Public-Private Mix

African Governments Urged to move with Speed to Address Over-Dependence on Imported Medicines
United Nations Economic Commission for Africa: UNECA Addis Ababa, 2019

At the two-day Horn of Africa trade forum in Addis Ababa, organized by the ECA, the Government of Ethiopia, the African Union Commission (AUC), and the European Union, participants agreed that with the African Continental Trade Agreement (AfCFTA) in force, it was time for the continent to increase domestic production of pharmaceutical products and end over-dependence on imported medicines. The AfCFTA, they agreed, provides an opportunity for economies of scale necessary for African pharmaceutical production. The Economic Commission for Africa's (ECA) Director for Regional Integration and Trade, Stephen Karingi, in closing the forum said that domestic policies that can be used to support the industry, including through investment assurances, grants, fiscal incentives and local content requirements. Regional centers of excellence could be used to overcome constraints in human capacities and resources for research and development and testing. The forum also agreed on the need to strengthen regulatory frameworks to develop the pharmaceutical sector; to encourage domestic production with a regional focus; and to ensure efficient and safe logistic chains that can bring down the cost of medicines.

After the handover: Exploring MSF’s role in the provision of health care to migrant farm workers in Musina, South Africa
de Gruchy T; Kapilashrami A: Global Public Health, doi:, 2019

Non-state actors, including humanitarian agencies, play a prominent role in providing health care in low- and middle-income countries. Between 2007 and 2009, Musina, a South African municipality bordering Zimbabwe, became the site of several interventions by non-state organisations as an unprecedented number of Zimbabweans crossed the border, putting strain on already burdened local systems. After the initial need for humanitarian relief dissipated, organisations started to implement projects that were more developmental in nature. For example, Médecins sans Frontières developed a mobile clinic programme to improve health care access for migrant farm workers, a programme that was subsequently integrated into the Department of Health. Since the handover of the programme, it has faced multiple challenges. Using qualitative methodology and a case study approach, this paper traces the development of the programme, exploring the changing relationship between MSF and the state during this time. This research raises questions about the implications of short-term ‘innovative’ interventions targeting the access that migrants have to care, within a context in which policy and programmatic responses to health are not 'migration aware'. The authors highlight the ways in which the energies and resources of local health department employees were redirected by MSF's involvement in the area.

Are public–private partnerships the future of healthcare delivery in sub-Saharan Africa? Lessons from Lesotho
Hellowell M: BMJ Global Health 4(2), doi:, 2019

Many governments in sub-Saharan Africa are seeking to establish public–private partnerships (PPPs) to finance and operate new healthcare facilities and services. While there is a large empirical literature on PPPs in high-income countries, much less is known about their operation in low-income and middle-income countries. This paper seeks to inform debates about the use of PPPs in sub-Saharan Africa by describing the planning and operation of a high-profile case in Maseru, Lesotho. The paper highlights several beneficial impacts of the transaction, including the achievement of high clinical standards, alongside a range of key challenges—in particular, the higher-than-anticipated costs to the Ministry of Health. Governments may use budget-related incentives to promote the use of PPPs which may threaten financial sustainability in the long term. The authors suggest that future proposals for PPPs need to be exposed to more effective scrutiny and challenge, taking into account state capacity to proficiently manage and pay for contracted services.

Resolution on States’ Obligation to Regulate Private Actors Involved in the Provision of Health and Education Services
African Commission on Human and People’s Rights: ACHPR, Egypt, 2019

The African Commission on Human and People’s Rights calls on States Parties to the African Charter to take appropriate policy, institutional and legislative measures to ensure respect, protection, promotion and realization of economic, social and cultural rights, in particular the right to health and education and to fulfil their obligations on this. The Commission calls on States Parties to adopt legislative and policy frameworks regulating private actors in social service delivery and ensure that their involvement is in conformity with regional and international human rights standards. States Parties are invited to ensure that the involvement of private actors in the provision of social services is a result of a participatory policy formulation process and continues to be subject to democratic scrutiny and to the human rights principles of transparency and participation. The Commission considers carefully the risks for the realization of economic, social and cultural rights of public-private partnerships and ensure that any potential arrangements for public-private partnerships are in accordance with their substantive, procedural and operational human rights obligations, and do not violate the norms and principles of the rights contained in the African Charter; and to ensure through regular impact assessments that the involvement of private actors in the provision of health services and education does not create systemic adverse impacts on human rights. Further States Parties are to ensure access to an effective remedy for violations of the right to health and education or other human rights violations by private actors involved in the provision of health and education services. The Commission reminds private actors of their responsibility to respect economic and social rights, particularly the right to health and education and to refrain from infringing on human rights as they engage in the provision of these services.

