Governments around the world are increasingly turning to the use of stand-alone, state-owned utilities to deliver core services such as water and electricity. This article reviews the history of such ‘corporatisation’ and argues that its recent resurgence has been heavily influenced by neoliberal theory and practice, raising important questions about whether it should be adopted as a public service model. Not all corporatisations promote commercialisation, however. The article also discusses stand-alone utilities that have managed to stave off market pressures and develop in more equity-oriented directions. The scope for non-commercialised corporatisation is narrow, but given the expansion of this organisational model, the author argues that it is important that we understand both its limitations and potentials, particularly in low-income countries where service gaps are large and equity is a major challenge.
Public-Private Mix
The National Cancer Registry (NCR) was established as a pathology-based cancer reporting system. From 2005 to 2007, private health laboratories withheld cancer reports owing to concerns regarding voluntary sharing of patient data.The study aimed to estimate the impact of under-reported cancer data from private health laboratories. A linear regression analysis was conducted to project expected cancer cases for 2005 - 2007. Differences between actual and projected figures were calculated to estimate percentage under-reporting. The projected NCR case total varied from 53 407 (3.8% net increase from actual cases reported) in 2005 to 54 823 (3.7% net increase) in 2007. The projected number of reported cases from private laboratories in 2005 was 26 359 (19.7% net increase from actual cases reported), 27 012 (18.8% net increase) in 2006 and 27 666 (28.4% net increase) in 2007. While private healthcare reporting decreased by 28% from 2005 to 2007, this represented a minimal impact on overall cancer reporting (net decrease of <4%).
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.
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.
While the South African government and private healthcare funders urged one another to make internal changes to enable faster progress towards a more equitable healthcare system, some concrete evidence of vitally needed partnership did emerge from the Board of Healthcare funders' conference held in August 2014. Government’s new Essential Drugs Committee will include representatives of the private healthcare funding industry to obtain consensus on just which essential medicines should be available to patients.
A blueprint on how the National Department of Health (NDoH) can partner
with the private healthcare funding sector in conducting economic evaluations of products to save both sectors time and money (and avoid
longstanding unnecessary duplication) has been drawn by NDoH. National Health Minister Dr Aaron Motsoaledi also pleaded with delegates to ‘embrace change’, warning that they would be hardest hit by the‘exploding’ epidemic of non-communicable diseases if they failed to introduce health promotion and disease prevention measures.
The demand for nurses is growing and has not yet been met in most low and middle-income countries. In India, Kenya, South Africa and Thailand, there has been a rapid proliferation of private training institutions to increase the supply of nurses. This infogram summarises evidence from RESYST research examining the role of these private institutions, their contribution to the wider health systems, and how governments in these countries have managed the opening of markets to the private sector. Private nurse training institutions are reported to be playing an increasingly important role in producing nurses in many low and middle income countries. Governments need to ensure that graduates from both private and public institutions are of sufficient quality to meet the health needs of their populations, and that training institutions have the capacity to train more nurses. In some countries including India and Kenya, the benefits of expanding nurse production through the private sector have been hindered by high levels of international migration. A balance needs to be struck between producing nurses for export, and ensuring sufficient supply and skill-mix for domestic markets.
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.
The authors argue that the World Bank Group should focus on supporting African governments to expand publicly provided healthcare – a proven way to save millions of lives worldwide and to drive down inequality. The International Finance Corporation (IFC)’s Health in Africa initiative is argued to be at odds with the World Bank Group’s welcome commitment to universal and equitable health coverage and to shared prosperity. The $1bn initiative, which promotes private sector healthcare delivery, is reported to be extremely unlikely to deliver better health outcomes for poor people, and the IFC is noted to fail to measure the extent to which Health in Africa impacts on people living in poverty.
Scarce evidence exists on the features, determinants and implications of physicians’ dual practice, especially in resource-poor settings. This study considered dual practice patterns in three African cities, Cape Verde, Maputo and Guinea Bissau, and the respective markets for physician services, with the objective of understanding the influence of local determinants on the practice. Forty-eight semi-structured qualitative interviews were conducted in the three cities to understand features of the practice and the respective markets. A survey was carried out in a sample of 331 physi-cians to explore their characteristics and decisions to work in public and private sectors. Descriptive analysis and infer-ential statistics were employed to explore differences in physicians’ engagement in dual practice across the three loca-tions. Different forms of dual practice were found to exist in the three cities, with public physicians engaging in private practice outside but also inside public facilities, in regulated as well as unregulated ways. Thirty-four per cent of the respondents indicated that they worked in public practice only, and 11% that they engaged exclusively in private prac-tice. The remaining 55% indicated that they engaged in some form of dual practice, 31% ‘outside’ public facilities, 8% ‘inside’ and 16% both ‘outside’ and ‘inside’. Local health system governance and the structure of the markets for phy-sician services were linked to the forms of dual practice found in each location, and to their prevalence. The authors analysis suggests that physicians’ decisions to engage in dual practice are influenced by supply and demand factors, but also by how clearly separated public and private markets are. Where it is possible to provide little-regulated services within public infrastructure, less incentive seems to exist to engage in the formal private sector, with equity and effi-ciency implications for service provision. The study shows the value of analysing health markets to understand physi-cians’ engagement in professional activities, and contributes to an evidence base for its regulation.
This presentation looks at Public-Private Partnerships (PPPs) in infrastructure through the lens of inequality, as wealth becomes concentrated in fewer and fewer hands and as the gap between rich and poor widens globally, regionally and within countries. PPPs are now used in more than 134 developing countries, are on the rise in the aftermath of the 2008 global financial crisis, and have moved from physical infrastructure into the provision of “social infrastructure,” such as schools, hospitals and health services. For the private sector, a PPP project needs to provide a stable, guaranteed income stream. Projects are devised to create multiple avenues for a flow of money that is transformed into private profit through loans, derivatives, shares, securitised income streams, and contract sales that anyone can buy and sell. The author argues that a PPP project enables millions of dollars worth of ancillary trading, mainly for the purpose of hedging risks. The choice of what infrastructure to build is thus argued to be heavily influenced by what serves the long-term profit-making interests of the private sector – and the state or public sector becomes more and more aligned with the interests of infrastructure investors and private companies. PPPs are thus reported to be not about building and providing public services but about constructing the subsidies, fiscal incentives, capital markets, regulatory regimes and other support systems necessary to transform “infrastructure” into an asset class that yields above average returns of 13-25%.