Health In Africa is a $1 billion investment project launched by the IFC in 2008, which aimed to ‘catalyze sustained improvements in access to quality health-related goods and services in Africa [and] financial protection against the impoverishing effects of illness’, through harnessing the potential of the private health sector. Specifically, it sought to improve access to capital for private health companies, and to help governments incorporate the private sector into their overall health care system. Health In Africa would do this through three mechanisms: an equity vehicle, a debt facility, and technical assistance. Perhaps of most importance, the initiative would make extra efforts to ‘improve the availability of health care to Africa’s poor and rural population’. The author reports that Oxfam’s assessment of the sporadic investment information available finds that far from delivering health care for the poorest, Health In Africa has favoured high-end urban hospitals, many of which explicitly target a country’s wealthy and expatriate populations. The initiative’s biggest investment to date has been in South Africa’s second largest private hospital group Life Healthcare. This $93 million endowment no doubt supported the company in its subsequent expansion, but there is no evidence it has used this investment to expand access to health care for the 85% of South Africans without health insurance. Oxfam has called on the IFC to cease all Health In Africa investments until a robust, transparent and accountable framework is put in place to ensure that the initiative is pro-poor, and geared towards meeting unmet need. In addition, it calls on the World Bank Group to conduct a full review of the IFC’s operations and impact to date in the health sector in low- and middle-income countries, to investigate how they are aligned with, and are accountable to, the overarching goals of the World Bank Group: to end extreme poverty and promote shared prosperity.
Public-Private Mix
The role for the private sector in health remains subject to much debate, especially within the context of achieving universal health coverage. This roundtable discussion offered perspectives from a range of stakeholders – a health funder, a representative from an implementing organisation, a national-level policy-maker, and an expert working in a large multi-national company – on what the future may hold for the private sector in health. The health funder argued that the discussion about the future role of the private sector has been bogged down in language. He argued for a ‘both/and’ approach rather than an ‘either/or’ when it comes to talking about health service provision in low- and middle-income countries. An implementer of health insurance in sub-Saharan Africa examined the comparative roles of public sector actors, private sector actors and funding agencies, suggesting that they must work together to mobilize domestic resources to fund and deliver health services in the longer term. Thirdly, a special advisor working in the federal government of Nigeria noted that the private sector plays a significant role in funding and delivering health services there, and that the government must engage the private sector or be left behind. Finally, a representative from a multi-national pharmaceutical corporation gave an overview of global shifts that are creating opportunities for the private sector in health markets. No community member views were provided.
This study examines the delivery of health services by faith-based organizations (FBOs) as a possible alternative to privatization in Uganda, where they have been servicing communities since the mid-19th century. Their facilities focus on primary care and operate in rural, under-serviced areas where they provide access to care without discrimination on the basis of religion or ethnic group, charging affordable user fees while also treating those who cannot pay. The sector presently contributes to more than a quarter of all health services in the country, including the training of health professionals. Based on literature reviews and more than 30 key informant interviews, this research finds that FBOs promote solidarity through multi-stakeholder engagement and through cross-subsidization using mechanisms such as community health financing schemes that protect patients from catastrophic health expenditure. It analyzes how this ‘private not-for-profit’ sector fosters the development of a strong quasi-public ethos in service delivery, especially at the primary level of the Ugandan health system, posing a challenge to western liberal ideas about how the state and religion interface.
New research on market concentration of private hospitals, medical schemes and administrators is reported to show that contrary to concerns over growing concentration, the market for private hospitals in South Africa has in fact remained flat since 2003.
A recent RESULTS report on nutrition and education in Tanzania, “You can’t study if you’re hungry…” found that levels of undernutrition are worryingly high, at 42% of all children under five, and, surprisingly, that buoyant economic growth levels are having little impact on nutrition figures. In Tanzania, a lack of essential nutrients in the average child’s diet is one of the key determinants of undernutrition. So it is not necessarily a lack of food, but a lack of nutritious and varied food. Micronutrient deficiency is widespread in Tanzania and contributes to the high level of stunting. Yet, Tanzania’s Gross Domestic Product (GDP) Annual Growth Rate averaged 7% from 2002 until 2013, reaching an all-time high of 11% in 2007. But the sectors which have driven Tanzania’s economic growth are mainly those which are capital intensive and urban. So while the urban middle class are expanding there is little benefit in rural areas. The fastest growing economic sectors are communications, financial services, construction, and a new natural gas sector. In a meeting with Tanzanian MPs on the Parliamentary Group for nutrition the MPs who were especially concerned were from the area of the country described as the ‘agricultural growth corridor’. Precisely the rural areas of the country that have been targeted for private sector growth are those constituencies with highest rates of stunting. One MP said that the emphasis on export-led growth means that parents are now so busy that they do not have the time to focus on the adequate nutrition of their children.
