Public-Private Mix

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.

Water operator partnerships as a model to achieve the Millenium Development Goals for water supply? Lessons from four cities in Mozambique
Coppel GP and Schwartz K: Water SA 37(4): 575-584, October 2011

The concept of ‘water operator partnerships’ (WOPs) has increasingly been promoted as a means to improving water services provision in developing countries. The International Water Association (IWA)defines WOPs as ‘any formal or informal collaboration or structured partnership aimed at capacity building on a not-for-profit basis. In the WOPs approach emphasis is on capacitating (rather than replacing) the public organisation. Researchers assessed the potential of such partnerships as a ‘model’ for contributing to the Millennium Development Goals (MDGs), by focusing on four water utilities in Mozambique. Although, the study found these partnerships to be successful, their replicability and potential for scale up was found to be quite limited. The study found that WOPs depended for success on the availability of investment funds, and the level of commitment to the partnership, both financial commitment and time and effort of the organisations involved.

We must engage the private sector to improve health care in low-income countries
Smith R, Feachem R, Feachem NS, Koehlmoos TP and Kinlaw H: PLoS Medicine, November 2008

This article argues that, with a complicated problem such as improving health care under constrained resources, two heads are better than one. The public and private sectors have different strengths and weaknesses, and a judicious blending of the two can produce optimal results. Indeed, there is no health system that is entirely public or private. The reality is that, in most low-income countries, most people receive most of their care from the broadly defined private sector. About 60% of the US$16.7 billion spent on health in sub-Saharan Africa in 2005 was private, most of it out-of-pocket spending by individuals, and about half of this went to private providers. Some countries are now exploring pluralistic models that partner with the private sector to serve public policy goals. These models should be encouraged and supported.

What can be done about the private health sector in low-income countries?

Improving the quality of private health care provision in developing countries is of major importance to the livelihoods of poor people. This article was published in the ‘Bulletin of the World Health Organisation’ and summarises how the activities of the private health sector in low-income countries can be influenced so that national health objectives are met. The article begins with an overview of the characteristics of the private health sector in developing countries. It continues with a summary of how to improve both the supply and the demand for private health care. To close, the authors list the possibilities available to governments for improved stewardship of the private sector.

What can be done about the private health sector in low-income countries?

Anne Mills, Health Policy Unit, London School of Hygiene and Tropical Medicine. Ruairi Brugha, Kara Hanson, Barbara McPake. Bulletin of the World Health Organization 2002;80(4):325-330. April 2002. Available on PDF. A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.

What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries
Mackintosh M; Channon A; Karan A; Selvaraj S; Cavagnero E; Zhao H: The Lancet, June 2016, doi:

Private health care in low-income and middle-income countries is noted to be extensive and heterogeneous, ranging from medicine sellers, through millions of independent practitioners—both unlicensed and licensed—to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors. In this paper, the authors propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. The authors develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sector's structure and behaviour, and vice versa.

What price health?
User fees and the poor in Sierra Leone

User fees are an increasingly common component of public health financing. The intention is to provide patients with a cheaper but high quality alternative to private healthcare. But does it work? What is the impact on the poorest households? Do poor people still use public health services when they have to pay fees?