Although the Bill and Melinda Gates Foundation’s contribution to global health generally receives acclaim, fairly little is known about its grant-making programme. This paper is an analysis of 1,094 global health grants awarded between January 1998 and December 2007, totalling US$895 billion, of which $582 billion (65%) was shared by only 20 organisations. In total, $362 billion (40% of all funding) was given to supranational organisations such as the World Health Organization, the GAVI Alliance, the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria. Of the remaining amount, 82% went to recipients based in the United States. Just over a third ($327 billion) of funding was allocated to research and development (mainly for vaccines and microbicides) or to basic science research. The findings of this report raise several questions about the foundation's global health grant-making programme, which needs further research and assessment.
Public-Private Mix
At this stage, very little is known about the details of the South African government’s national health insurance (NHI) proposals, as all discussions are being held behind closed doors. However, key elements of the proposals are reported to include implementing a dedicated payroll tax for healthcare and establishing an administrative infrastructure to oversee these funds. The author, who is the head of strategy and risk management at Discovery Health (a private health services provider in South Africa) makes four proposals: transparent and vigorous public debate, based on hard evidence, is needed; healthcare reform, including NHI, must uplift the standards of public healthcare and improve the quality and accessibility of decent healthcare for all South Africans; healthcare reform must be rooted in South Africa’s economic realities; and South Africa’s private healthcare system should be seen as part of the solution, not part of the problem.
Major public health funders have alighted upon an industry-favoured approach of guaranteeing certain prices to industry to make vaccines available to least-developed country markets. The pilot project, the AMC Approach, announced on 12 June, provides nearly US$3 billion to make (presumably patented) vaccines against pneumococcal disease available sooner to the world’s poorest countries. There will be a commitment by industry to continue offering the vaccines at “lower and sustainable” prices after the funding runs out, the Global Alliance for Vaccines and Immunization (GAVI) said. The current pneumococcal vaccine is sold for more US$70 per dose in industrialised countries, while the new project will make the ‘long term’ price for developing countries US$3.50, GAVI added. It hopes to assist up to 60 of the world’s poorest countries to introduce these vaccines by 2015, well ahead of the time it might take without subsidising industry. A World Health Organization working group is set to discuss the issue from 29 June to 1 July.
The point made by Oxfam’s chief executive concerning failed states and the proliferation of private security firms is indicative of the ideological predisposition that impedes an open debate regarding healthcare delivery in developing countries. The view that healthcare is a fundamental responsibility of the State and must be largely provided by agencies of the State is not generally accepted outside of the UK, and is increasingly being challenged within the UK. British organisations tend to be skeptical of the private sector, but elsewhere the important role of the private sector in health systems, in countries both with and without well functioning state health programmes, is widely acknowledged. Public versus private provision is not a binary choice facing governments, donors, patients, and global policy makers – there is enough space for both to co-exist.
A primary objective of Oxfam’s new paper ‘Blind optimism’ is to encourage and advance an evidence-based debate on the appropriate role of the private sector in health care delivery in poor countries. Montagu’s response detracts from this important debate by misrepresenting the paper. Oxfam advises against investing in risky and unproven private -sector approaches to expand health care in poor countries. It is not the same as advocating that all engagement with the private sector should cease. Unchallenged enthusiasm for private sector solutions is neither justified nor helpful. Based on the evidence available, there is an urgent need for more honesty about the significant risks to efficiency and equity associated with private sector growth in health care, and more openness about the paucity of comprehensive evaluations of private sector approaches and the lack of evidence that these approaches can be scaled up properly.
The World Bank Group’s support for health, nutrition, and population (HNP) has been sustained since 1997—totaling $17 billion in country-level support by the World Bank and $873 million in private health and pharmaceutical investments by the International Finance Corporation (IFC) through mid-2008. This report evaluates the efficacy of the Bank Group’s direct support for HNP to developing countries since 1997 and draws lessons to help improve the effectiveness of this support. The report presents findings that The Bank Group now funds a smaller share of global support for health, nutrition, and population than it did a decade ago, but its support remains significant; About two-thirds of the Bank’s HNP projects show satisfactory outcomes, but a third do not; the accountability of Bank Group investments for demonstrating results for the poor has been weak; the Bank Group has an important role in helping countries to improve the efficiency of health systems and the potential for improving HNP outcomes through actions by non-health sectors is great, but incentives to deliver them are weak. Adding HNP objectives to Bank projects in other sectors, such as water supply and sanitation, raises the incentive to deliver health benefits. For the Bank Group to achieve its objectives of improving health sector performance and HNP outcomes among the poor, the report indicates that it needs to act in five areas: Intensify efforts to improve the performance of the World Bank portfolio; Renew the commitment to delivering results for the poor, including greater attention to reducing high fertility and malnutrition;
Build its own capacity to help countries to make health systems more efficient; Enhance the contribution of other sectors to HNP outcomes; Boost evaluation to implement the results agenda and improve governance.
Oxfam’s latest publication characterises as illogical and unethical the view that governments could serve their people by facilitating and regulating a private sector contribution to health care delivery. The author’s research in South Asia shows that, at least for antiretroviral therapy (ART), there is a role for public as well as private provision in developing countries. In countries like India, the private health care sector is industrious, entrepreneurial and accounts for most health care delivery. However, its quality is extremely varied. This variability of quality is less of a problem when health care addresses non-infectious health problems, like broken arms or diabetes. For these problems, lower quality care may be better than no care at all. So even if the government were able to successfully ban all the lower quality health care providers, it may only end up making health care less accessible to the poorest.
People use a variety of market-based providers of health-related goods and services ranging from highly organised and regulated hospitals and specialist doctors to informal health workers and drug sellers operating outside the legal framework. Many encounters with health workers and suppliers of pharmaceuticals involve a cash payment. The boundary between public and private sectors is often very porous, with people either paying government health workers informally or consulting them outside their official hours. Unregulated markets, in particular, raise problems with safety, efficacy and cost. This editorial of id21 insights explores some of the responses to these problems.
While universal access to reproductive health care – including family planning, maternal health care, and prevention of HIV/AIDS and other sexually transmitted infections – is critical to achieve the United Nation's Millennium Development Goals, it is far from becoming a reality. Governments are often major providers of reproductive health services, but inadequate funding greatly limits the availability and quality of the services. The private sector can help expand access to and quality of reproductive health services through its resources, expertise, and infrastructure. This brief provides an overview of the private sector, highlights the critical role it plays in delivering health services and products in developing countries, and explains how governments and donor agencies can engage this sector to achieve reproductive health goals.
In many countries people use a wide variety of market-based providers of health-related goods and services ranging from highly organised and regulated hospitals and specialist doctors to informal health workers and drug sellers operating outside the legal framework. The boundary between public and private sectors is often very porous, with people either paying government health workers informally or consulting them outside their official hours. Unregulated markets, in particular, raise problems in terms of safety, efficacy and cost. Understanding health markets and improving system performance is central to accelerating action to scale-up coverage and use of health services and deliver improved outcomes against the health-related MDGs and universal access commitments.