Public-Private Mix

Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation
Maluka S; Chitama D; Dungumaro E; et al: International Journal for Equity in Health 17(118) 1-13, 2018

This paper reports on the design and implementation of service agreements between local governments and non-state providers for the provision of primary health care services in Tanzania. The authors used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. The institutional frameworks shaping the engagement of the government with non-state providers are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage non-state providers facilities. Development partners provided significant technical and financial support, signalling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with non-state providers, financing the contracts remained largely dependent on external funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. The authors indicate that Tanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with non-state providers for primary health care services; and that forums for continuous dialogue between the government and contracted non-state providers be fostered to clarify the expectations of all parties and resolve any misunderstandings.

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 17(130) 1-12, 2018

In this paper, the authors examine government resource contributions (GRCs) to providers in Uganda focusing 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 government resource contributions (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 initiation, rapid increase in GRCs, and declining GRCs. The main factors affecting the relationship’s evolution were: financial deficits at private-not-for-profit (PNFP) facilities, advocacy by PNFP network leaders, changes in the government financial resource envelope, variations in the “good will” of government actors, and 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. GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The authors argue that 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. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. They further suggest that governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.

Moving towards universal health coverage: engaging non-state providers
Rao K; Paina L; Ingabire M; et al: International Journal for Equity in Health 17(127) 1-9, 2018

This paper provides a unique opportunity to understand the dynamics of non-state providers (NSP) engagement in different contexts. A standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes. Governments contracted NSPs for a variety of reasons – limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance. The authors suggest that for countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage.

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system
Grieve A; Olivier J: International Journal for Equity in Health 17(97)1-20, 2018

This paper presents a mapping of faith-based health assets in Ghana using both qualitative and quantitative evidence to provide a visual representation of changes in the spatial footprint of the faith-based non-profit (FBNP) health sector. The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. The sector has had a long-standing role in the provision of health services and remains a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. The authors observe that collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of universal health coverage.

Health market inquiry: Provisional findings and recommendations
Competition Commission: South Africa July 2018

The South African private healthcare sector comprises a complex set of interrelated stakeholders that interact in markets that are not transparent and so not easily understood. This report highlights key features that describe how the private healthcare sector operates. The author identifies features of the private healthcare sector that, alone or in combination, prevent, restrict or distort competition. The report presents recommendations to remedy these adverse effects on competition. Overall, the market is characterised by high and rising costs of healthcare and medical scheme cover, highly concentrated funders’ and facilities’ markets, disempowered and uninformed consumers, a general absence of value-based purchasing, ineffective constraints on rising volumes of care, practitioners that are subject to little regulation and failures of accountability at many levels. An incomplete regulatory regime is attributed to a failure in implementation on the part of regulators and inadequate stewardship by the Department of Health over the years. Intrinsic and extrinsic incentives in the market have promoted over-servicing by medical practitioners which include increased admissions to hospitals, increased length of stay, higher levels of care, greater intensity of care or use of more expensive modalities of care than can be explained by the disease burden of the population. The report presents We evidence of supply induced demand. Various marketing choices are reported to leave consumers confused and disempowered, compounding their inability to use choice as a pressure on schemes. The market is characterized by a dominance of a few schemes and by an absence of effective direct competition between the three big hospital groups. The report recommends changes to the way scheme options are structured to increase comparability between schemes and increase competition in that market; a system to increase transparency on health outcomes to allow for value purchasing and a set of interventions to improve competition in the market through a supply side regulator.

It’s a stick-up. Your money or your health!
Heywood M; Daily Maverick, September 2018

The Health Market Inquiry (HMI) report published in South Africa is a result of widespread complaints about rising prices and declining benefits in 2014, and was set up by the Competition Commission as an inquiry into the private health care market. A panel of independent experts was appointed, chaired by former Chief Justice Sandile Ngcobo. According to the Competition Commission nearly nine million people in South Africa (16.9% of the population) are members of medical schemes. Many are reported to feel resentful of paying a lot to medical schemes and still having to pay more out of pocket when they need care. The HMI report confirms that premiums are rising and benefits are falling. Expenditure on private health, where R235-billion is spent on nine million people, overshadows the R201-billion the government spends on the other 44-million. Yet the two systems are tied at the hip: they have overlapping staff, overlapping regulatory institutions, and of course an overlapping population for whom healthcare is a right. The National Health Insurance (NHI) reform is raising a need for scrutiny of all providers. The HMI recommends regulations, systems for effective and fair price control and institutions to oversee the market. Scheme members are urged by the author to obtain the report and to challenge the Minister of Health to implement the recommendations.

