Public-Private Mix

User fees in private non-for-profit hospitals in Uganda: a survey and intervention for equity
International Journal for Equity in Health 2005

"...user fees represent an unfair mechanism of financing for health services because they exclude the poor and the sick. To mitigate this effect, flat rates and lower fees for the most vulnerable users were introduced to replace the fee-for-service system in some hospitals after the survey. The results are encouraging: hospital use, especially for pregnancy, childbirth and childhood illness, increased immediately, with no detrimental effect on overall revenues. A more equitable user fees system is possible."

Using pharmacists and drugstore workers as sexual healthcare givers: a qualitative study of men who have sex with men in Dar es Salaam, Tanzania
Agardh C; Weiji F; Agardh A; et al: Global Health Action 10(1), doi:, 2017

This study explored the perceptions and experiences of seeking treatment and advice from pharmacists and drugstore workers in Dar es Salaam, Tanzania, by men who have sex with men (MSM) with regards to their sexual health and STI-related problems. Fifteen in-depth interviews were conducted with MSM with experience of seeking assistance relating to their sexual health at pharmacies and drugstores in Dar es Salaam in 2016. Four themes related to different aspects of MSM’s perceptions and experiences of pharmacy care emerged from the analysis: Balancing threats against need for treatment reflected informants’ struggles concerning risks and benefits of seeking assistance at pharmacies and drugstores; Identifying strategies to access required services described ways of approaching a pharmacist when experiencing a sexual health problem; Seeing pharmacists as a first choice of care focused on informants’ reasons for preferring contact with pharmacies/drugstores rather than formal healthcare services; and lacking reliable services at pharmacies indicated what challenges existed related to pharmacy care. MSM perceived the barriers for accessing assistance for STI and sexual health problems at pharmacies and drugstores as low, thereby facilitating their access to potential treatment. However, the results further revealed that MSM at times received inadequate drugs and consequently inadequate treatment.

Using the Right to Health to Enforce the Corporate Responsibilities of Pharmaceutical Companies with Regard to Access to Medicines
Oke E: Journal of Health Diplomacy (1) 1: July 2013

This paper seeks to determine how the corporate responsibilities of pharmaceutical companies in relation to access to medicines can be clarified and enforced. Two cases, one each from India and South Africa, are examined to determine how the domestic courts in both countries indirectly utilized the right to health to ensure that pharmaceutical companies did not impede access to affordable medicines through exercising their patent rights. There is a need to clarify and enforce the responsibilities pharmaceutical companies have to promote the right to health. The two cases from India and South Africa demonstrate the potentials of domestic courts as forums where these responsibilities can be effectively enforced. In the absence of a global enforcement mechanism for enforcing the right-to-health responsibilities of pharmaceutical companies, domestic courts can effectively fill this gap. In addition, this paper demonstrates that domestic courts can equally serve as forums for health diplomacy.

Vaccine production, distribution, access and uptake
Smith J, Lipsitch M and Almond JW: The Lancet 378(9789): 428-438, 30 July 2011

For human vaccines to be available on a global scale, complex production methods, meticulous quality control and reliable distribution channels are needed to ensure that the products are potent and effective at the point of use, the authors of this article argue. The technologies used to manufacture different types of vaccines can strongly affect vaccine cost, ease of industrial scale-up, stability and, ultimately, worldwide availability. The complexity of manufacturing is compounded by the need for different formulations in different countries and age-groups. Reliable vaccine production in appropriate quantities and at affordable prices is the cornerstone of developing global vaccination policies, the author argue. However, they emphasise that to ensure optimum access and uptake, strong partnerships are needed between private manufacturers, regulatory authorities, and national and international public health services. For vaccines whose supply is insufficient to meet demand, prioritisation of target groups can increase the effect of these vaccines.

Value for money in working with the non-state sector in health: What do we know from DFID experience?
Walford V: Department for International Development DFID Health Resource Centre 2009

This paper, by the Department for International Development DFID Health Resource Centre, looks at the extent of DFID’s engagement with non-state actors (NSAs) in the health sector and what is known about the value for money of working with different types of NSAs in various ways. The paper details how DFID provides most of its support to health to the public sector. However there are cases where DFID provides funding directly to NSAs. In other cases, DFID support goes to the government, which then uses some of those funds to fund service delivery by NSAs. The author argues that, in addition to seeking value for money, it is important to consider equity. The evidence suggests that all income groups use non-state services but, as in most public sectors, there is higher use by the relatively better off. Whether working with the non-state sector provides better value for money will substantially depend on the quality of design and implementation. There is growing experience in contracting, social franchising, vouchers and performance incentives. The paper outlines various aspects which DFID might want to consider for the future including that in developing or reviewing health sector plans, they should consider opportunities to improve NSA efficiency and effectiveness and as a way to enhance access.

Video: The role of private nurse training institutions in the production of nurses in Kenya
Mwita N; Ngwawe C; Okaro S: AMREF Health Africa, Kenya, 2016

Kenya faces severe health workforce shortages, especially at the primary health care level. Currently, the density of nurses per 100,000 of the population is 103.4, far below the World Health Organisation minimum target threshold of 500 nurses per 100,000 required to provide sufficient coverage for essential interventions. RESYST research has shown that private and faith-based training institutions currently make up 30% of admissions for nursing courses in Kenya, and are increasingly being considered an important way of increasing nurse production. Students from private nursing institutions are much more likely to graduate than public sector students; of which up to 40% do not successfully complete their training. The curriculum of private institutions, however, is more limited with less focus on public health issues such as health equity and the social determinants of health. Whilst Kenya has increased capacity to train nurses in recent years, severe blockages remain in the system, including in nurses’ employment prospects upon graduation. This video is based on research carried out as part of the RESYST health workforce theme, which looks at the role of the private sector in addressing human resource constraints in Kenya.

Waivers and Exemptions for Health Services in Developing Countries
The World Bank, 2003

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. Different countries have tried different approaches. Those which have carefully designed and implemented waiver systems (e.g., Thailand and Indonesia) have had much greater success in terms of benefits incidence than countries that have improvised such systems (Ghana, Kenya, Zimbabwe).

World Bank 2003

This paper asks how to make a much needed system of user fees for government health services compatible with the goal of preserving equitable access to services. It demonstrates that different countries have tried different approaches and that those which have carefully designed and implemented waiver systems have had much greater success in terms of benefits incidence than countries that have improvised such systems.

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.

Water and WSSD -
Privatisation is not the only answer

The British government and its EU allies were accused at the WSSD of pushing privatisation as a one size fits all model for delivery of vital basic services such as water, despite considerable evidence that it has failed to deliver affordable, clean water to poor communities around the world.