Public-Private Mix

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: https://doi.org/10.1186/s12889-018-5573-8, 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: https://doi.org/10.1186/s12992-018-0366-5, 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.

Use of family planning and child health services in the private sector: an equity analysis of 12 DHS surveys
Chakraborty N; Sprockett A: International Journal for Equity in Health 17(50) 1-12, 2018

This paper seeks to explore improved access to healthcare while minimizing financial hardships or inequitable service delivery. The authors analyzed Demographic and Health Survey data from Bangladesh, Cambodia, DRC, Dominican Republic, Ghana, Haiti, Kenya, Liberia, Mali, Nigeria, Senegal and Zambia. They conducted weighted descriptive analyses on current users of modern family planning and the youngest household child under age 5 to understand and compare country-specific care seeking patterns in use of public or private facilities based on urban/rural residence and wealth quintile. The modern contraceptive prevalence rate ranged from 8.1% to 52.6% across countries, generally rising with increasing wealth within countries. For relatively wealthy women in all countries except Ghana, Liberia, Mali, Senegal and Zambia, the private sector was the dominant source. Source of family planning and type of method sought across facilities types differed widely across countries. Across all countries women were more likely to use the public sector for permanent and long-acting reversible contraceptive methods. Wealthier women demonstrated greater use of the private sector for family planning services than poorer women. Overall prevalence rates for diarrhoea and fever/ARI were similar, and generally not associated with wealth. Over 40% of children with cough or fever did not seek treatment in DRC, Haiti, Mali, and Senegal. Of all children who sought care for diarrhoea, more than half visited the public sector and just over 30% visited the private sector; with differences more pronounced in the lower wealth quintiles. Use of the private sector varies widely by reason for visit, country and wealth status. Given these differences, the authors suggest that country-specific examination of the role of the private sector furthers an understanding of its utility in expanding access to services across wealth quintiles and providing equitable care.

Health-industry linkages for local health: reframing policies for African health system strengthening
Mackintosh M; Mugwagwa J; Banda G; et al: Health Policy and Planning 33(4) 602–610, 2018

A current wave of pharmaceutical industry investment in sub-Saharan Africa is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. The authors present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. The authors identify key policies that can ensure that local health systems benefit from the investments. They argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. This local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.

From Kenya’s postelection violence, an online community forms to give aid
Habib J: The Christian Science Monitor, March 2018

Kenya’s post election violence has led to the founding of RescueBnB – a community with the mission to map the locations of those in need of shelter and connect them with volunteer hosts. With a core team of volunteers, a web developer set up the pro bono website, and Kenyans have spread the word on social media. Within 48 hours of this, they had assembled more than 100 volunteers across the country and had arranged multiple home stays with vetted hosts. To date, RescueBnB has supported 800 people across Kenya, and team members say that’s just the start. RescueBnB has since begun crowdfunding to provide care packages as well as to cover medical expenses. Its partnerships with community organizations and religious groups helped it reach more individuals, and companies stepped in to assist. A supermarket chain welcomed shoppers to drop off donations, and a boda boda (motorbike) delivery company volunteered to get the donations into the hands of people who needed them.

Health-industry linkages for local health: reframing policies for African health system strengthening
Mackintosh M; Mugwagwa J; Banda G; et al: Health Policy and Planning 33(4), doi: https://doi.org/10.1093/heapol/czy022, 2018

Low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialisation strategies. The authors present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. Key policies are identified that can ensure that local health systems benefit from the investments. The authors argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. This local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.

Fiscal policy to improve diets and prevent non-communicable diseases: from recommendations to action
Thow A; Downs S; Mayes C; et al: Bulletin of the World Health Organisatio 96(3) 201–210, 2018

The World Health Organization has recommended that Member States consider taxing energy-dense beverages and foods and/or subsidizing nutrient-rich foods to improve diets and prevent noncommunicable diseases. Numerous countries have either implemented taxes on energy-dense beverages and foods or are considering the implementation of such taxes. However, several major challenges to the implementation of fiscal policies to improve diets and prevent noncommunicable diseases remain. Some of these challenges relate to the cross-sectoral nature of the relevant interventions. For example, as health and economic policy-makers have different administrative concerns, performance indicators and priorities, they often consider different forms of evidence in their decision-making. In this paper, the evidence base for diet-related interventions based on fiscal policies are described and the key questions that need to be asked by both health and economic policy-makers are considered. From the health sector’s perspective, there is most evidence for the impact of taxes and subsidies on diets, with less evidence on their impacts on body weight or health. The authors highlight the importance of scope, the role of industry, the use of revenue and regressive taxes in informing policy decisions.

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