pricing model has pharmacists worried
Business Day (Johannesburg), 11 March 2006

Having endured months of uncertainty in the wake of protracted legal wrangling over government’s initial proposals on dispensing fees, introduced in April 2004, pharmacists say they are uneasy about the latest model unveiled by the health department on Thursday.

Privatising basic utilities in Sub-Saharan Africa: The MDG impact
Bayliss K, McKinley T: International Poverty Centre (IPC), January 2007

This policy research brief draws on the findings of a UNDP-supported book, Privatization and Alternative Public Sector Reform in Sub-Saharan Africa (Bayliss and Fine, forthcoming), to analyse the effects of privatisation on the delivery of water and electricity. Its chief conclusion? Privatisation has been a widespread failure. This has hampered progress on the MDGs for both water and sanitation, and on many other MDGs dependent on energy. Privatisation has failed on several counts. Contrary to expectations, private investors have shied away from investing in such utilities in the region. So it has been costly for governments to motivate them to invest. Moreover, the focus of investors on cost recovery has not promoted social objectives, such as reducing poverty and promoting equity. Thus, current realities dictate refocusing on building up the capacity of the public sector. It continues to dominate the provision of water and electricity, and will do so for the foreseeable future. But a dramatic scaling up of both external and domestic resources will be needed to finance more extensive public investment in these sectors. This approach is consistent with the current priority of adopting more ambitious MDG-based development strategies in the region.

'Public-private partnerships fail to involve African researchers'
Tucker TJ and Makgoba MW: Science 320(5879):1016-1017, 23 May 2008

Diseases that dominate the health of most African populations, such as AIDS, malaria, and tuberculosis, have always received a small proportion of the global financial support available for medical science and health interventions. Of the 1393 new drugs approved in the 25 years before 2000, only 13 were specifically indicated for tropical diseases. Health-related public-private partnership organisations have been supported for decades by the traditional public-sector research funding bodies. These major public-sector funding bodies are located in developed countries and, although the situation is changing, direct access to funding has historically been very difficult (or legally impossible) for researchers from developing countries. As a result, even where developing-country researchers have received research funds from such agencies, most of the funding has been channeled through host country institutions. This creates a dependency relationship, as well as multiple bureaucratic hierarchies in administering such grants.

A comparative study of an NGO-sponsored CHW programme versus a ministry of health sponsored CHW programme in rural Kenya: a process evaluation
Aridi J, Chapman S, Wagah M, Negin J: Human Resources for Health 12:64, November 2014

This paper presents the results of process evaluations conducted on two different models of Community Health Worker (CHW) programme delivery in adjacent rural communities in in Gem District of Western Kenya. One model was implemented by the Millennium Villages Project (MVP), and the other model was implemented in partnership with the Ministry of Health (MoH) as part of Kenya’s National CHW programme. Both the MVP and national CHW programmes faced challenges in implementation. Due to better flexibility, resources and scope for rapid innovation on the ground, the MVP model was able to introduce a number of innovations that aimed to strengthen CHW management, supervision and improve CHW responsiveness. Many of these innovations proved very effective in smoothing programme operations, but programme adherence still faced a number of challenges with respects to ensuring that CHW coverage was adequate, visitation frequency was sufficient and services were delivered with the same consistency over time by all CHWs.

A Dangerous Diversion: Will the IFC’s flagship health PPP bankrupt Lesotho’s Ministry of Health?
Marriot A, Oxfam and the Consumer Protection Association (Lesotho): April 2014

Lesotho has a new hospital – built and operated under the first public-private partnership (PPP) of its kind in any low-income country. The IFC advice and promise was that it would cost the same as the public hospital it replaced. Instead the PPP hospital is costing the government 51% of their total health budget while providing 25% returns to the private partner and a success fee of $723,000 for the IFC. This report explains how the Lesotho health PPP was developed under the advice of the International Finance Corporation (IFC – the private sector investment arm of the World Bank) and now costs the government $67 million per year, or at least three times the cost of the old public hospital. The hospital is reported by the IFC to be delivering better outcomes in some areas. But the biggest concern is that as costs escalate for the PPP hospital in the capital, fewer and fewer resources will be available to tackle serious and increasing health problems in rural areas where three quarters of the population live.

A landscape analysis of global players’ attitudes toward the private sector in health systems and policy levers that influence these attitudes
Hozumi D, Frost L, Suraratdecha C, Pratt BA, Yuksel S, Reichenbach L and Reich M: Rockefeller Foundation, 2009

This research project aimed to assess current attitudes of major global and national stakeholders on the role of the private sector in low- and lower-middle-income countries in health service provision and financing. The research team used qualitative and quantitative methods to gather data on attitudes toward the private sector. The research found that there was no agreement about what the 'private sector' or a 'public-private partnership' was. Most respondents gave qualified responses in their views of the private sector, although their perceptions varied depending on their personal ideology and history, type of intervention, area of focus, and country context. Negative views were deeply rooted. The public sector viewed the private sector as a means to an end. At the national level, the private sector feared government interference, while the public sector feared a loss of control. There was significant experience with many different forms and models of public-private interaction.

A literature review: the role of the private sector in the production of nurses in India, Kenya, South Africa and Thailand
Reynolds J, Wisaijohn T, Pudpong N, Watthayu N, Dalliston A, Suphanchaimat R et al: Human Resources for Health 11(14), 12 April 2013

This scoping systematic review was undertaken to assess the evidence for the role of private sector involvement in the production of nurses in India, Kenya, South Africa, and Thailand. The authors performed an electronic database search and also captured grey literature from the websites of relevant human resources organisations and networks. The review revealed that despite very different ratios of nurses to population ratios and differing degrees of international migration, there was a nursing shortage in all four countries, which were struggling to meet growing demand. All four countries saw the private sector play an increasing role in nurse production. Policy responses varied from modifying regulation and accreditation schemes in Thailand, to easing regulation to speed up nurse production and recruitment in India. There were concerns about the quality of nurses being produced in private institutions. The authors recommend that strategies must be devised to ensure that private nursing graduates serve public health needs of their populations. They call for policy coherence between producing nurses for export and ensuring sufficient supply to meet domestic needs, in particular in under-served areas. Further research is needed to assess the contributions made by the private sector to nurse production and to examine the variance in quality of nurses produced.

Produced by: Bulletin of the World Health Organisation (WHO): the International Journal of Public Health (2003)

The use of private health care providers in low- and middle-income countries is widespread and is the subject of considerable debate. This article, produced by the Bulletin of the World Health Organisation, reviews a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardised primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In addition, implications for public health policy of the emergence of this new model of private provider are discussed.