Health Market Inquiry: ‘Nothing we don’t already know’, says Health Minister
Unnamed author: Medical Brief, South Africa, July 2018

This article raises that the four-year long Competition Commission Health Market Inquiry’s findings reveal what Health Minister Dr Aaron Motsoaledi says he already knew – that South Africa’s private healthcare has become so expensive that even those on medical aid can’t afford it. The article reports that the inquiry singled out the dominance of Discovery Health among medical schemes, and Netcare, Mediclinic and Life Healthcare among hospital groups, as illustrations of competitive market failure. The commission found that the market was characterised by high and rising costs of healthcare and medical scheme cover, by disempowered and uninformed consumers, and by a general absence of value-based purchasing. According to the inquiry’s chair, former Chief Justice, Sandile Ngcobo – who presented the executive summary of the report – the private healthcare sector market displayed consistently rising medical scheme premiums accompanied by increasing out-of-pocket payments for the insured, almost stagnant growth in covered lives and a progressively decreasingly range and depth of services covered by scheme options. Although there were 22 open schemes, two medical schemes constitute 70% of the total open scheme market and Discovery Health Medical Scheme comprised 55% of the open scheme market. The Government Employees Medical Scheme (GEMS) was the second largest restricted scheme. There were 16 medical scheme administrators and Discovery Health and Medscheme accounted for 76% of the market based on gross contribution income. The inquiry also found that there was a failure by practitioners to explore multi-disciplinary models of care and that the fee-for-service model of remuneration stimulated oversupply, and incentivised practitioners to provide more services than needed. The inquiry was also reported to raise the issue of an incomplete regulatory regime in the private healthcare sector: Medical facilities were not regulated beyond the requirement to have a licence to operate and practitioners licensed to practice by the Health Professions Council of SA but little more. The report is open for comments until 7 September 2018 and the final report is expected to be released on 30 November.

Washing with hope: evidence of improved handwashing among children in South Africa from a pilot study of a novel soap technology
Burns J; Maughan-Brown B; Mouzinho Â: BMC Public Health 18(709), doi:, 2018

While regular handwashing effectively reduces communicable disease incidence and related child mortality, instilling a habit of regular handwashing in young children continues to be a challenging task, especially in low income countries. A randomised controlled pilot study assessed the effect of a novel handwashing intervention – a bi-monthly delivery of a colourful, translucent bar of soap with a toy embedded in its centre (HOPE SOAP©) – on children’s handwashing behaviour and health outcomes. Between September and December 2014, 203 households in an impoverished community in Cape Town, South Africa, were randomised (1:1) to the control group or to receive HOPE SOAP©. Of all children aged 3–9 years and not enrolled in early childhood development programmes, Two ‘snack tests’ (children were offered crackers and jam) were used to provide objective observational measures of handwashing. Through baseline and endline surveys, data were collected from caregivers on the frequency (scale of 1–10) of handwashing by children after using the toilet and before meals, and on soap-use during handwashing. Data on 14 illnesses/symptoms of illness experienced by children in the two weeks preceding the surveys were collected. At the end, HOPE SOAP© children were directly observed as being more likely to wash their hands unprompted at both snack tests (49% vs 39%) and were more likely to use soap when washing their hands. HOPE SOAP© children, in general, had better health outcomes, used the soap as intended and were less likely to have been ill. Results point towards HOPE SOAP© being an effective intervention to improve handwashing among children.

Leveraging the power of partnerships: spreading the vision for a population health care delivery model in western Kenya
Mercer T; Gardner A; Andama B; et al.: Globalization and Health 14(44), doi:, 2018

This paper describes an academic partnership to support the public-sector health care system, with a major focus on scaling up HIV care in western Kenya to build a system able to take responsibility for the health of an entire population. The population health care delivery model involved comprehensive, integrated, community-centred, and financially sustainable services, with a path to universal health coverage. The authors share information on the partnership with strategic planning and change management experts from the private sector to use a ‘Learning Map®’ to collaboratively develop and share a vision of population health, and achieve strategic alignment with key stakeholders at all levels of the public-sector health system in western Kenya. The authors describe how the model has leveraged the power of partnerships to move beyond the traditional disease-specific silos in global health to a model focused on health systems strengthening and population health.

Experimental vaccine to be used against Ebola outbreak in the DRC
Branswell H: Stat, 2018

A campaign to vaccinate people at risk of developing Ebola in the latest outbreak in the Democratic Republic of the Congo began in May 2018. The government of the DRC has formally asked to use an experimental vaccine being developed by Merck. The WHO has a stockpile of 4,300 doses of the vaccine in Geneva and the company has 300,000 doses of the vaccine stockpiled in the United States. Merck has given its permission for the vaccine to be used in this outbreak. As the vaccine — provisionally called V920 — is not yet licensed, the government deployed it under a compassionate use protocol. At this stage, it can only be used in the context of a clinical trial, plans for which are already in the works. The WHO director-general noted that DRC has lots of experiencing combating Ebola, since the first known outbreak in 1976 happened there. The 2018 outbreak marks the ninth known time Ebola has broken out in the DRC.