Public-Private Mix

Untangling the web of anti-retroviral price reductions
Campaign for Essential Medicines: Médecins Sans Frontières, 17 July 2011

In this report, Médecins Sans Frontières (MSF) notes that middle-income countries with large numbers of people living with HIV, such as South Africa, will no longer benefit from preferential pricing when buying antiretroviral drugs from large pharmaceutical companies. According to the report, pharmaceutical firm ViiV Healthcare - owned by Pfizer and GlaxoSmithKline - no longer offers reduced prices to middle-income countries, even when their programmes are fully funded by the Global Fund to fight HIV, Tuberculosis and Malaria. Merck has also ceased to offer discounted prices to all lower middle- and upper middle-income countries, proposing instead to negotiate discounts on a case-by-case basis. Previously, Merck offered middle-income countries discounts that were still up to ten times the price of generic versions. MSF warns that drug company discount programmes are not a long-term solution, and urges governments to start using Trade-related Aspects of Intellectual Property Rights (TRIPS) measures to override patents.

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.

Use of over-the-counter malaria medicines in children and adults in three districts in Kenya: implications for private medicine retailer interventions
Abuya TO , Mutemi W, Karisa B, Ochola SA, Fegan G, Marsh V: Malaria Journal 6:57, 10 May 2007

Global malaria control strategies highlight the need to increase early uptake of effective antimalarials for childhood fevers in endemic settings, based on a presumptive diagnosis of malaria in this age group. Many control programmes identify private medicine sellers as important targets to promote effective early treatment, based on reported widespread inadequate childhood fever treatment practices involving the retail sector. Data on adult use of over-the-counter (OTC) medicines is limited. This study aimed to assess childhood and adult patterns of OTC medicine use to inform national medicine retailer programmes in Kenya and other similar settings.

User Fees and the impact on female children in rural zambia

The World Bank and International Monetary Fund favour healthcare user fees. User fees offer revenue and may decrease inappropriate care. However, user fees may deter needed care, especially in vulnerable populations. A cross-sectional analysis of healthcare utilization in a large Zambian hospital was conducted for children 3-6 years of age during a one-month observation period. Trends suggest female children may be less likely to present for care when user fees are imposed. This paper concludes that user fees appear to decrease differentially utilization of inpatient care for female children in rural Zambia.

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.