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. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. It is concluded that encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened.
Public-Private Mix
Equity is a frequently stated justification for government involvement in the health care market. This is often taken to mean directly providing all segments of the population with a wide range of government-operated health services at no cost: free universal care. Yet a look at the record suggests that this goal all too often remains elusive, especially in poor countries; that governments in fact serve only some of the population; and that the people served are disproportionately concentrated among the better-off. When this happens, government health services, far from promoting equity, work against it. The purpose of this chapter is to illustrate that there are many ways for governments to pursue the goal of ensuring that the poor receive adequate, affordable services through alternative approaches to resource allocation and purchasing. The first section summarizes the information known about the distribution of benefits from government health services across social groups in order to document the regressive pattern that now frequently exists and the need for significant changes in approach if the poor are to benefit. The second and third sections illustrate the kinds of changes that might be considered.
This backgrounder to a session of the WHO 56th World Health Assembly looks at issues surrounding innovation in public health particularly focusing on biotechnology, including genomics, pharmaceuticals, medical devices and other diagnostics. The report argues that innovation to address conditions which particularly affect the poor are often held back by market failure and/or under investment by the public sector. The report highlights a number of mechanisms to stimulate innovation. These include: Investment in basic science in developing countries; Public / private partnerships to address neglected diseases; IP mechanisms to promote private sector investment such as advance-purchase funds; Flexibility in the application of TRIPS as advocated in the Doha Declaration particularly with regard to licensing and exemptions; Improved technology transfer from North to South; Increased capacity building in developing countries; Greater international cooperation; Clear, co-ordinated setting of research priorities; and A sound regulatory environment.
Neo-liberal economic policies and World Bank/IMF inspired 'health reforms' being pushed through in developing countries have resulted in: Privatisation of public health services; The introduction of user fees for patients; Lack of public investment in state-run primary health care systems; and Lack of attention to leadership and management development for PHC. "All this has obviously also resulted in the overall deterioration in quality and equitable delivery of public health services and had a devastating effect on the ability of the poor to access health care," says a recent press release from the People's Health Movement (PHM). PHM has called for wider consultation between the World Health Organisation and civil society mem-
bers.
Global health problems require global solutions, and public-private partnerships are increasingly called upon to provide these solutions. Such partnerships involve private corporations in collaboration with governments, international agencies, and non-governmental organizations. They can be very productive, but they also bring their own problems. This volume examines the organizational and ethical challenges of partnerships and suggests ways to address them. How do organisations with different values, interests, and worldviews come together to resolve critical public health issues? How are shared objectives and shared values created within a partnership? How are relationships of trust fostered and sustained in the face of the inevitable conflicts, uncertainties, and risks of partnership? This book focuses on public-private partnerships that seek to expand the use of specific products to improve health conditions in poor countries. The volume includes case studies of partnerships involving specific diseases such as trachoma and river blindness, international organizations such as the World Health Organization, multinational pharmaceutical companies, and products such as medicines and vaccines. Individual chapters draw lessons from successful partnerships as well as troubled ones in order to help guide efforts to reduce global health disparities.
Does competition improve hospital services? Do market forces in healthcare benefit the poorest members of society? Reforms which involve exposing hospitals to market forces are being introduced in many developing countries. However, very little is known about how these markets operate, particularly in developing countries. The University of Zambia, together with the London School of Hygiene and Tropical Medicine, considered the effect of competition among hospitals in Zambia. The study examined hospitals in Lusaka, Central and Copperbelt provinces. Data on hospital use, revenues and expenditure, and charges for services were collected for the period 1996 to 1999 from each hospital using routine hospital records. In addition, a patient questionnaire was used in facilities to elicit patients’ views of the quality of services. As well as private for-profit and mine hospitals (facilities operated by the mining industry), "private" services included the private fee-paying services provided in government hospitals (known in Zambia as "high cost" services").
Public-private partnerships (PPPs) are becoming a popular mode of tackling large, complicated, and expensive public health problems. However, little is known about the conditions when partnerships succeed, about the strategies for structuring partnerships, or about the ethical underpinnings of partnerships. This book from the Harvard Center for Population and Development Studies presents the results of a workshop examining questions about public-private partnerships in international public health, focusing on the organisational and ethical challenges of partnerships, and ways to address them. The essays in this volume offer some new perspectives on partnerships and provide empirical evidence of both benefits and challenges of PPPs.
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.
There is a lack of effective, safe, and affordable pharmaceuticals to control infectious diseases that cause high mortality and morbidity among poor people in the developing world. This article from The Lancet analyses the outcomes of pharmaceutical research and development over the past 25 years, and reviews current public and private initiatives aimed at correcting the imbalance in research and development that leaves diseases that occur predominantly in the developing world largely unaddressed. It found that of 1393 new chemical entities marketed between 1975 and 1999, only 16 were for tropical diseases and tuberculosis. The article concludes that private-sector research obligations should be explored, and a public-sector not-for-profit research and development capacity promoted.
In response to shortages in public budgets for government health services many developing countries around the world have adopted formal or informal systems of user fees for health care. In most countries user fee proceeds seldom represent more than 15 percent of total costs in hospitals and health centres, but they tend to account for a significant share of the resources required to pay for non-personnel costs. The problem with user fees is that the lack of provisions to confer partial or full waivers to the poor often results in inequity in access to medical care. The dilemma, then, is how to make a much needed system of user fees compatible with the goal of preserving equitable access to services, says this paper from the World Bank.