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.

Determinants of paying national health insurance premium with mobile phone in Ghana: a cross-sectional prospective study
Boaheng J; Amporfu E; Ansong D; Osei-Fosu A: International Journal for Equity in Health 18 (50) 1-9, 2019

This study investigated the determinants of renewing membership and paying the National Health Insurance Scheme premium through a mobile phone. The prospective cross-sectional survey was used to solicit information from 1192 respondents living in Kumasi Metropolis, Atwima Nwabiaya and Sekyere Central Districts of Ghana to estimate the determinants of paying the National Health Insurance Scheme premium with the mobile phone. The study found that residing in an urban area, senior high education, tertiary education and informal employees are the determinants of paying the NHIS premium with the mobile phone. It was recommended that the NHIS consider making the mobile payment as simple as possible for the less educated and for rural members to access it.

Universal Health Coverage, Primary Health Care and the role of the Private Sector
Ozano K; Simkhada P; Porcellato L; Khatri R: Health Systems Global, 2019

This report provides an overview of the discussions around Primary Health Care (PHC) and the private sector, which took place during the 5th Global Symposium on Health Systems Research 2018: Advancing health systems for all in the SDG era. Universal Health Coverage (UHC) and how health systems are working to deliver this global goal by 2030 was a major theme of the conference. Discussions were captured through session data capture and semi-structured interviews. 26 conference rapporteurs captured data in 93 sessions; and 21 interviews were conducted with policy makers, implementers and practitioners from the public and private sector. The discussions referred to initiatives to better engage, train and support small private providers such as community pharmacists to broaden their role and regulate their prescribing to develop safer PHC services. Urgent policy level exploration was called for on public-private links to achieve comprehensive PHC and UHC and clear mechanisms and legal frameworks for strategic purchasing and regulation that consider the power of purchasing medicines and supplies across countries within geographic regions.

Perceptions of and support for national health insurance in South Africa's public and private healthcare sectors
Booysen F; Hongoro C: The Pan African Medical Journal 30(277), doi: doi:10.11604/pamj.2018.30.277.14147, 2018

For the purpose of effective implementation of a National Health Insurance (NHI) policy the authors argue that it is necessary to have an understanding of the awareness and perceptions of and support for such policy among clients using the healthcare system. The South African National Health and Nutrition Examination Survey asked household heads a series of questions on healthcare utilisation and access and collected information on knowledge and perceptions of and support for national health insurance. Comparisons are drawn between private sector healthcare users with medical aid and public sector healthcare users without medical aid, using descriptive and regression analysis. Inequalities in access to quality healthcare remain stark. Only 8.5% of private users had postponed seeking healthcare compared to 23.9% of public users. Only 11.9% of public users were very satisfied with the quality of healthcare services compared to 50.2% of private users. More than eighty percent of healthcare users however were of the opinion that NHI is a top priority. The findings suggest that this requires a national health insurance that provides better quality healthcare, increasing the probability of support for an NHI with lower cost and full coverage by 10.1%. The authors suggest that it is imperative to provide better quality healthcare services in the public sector for private sector users to be supportive of national health insurance. Concerted efforts are also required to develop a proper communication strategy to disseminate information on and garner support for national health insurance, both in the public and private healthcare sectors.

Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study
Suchman L: International Journal for Equity in Health 17(179) 1-18, 2018

This paper pulled together data collected from private providers, patients, and social health insurance (SHI) officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services? In-depth interviews were held with 204 providers over three rounds of data collection in Kenya and Ghana. The authors also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency and the Kenya National Hospital Insurance Fund across four rounds of data collection. Provider interviews covered reasons for enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. Focus Group Discussions covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system, providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.

Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage
Ssennyonjo A, Namakula J, Kasyaba R et al.: International Journal for Equity in Health, 2018

This case study examined government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders. Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship’s evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the “good will” of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. The authors concluded that GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC.