In responding to the goal of rapidly increasing access to antiretroviral treatment (ART), the government of Botswana undertook a major review of its health systems options to increase access to human resources, one of the major bottlenecks preventing people from receiving treatment. In mid-2004, a team of government and World Health Organization (WHO) staff reviewed the situation and identified a number of public sector scale up options. The team also reviewed the capacity of private practitioners to participate in the provision of ART. Subsequently, the government created a mechanism to include private practitioners in rolling out ART. At the end of 2006, more than 4500 patients had been transferred to the private sector for routine follow up. It is estimated that the cooperation reduced the immediate need for recruiting up to 40 medically qualified staff into the public sector over the coming years, depending on the development of the national standard for the number and duration of patient visits to a doctor per year. Thus welcome relief was brought, while at the same time not exercising a pull factor on human resources for health in the sub-Saharan region.
Public-Private Mix
This paper shows there is an urgent need to reassess the arguments used in favor of scaling-up private-sector provision in poor countries. The evidence shows that prioritising this approach is extremely unlikely to deliver health for poor people. The paper recommends that donors should rapidly increase funding for the expansion of free universal public health-care provision in low-income countries, including through the International Health Partnership. Developing countries must resist donor pressure to implement unproven and unworkable market reforms to public health systems and an expansion of private-sector health-service delivery. Civil society must also act together to hold governments to account by engaging in policy development, monitoring health spending and service delivery, and exposing corruption.
This study, from the National Bureau of Economic Research, examines the distribution of such spending according to income and type of health care in order to assess whether it would be possible to supply voluntary private health insurance to reduce variation in spending. Using data from the World Health Survey for 14 developing countries, the report finds that out variations in out-of-pocket spending depend on income. The authors use estimates of the variance of total spending, hospital spending, physician spending and outpatient drug spending tends to generate estimates of the amounts of money risk averse consumers might pay for insurance coverage. For hospital spending and total spending, these amounts are larger than the authors consider reasonable, suggesting that voluntary insurance might be feasible. However, the strong relationship between spending and income suggests that insurance markets may need to be segmented by income.
The event ‘Public private partnerships against HIV: How can we together turn the tide?’ was organised by UNAIDS and explored the benefits and challenges of public-private partnerships in the global response to AIDS. Participants agreed that attention should be paid to ensure wide participation and representation across the private sector including from the labour unions, employers’ federations, small and medium enterprises and the informal sector. There is still a lot to do to improve participation by small and medium enterprises and the informal sector which employ most of the labour force in Africa. The group identified four factors as critical in creating and sustaining successful PPPs: clear definition of partners’ roles and responsibilities, transparency and respect for ethical standards, coordination between partners, and periodic assessments of the partnership.
Richard Smith and colleagues are forceful advocates for a greater role for the private sector in the health systems of low-income countries. Unfortunately, as they also recognise, the evidence to support their position is limited. First, Smith and colleagues pay insufficient attention to the diversity of the private sector in developing countries. Second, they place considerable weight on the proportion of private spending in total health financing. However, this is an imperfect measure of the size of the private sector. Third, it is not true to say that governments and donors have completely ignored the private sector. What is needed is for the global public health community to commit to developing a strong evidence base on private sector engagement so that future debates can be grounded in better understanding.
Danone, the world’s second largest baby food company, now sits on the governing body of the Global Fund for Improved Nutrition (GAIN). But there is no mention of Danone’s interest in baby foods on the GAIN website nor any mention that it is a systematic Code violator. GAIN claims to be working to improve nutrition by building markets for fortified foods in the developing world and has now launched a project on infant and young child nutrition. Concerned about this unacceptable conflict of interest, 53 experts from 24 countries, attending the World Alliance for Breastfeeding Action (WABA) workshop in October, have written to WHO and UNICEF calling on them to reconsider their partnership with GAIN. GAIN is bound to undermine breastfeeding and the use of indigenous, traditional and low-cost foods, they say.
These two viewpoints agree much more than they disagree. Both agree that the public sector cannot be ignored and both agree that there is a role for the private sector in improving the health of the world's poorest. The disagreement is about emphasis. Smith et al believe that many countries will benefit more from harnessing the energy of the private sector rather than continuing to invest solely or mainly in the public sector. The public sector, growing evidence of the effectiveness of the private sector, and energetic non-state organisations, are already working to harness the power of the private sector to achieve better health care for all. Evaluation will be crucial, but the most important research question is not ‘Can the private sector help?’ but ‘How can public–private partnerships be made most effective and equitable?’
Is private health care the answer for the world's poor? This article’s starting point is that there are no strong grounds for assuming the superiority of either public or private health care. Theory dictates that it is not whether a health facility is publicly or privately owned that determines health provider performance. Instead, what influences performance is the nature of incentives that providers face and the quality of management and oversight. Theory does, however, suggest that the profit-making incentive dominant in much of the private sector is likely to be problematic for health care. Is there then scope for private providers to be paid through public financing? Past experiences all point to the significant transactions costs of such arrangements and the need for strong and capable contracting units within health ministries.
This article argues that, with a complicated problem such as improving health care under constrained resources, two heads are better than one. The public and private sectors have different strengths and weaknesses, and a judicious blending of the two can produce optimal results. Indeed, there is no health system that is entirely public or private. The reality is that, in most low-income countries, most people receive most of their care from the broadly defined private sector. About 60% of the US$16.7 billion spent on health in sub-Saharan Africa in 2005 was private, most of it out-of-pocket spending by individuals, and about half of this went to private providers. Some countries are now exploring pluralistic models that partner with the private sector to serve public policy goals. These models should be encouraged and supported.
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).