Public-Private Mix

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.

Free Zimbabwean contraceptives smuggled for sale in South Africa
K Mutandiro: Groundup, Times Live, March 2017

This article tells a story of Nancy (not her real name), who every month travels to Zimbabwe to stock up on Marvelon family planning pills distributed at hospitals‚ clinics and pharmacies through the Family Planning Council of Zimbabwe. She smuggles them back into South Africa‚ where she sells them at a healthy profit to other Zimbabweans who for various reasons don’t want the contraceptive pills dispensed in South African clinics. Nancy’s suppliers are hospital staff in Zimbabwean hospitals who sell the pills to her for R5 a blister pack. If she runs short of stock‚ she buys packets for R10 from a “wholesale” supplier in Johannesburg who also illegally imports the pills from Zimbabwe. Nancy says she has a 100 customers a month in Springs alone‚ and she sells the packets for R20 to bulk buyers or R30 to individuals. By contrast‚ Marvelon tablets were reported to be sold for about R130 per 28 tablets in Johannesburg pharmacies

Can the private sector help achieve universal health coverage?
Nishtar S: World Economic Forum, 2016

When the world committed to ending poverty, protecting the planet and ensuring prosperity for all with the 17 Sustainable Development goals, we knew no single entity would be able to achieve such lofty goals – it would take collaboration. “A successful sustainable development agenda requires partnerships between governments, the private sector and civil society,” Goal 17 stated. The author argues that in few areas is that more obvious than in the fight to achieve universal health coverage, which falls under Goal 3 of Good Health and Wellbeing. If universal health coverage in all countries is to be achieved, even those where privately-financed market delivery is predominant, this will depend on the ability of governments to harness their potential. In such contexts, she observes, it is critical to build the stewardship capacity of public agencies so that they can frame and implement rules that define the environment and the incentives that guide the behaviours of health system players. Rather than focusing on privatisation, marketisation or the scaling up of private provision, the idea would be to get private actors involved in the pursuit of universal health coverage and financial protection goals. Although the private sector often has a dominant role in the provision of healthcare, too often governments do not know enough about how these providers operate, and there is little, if any, regulation in place. She recommends that countries examine if service delivery models incorporating tools such as franchising and social marketing and utilising economies of scale, standardisation, and/or market incentives can enable universal health coverage within their respective health systems. In recent years, public ownership and not-for-profit service provision and autonomous governance arrangements have been promoted over publicly financed, owned and operated models. However, gains due to hospital autonomy should go beyond revenues for hospitals and incentives for staff and must also enhance quality and equity. New frameworks of participatory governance and appropriate channels of accountability and regulation need to be established. She notes however that the commercial presence of a foreign service provider could create a dual market structure, with high-quality services being provided to affluent consumers to the detriment of the healthcare needs of poorer people. Additionally, the movement of healthcare providers and brain drain – both internal and external – can lead to a loss of trained healthcare providers in the home country. Policy safeguards will be needed to prevent this type of situation.

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.

An assessment of private General Practitioners contracting for public health services delivery in O.R. Tambo District, South Africa
Hongoro C; Funani I; Chitha W; Godlimpi L: Journal of Public Health in Africa 6(2) doi:

Low- and middle-income countries are striving towards universal health coverage in a variety of ways. Achieving this goal requires the participation of both public and the private sector providers. The study sought to assess existing capacity for independent general practitioner contracting in primary care, the reasons for the low uptake of government national contract and the expectations of general practitioners of such contractual arrangements. This was a case study conducted in a rural district of South Africa. The study employed both quantitative and qualitative data collection methods. Data were collected using a general practitioner and practice profiling tool, and a structured questionnaire. A total of 42 general practitioners were interviewed and their practices profiled. Contrary to observed low uptake of the national general practitioner contract, 90% of private doctors who had not yet subscribed to it were actually interested in it. Substantial evidence indicated that private doctors had the capacity to deliver quality care to public patients. However, low uptake of national contract related mostly to lack of effective communication and consultation between them and national government which created mistrust and apprehension amongst local private doctors. Paradoxically, these general practitioners expressed satisfaction with other existing state contracts. An analysis of the national contract showed that there were likely to benefit more from it given the relatively higher payment rates and the guaranteed nature of this income. Proposed key requisites to enhanced uptake of the national contract related to the type of the contract, payment arrangements and flexibility of the work regime, and prospects for continuous training and clinical improvements. Low uptake of the national General Practitioner contract was due to variety of factors related to lack of understanding of contract details. Such misunderstandings between potential contracting parties created mistrust and apprehension, which are fundamental antitheses of any effective contractual arrangement. The authors suggest that the idea of a one-size-fits-all contract was probably inappropriate.

Health system’s barriers hindering implementation of public-private partnership at the district level: a case study of partnership for improved reproductive and child health services provision in Tanzania
Kamugumya D; Oliver J: BioMed Central 16(596), 2016

Public-private partnership (PPP) has been suggested as a tool to assist governments in lower to middle income countries fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level – which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP. This case study was conducted in the Bagamoyo district of Tanzania, and employed 30 in-depth interviews, document reviews, and observations methods. A stakeholder analysis was conducted to understand power distribution and the interests of local actors to engage non-state actors. The study findings reveal several forms of informal partnerships, and the untapped potential of non-state actors. Lack of formal contractual agreements with private providers including facilities that receive subsidies from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. Furthermore, findings highlight weak capacity of governing bodies to exercise oversight and sanctions, which is acerbated by weak accountability linkages and power differences. Disempowered Council Health Services Board, in relation to engaging non-state actors, is shown to impede PPP initiatives. Effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Orientation towards collaborative efforts that create value and enable its distribution is argued to facilitate healthy partnership, and in return, strengthen a district health system. This study highlights a need for new social contracts that will support integrative collaboration at the local level and bring all non-state actors to the centre of the district health system.