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.
Days after the Council for Medical Schemes in South Africa announced it had ordered a forensic investigation into its registrar, Monwabisi Gantsho, for allegedly soliciting a R3m kickback, an earlier report has come to light raising further questions about his conduct.Dr Gantso heads the agency charged with overseeing the R110bn medical schemes industry. In November 2012, the council’s acting chairman Trevor Bailey instructed law firm Bell Dewar to investigate a series of allegations made by senior staff against the registrar. The law firm’s report, according to Business Day, concluded that the registrar:
• Ignored recommendations made by a council task team for the appointment of independent curators to three different medical schemes — Bonitas, Sizwe and Medshield — and had instead appointed curators "with whom he appear(ed) to have a relationship";
• Delayed an investigation into troubled medical scheme Medshield "without justification";
• Refused to approve the merger of Nampak Medical Scheme and Discovery Health Medical Scheme for "no justifiable reason";
• Appointed staff without following due process; and
• Put pressure on a junior staff member to reveal confidential minutes of meetings of the medicine pricing committee.
The article provides further report on the follow up actions according to Business Day.
On 6 January 2014, South Africa’s Competition Commission began a market inquiry (an investigation)into the private health sector. The Commission was concerned about high prices in private health care and will use its wide powers to investigate the general state of competition in this sector to determine what can be done to achieve accessible, affordable, high quality and advanced private health care in South Africa. According to the Commission, there are indications that the private health care market is not working well for consumers. The market inquiry will examine the causes of why the market may not be working effectively, and will make recommendations as to how they might be made to work better in order to promote and protect consumer interests, while ensuring that markets
are fair and competitive. As such the Commission will specifically look into the increases in prices in private health care and determine the factors that are driving prices. This fact sheet outlines the terms of the Commission inquiry. It points to the opportunity to address inequality in the health system in South Africa. SECTION27, together with its partners, report that they will closely monitor the inquiry and ensure that the voice of ordinary users of private health services.
This paper describes a reproductive health voucher program that contracts private facilities in Uganda and explores the policy and implementation issues associated with expansion of the program to include public sector facilities. Data presented here describes the results of interviews of six district health officers and four health facility managers purposefully selected from seven districts with the voucher program in southwestern Uganda. Interviews were transcribed and organized thematically, barriers to seeking RH care were identified, and how to address the barriers in a context where voucher coverage is incomplete as well as opportunities and challenges for expanding the program by involving public sector facilities were investigated. The findings show that access to sexual and reproductive health services in southwestern Uganda is constrained by both facility and individual level factors which can be addressed by inclusion of the public facilities in the program. This will widen the geographical reach of facilities for potential clients, effectively addressing distance related barriers to access of health care services. Further, intensifying ongoing health education, continuous monitoring and evaluation, and integrating the voucher program with other services is likely to address some of the barriers. The public sector facilities were also seen as being well positioned to provide voucher services because of their countrywide reach, enhanced infrastructure, and referral networks. The voucher program also has the potential to address public sector constraints such as understaffing and supply shortages. Accrediting public facilities has the potential to increase voucher program coverage by reaching a wider pool of poor mothers, shortening distance to service, strengthening linkages between public and private sectors through public-private partnerships and referral systems as well as ensuring the awareness and buy-in of policy makers, which is crucial for mobilization of resources to support the sustainability of the programs. Specifically, identifying policy champions and consulting with key policy sectors is key to the successful inclusion of the public sector into the voucher program.
This paper seeks to determine how the corporate responsibilities of pharmaceutical companies in relation to access to medicines can be clarified and enforced. Two cases, one each from India and South Africa, are examined to determine how the domestic courts in both countries indirectly utilized the right to health to ensure that pharmaceutical companies did not impede access to affordable medicines through exercising their patent rights. There is a need to clarify and enforce the responsibilities pharmaceutical companies have to promote the right to health. The two cases from India and South Africa demonstrate the potentials of domestic courts as forums where these responsibilities can be effectively enforced. In the absence of a global enforcement mechanism for enforcing the right-to-health responsibilities of pharmaceutical companies, domestic courts can effectively fill this gap. In addition, this paper demonstrates that domestic courts can equally serve as forums for health diplomacy.