Public-Private Mix

Healthcare is not a commodity but a public good
Vermuyten S; Public Services International (PSI): Spotlight on Sustainable Development, 2017

The author argues that social protection systems that are based on solidarity, sharing of risks, and built on collective bargaining and social dialogue, democratic structures and long-term strategies are needed to combat poverty and address inequalities and inequity. Universal social protection is essential to achieve gender equality, given a strong link between the provision of public services and the ability of women to enter the labour market, to address unpaid care work responsibilities and to ensure that children have access to health and social services. The push for the individualisation of social protection is reported to have had a major impact on the delivery of these services, including on the provision of health and social care, pensions and unemployment benefits, to which austerity programmes have added perverse effects that lead to social exclusion or risk exposure – instead of inclusion and protection. Genuine support for universal social security and healthcare could thus, he argues, make important contributions to the achievement of decent work and reduced inequality. However, the international financial institutions (IFIs) continue to promote social protection reforms that focus on targeting, which is less efficient and more costly, rather than broad coverage. Reforms promoted by the World Bank, IFC and Regional Development Banks, including marketisation, decentralisation and corporatization of the public sector, provide opportunities for multinational companies to enter the public health care sector. In addition, public health spending is coming under increasing scrutiny across the world, particularly since the 2008-2009 global financial and economic crisis. Cuts to public sector funding often penalise health workers and lead to reduced services at a time when demand for such services is increasing, as the economic crisis impacts on the wider economy. The author thus argues that the main policy tools in the orthodox approach to health sector financing risk being counter-productive. Efforts to reduce costs by increasing competition have created fragmented structures that work against the integration and coordination of healthcare. Bringing in the private sector is likely to accentuate this silo mentality in provision, in the name of commercial confidentiality and profit maximisation.

Philanthropy in a Recession
Gastrow S: Daily Maverick, South Africa, August 2017

The author raises that South Africa has limited data on what grant making takes place and on the size and scope of the civil society sector, despite a a dependency on international funding and support from private philanthropic foundations. According to Nedbank Private Wealth’s Giving Report III, however, only 5% of the high net worth individuals surveyed had actually established a giving trust or foundation. That meant that the balance were giving money on an ad hoc basis. The same report indicated that South African givers “demonstrated a long-term commitment to the causes they support. Nearly half had supported beneficiaries for longer than five years (and) 22% had been supporting them for their entire lives. The author suggests that in principle, philanthropy should be focusing on organisations that are involved in systemic change and government should be supporting those organisations that deal with basic human requirements. In that case, non-profits are unlikely to be greatly affected by recession. However, that does not apply in South Africa where philanthropy is being stretched to its limits by the high level of needs not being met by the state. The choice of where limited resources can go is a hard one, but it is argued that those donating funds will support those organisations that are aligned with their individual passions for specific causes and their values, combined with effective and efficient outcomes.

Improving primary health care facility performance in Ghana: efficiency analysis and fiscal space implications
Novignon J; Nonvignon J: Biological Medical Central Health Services Research 17(1) 399, doi: 10.1186/s12913-017-2347-4, 2017

This study estimated efficiency among primary health facilities (health centres), examined the potential fiscal space from improved efficiency and investigated the efficiency disparities in public and private facilities. Data was from the 2015 Access Bottlenecks, Cost and Equity project conducted by the Institute for Health Metrics and Evaluation. The Stochastic Frontier Analysis was used to estimate efficiency of health facilities. Efficiency scores were then used to compute potential savings from improved efficiency. Outpatient visits was used as output while number of personnel, hospital beds, expenditure on other capital items and administration were used as inputs. Disparities in efficiency between public and private facilities were estimated using the Nopo matching decomposition procedure. The average efficiency score across all health centres included in the sample was estimated to be 0.51, about 0.65 and 0.50 for private and public facilities, respectively. Significant disparities in efficiency were identified across the various administrative regions. With regards to potential fiscal space, the authors found that, on average, facilities could save about US$7634 if efficiency was improved. The authors also found that fiscal space from efficiency gains varies across rural/urban as well as private/public facilities, if best practices are followed. They argue for primary health facility managers to improve productivity via effective and efficient resource use, through training of health workers and improving the facility environment alongside effective monitoring and evaluation exercises.

The medical device development landscape in South Africa: Institutions, sectors and collaboration
De Jager K; Chimhundu C; Saidi T; Douglas TS: South African Journal of Science 13(5/6), 2017

A characterisation of the medical device development landscape in South Africa would be beneficial for future policy developments that encourage locally developed devices to address local healthcare needs. The landscape was explored through a bibliometric analysis (2000–2013) of relevant scientific papers using co-authorship as an indicator of collaboration. Collaborating institutions found were divided into four sectors: academia (A); healthcare (H); industry (I); and science and support (S). A collaboration network was drawn to show the links between the institutions and analysed using network analysis metrics. The academic sector collaborated the most extensively both within and between sectors; local collaborations were more prevalent than international collaborations. Translational collaborations (AHI, HIS or AHIS) are considered to be pivotal in fostering medical device innovation that is both relevant and likely to be commercialised. Few such collaborations were found, suggesting room for increased collaboration of these types in South Africa. These results could inform the development of strategies and policies to promote certain types of medical device development. Further studies could identify drivers and barriers to successful medical device development in South Africa.

Bill Gates Won’t Save You From The Next Ebola
Fortner R; Park A: The World Post, May 2017

The author points out that no single non-governmental institution or individual wields more influence, and no one’s support is more powerful in global health, than the Gates Foundation and its namesake founders, Bill and Melinda Gates. The foundation has $39.6 billion in assets and spent $2.9 billion on developmental assistance for global health in 2015 alone ― more than every country in the world except the U.S. and the U.K. The author argues that WHO has frequently fallen short of its goal to protect and promote health of all people, leading some to propose returning to a more philanthropy-focused model. That means private charities such as the Gates Foundation might play an even larger role in protecting public health, which calls for scrutiny of the role that philanthropy has played in recent years. When the Gates Foundation takes aim at a disease, it can elicit billions of dollars from governments and reshape the world’s agenda for scientific research, to the cost of other diseases. WHO reliance on voluntary contributions from countries and private donors, including the Gates Foundation, for around 80 percent of its budget is argued to make the organisation vulnerable to outside pressure and funder 'pet programs', which skews global health priorities. The author documents trends post 2014 and argues that the world remains grossly underprepared for outbreaks of infectious disease, which are likely to become more frequent in the coming decades, according to a meta-analysis of post-Ebola studies published in January 2017. The author indicates that public and state funding remains critical for international health efforts and cannot be left to private players to fill the void.

African app cuts medical costs with community "virtual pharmacy"
Reuters: Times Live, February 2017

A mobile app in Senegal helps families save money and reduce waste through a "virtual pharmacy" where users can exchange leftover medication for new prescriptions. JokkoSante is scaling up after a two-year pilot phase in one Senegalese town. It aims to reach 300,000 families in the West African nation by the end of the year. The app allows users to trade in unused, packaged medicine for points which can go toward the purchase of new medicine when they need it. All of the exchanges are done at health centres or pharmacies by licensed professionals. Users can send points to family members and friends, and donors can buy points for people in need. The project has been driven by telecoms companies. It reaches a certain demographic, such as women in their thirties, and if a matching user doesn't have enough points to pay for a prescription she will receive a text saying which company donated to complete her purchase.

Open letter to WHO DG candidates: keep policy and priority setting free of commercial influence
Brown K; Rundall P; Lobstein T; Mwatsana M; Jeffery B: The Lancet 389(10082) 1879, May 2017

An open letter was submitted by the authors on behalf of 61 signatories for the election of the new WHO Director General (DG) to take into account how the new leadership will ensure appropriate interactions with alcohol, food, pharmaceutical, and medical technology industries. In May 2016, WHA adopted the Framework of Engagement with Non-State Actors (FENSA), a policy due to be fully operational by May, 2018. While FENSA envisages that WHO will “exercise particular caution…when engaging with private sector entities …whose policies or activities are negatively affecting human health..”, the rhetoric and direction of WHO's reform process as well as WHO's chronic funding challenges are argued to have left the signatories concerned rather than reassured. They fear that instead of protecting WHO's mandate, FENSA risks relegating WHO to a limited role, unable to stand up for human rights and democratic decision making. The signatories draw attention to the conflict of interest statement signed by more than 175 NGOs and networks representing more than 2000 groups and first launched at the UN High-Level Meeting on Non-communicable Diseases in 2011: “The policy development stage should be free from industry involvement to ensure a ‘health in all policies’ approach, which is not compromised by the obvious conflicts of interests associated with food, alcohol, beverage and other industries, that are primarily answerable to shareholders.” They indicate that alcohol, food, pharmaceutical, and medical technology industries should comply with policies developed by WHO and its Member States, and that their role is not in public health policy formulation, risk assessments, risk management, or priority setting, nor in determining normative quality standards and legally binding regulations to protect and promote public health. These processes, it is argued, must be undertaken in an environment free of commercial influence. The signatories believe that only a WHO that protects its independence and integrity of decision making will have the ability to fulfil its constitutional mandate.

Social and Economic Impacts of Public Private Partnership Agreements to the Realisation of the Right to Health: The Case of Chitungwvza Central Hospital
Zimbabwe Coalition on Debt and Development (ZIMCODD), Harare, 2017

Zimbabwe's health sector has been under-funded for some time causing public health service providers, including Chitungwiza Central Hospital (CCH), to operate below capacity despite the increasing patient demand. CCH entered into a Public Private Partnership (PPP) agreement, now a Joint Venture Partnership, to upgrade quality and availability of health services. However, in this report the authors argue that the intended benefits of the PPP are not being realised because the poor people face increasing fee barriers due to the demand for upfront payment. A survey in 2016 included key informant interviews, client interviews and focus group discussions. It found that the majority of respondents have below poverty monthly household incomes. Most users did not understand the PPP model, and indicated that the hospital did not consult residents on the adoption of the PPP model. Two thirds of respondents felt that services were better before the adoption of the PPP model. Poorer respondents mainly raised the fact that they could not afford services after the PPP due to fee charges, while those with higher incomes felt services had improved due to improved availability of medicines and other supplies. The respondents perceived that not accessing services due to cost barriers for example violated their right to health. The authors note that while there are opportunities to adopt PPP models in sectors such as transport for the construction of roads, rails, and toll gates, these models should not be used in health sectors and other essential services where commoditisation of public services affects access.

The Importance of Health and Safety at African Mine Sites
Bocoum B: World Bank, Live Wire 2017/70, doi:

This brief observes that equity and shared prosperity calls for a closer look at the working and living conditions of millions of mine workers in Africa, where tuberculosis (TB) imposes a high burden on mining economies and constitutes a regional public health crisis. Health hazards are reported to be perpetuated by poor enforcement of mining legislation, limited application of best international practices, weak institutions, and inadequate equipment and skills. In uncontrolled mining operations and communities of the type common in Africa, several factors are argued to combine to form a perfect storm for TB infection and transmission. They argue that the practice of allowing mining companies to self-report on health issues should be eliminated and that legislation on the health aspects of mining operations in Africa must be developed in line with international standards and best practices. The continent’s regional development communities should act urgently to establish public-private partnerships capable of ensuring that mining in fact benefits the region’s people in their path toward sustainable development. The goal should be the adoption of preventive measures to avoid further damage to the region’s health and skilled human capital.

Gold mining pollution and the cost of private healthcare: The case of Ghana
Akpalu W; Normanyo A: United Nations University, WIDER Working Paper 2016/121, 2016

To attract greater levels of foreign direct investment into their gold mining sectors, the authors observe that many mineral-rich countries in sub-Saharan Africa have been willing to overlook serious instances of mining company non-compliance with environmental standards, and that these lapses in regulatory oversight and enforcement have led to high levels of pollution in many mining communities. This is argued to raise the risk of pollution-related sicknesses, such as skin infections, upper and lower respiratory disorders, and cardiovascular diseases, will necessitate increasingly high healthcare expenditures in affected communities. In this study, the authors propose and estimate a model that relates healthcare expenditure to the degree of residents’ exposure to mining pollution using data obtained on gold mining in Ghana. The empirical results confirm that, after controlling for factors such as current and long-term health status, increased mining pollution leads to higher healthcare expenditure.