Public-Private Mix

One year on, Global Observatory on Health R&D identifies striking gaps and inequalities
World Health Organisation: WHO, Geneva, 2018

Each year, hundreds of billions of dollars are spent on research and development (R&D) into new or improved health products and processes, ranging from medicines to vaccines to diagnostics. But the way these funds are distributed and spent is often poorly aligned with global public health needs. in 2017, the World Health Organization launched an initiative to gather information and provide an accurate picture of where and how R&D monies are being spent. The Global Observatory on Health R&D has identified striking gaps and inequalities in investment both between countries and between health issues, with frequent disconnects between burden of disease and level of research activity. High income countries have an average of 40 times more health researchers than low income countries. Serious imbalances in funding flows mean countries with comparable levels of poverty and health needs receive strikingly different levels of Official development assistance (ODA) for medical research and basic health sectors (health ODA). As little as 1% of all funding for health R&D is allocated to diseases such as malaria and tuberculosis, despite these diseases accounting for more than 12.5% of the global burden of disease. Investing in R&D to discover and develop medicines and vaccines is argued to be key to improving access to medicines and quality health care for people across the world and to achieving universal health coverage.

Private Sector Participation and Health System Performance in Sub-Saharan Africa
Yoong J; Burger N; Spreng C; et al: PLoS ONE 5(10), doi: https://doi.org/10.1371/journal.pone.0013243, 2017

The role of the private health sector in developing countries remains a much-debated and contentious issue. Critics argue that the high prices charged in the private sector limits the use of health care among the poorest, consequently reducing access and equity in the use of health care. Supporters argue that increased private sector participation might improve access and equity by bringing in much needed resources for health care and by allowing governments to increase focus on underserved populations. However, little empirical exists for or against either side of this debate. The authors examined the association between private sector participation and self-reported measures of utilization and equity in deliveries and treatment of childhood respiratory disease using regression analysis, across a sample of nationally-representative Demographic and Health Surveys from 34 SSA economies. To measure private sector participation, we computed the percentage of live births that took place in a private (for-profit or non-profit/mission) health facility and the percentage of children with ARI symptoms who were treated at a private health facility. Private sector participation was positively associated with greater overall access and reduced disparities between rich and poor as well as urban and rural populations, including after controlling for confounders including per capita income and maternal education. However, higher private sector participation may be affected by other variables that also affect access and equity. In addition to an increased level of overall service utilization, countries with a relatively large share of private sector participation tend to also have significantly higher levels of maternal education and also higher levels of GDP per capita, so the relationships may be confounded by differences in socioeconomic development (particularly maternal education, a well-established key determinant of health service utilization and child health outcomes). The authors controlled for maternal education and per capita income but report that other confounders such as better functioning transportation infrastructure may also influence both private sector participation and access. They further notes that the appropriate role of the private sector might depend on the capacity of governments to provide effective stewardship and regulation, the health care financing environment, and the organization of the public health sector.

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: http://dx.doi.org/10.1080/16549716.2017.1389181, 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.

Mental health leadership and patient access to care: a public–private initiative in South Africa
Szabo C; Fine J; Mayers P; et al.: International Journal of Mental Health Systems 11(52)1-8, 2017

Despite the significant adverse social and economic costs of mental illness, psychiatric and related services receive a low level of priority within the health care system. A public–private mental health leadership initiative, emanating from a patient access to care programme, was developed to build leadership capacity within the South African public mental health sector. The projects were varied in nature but all involved identification of and a plan for addressing an aspect of the participants’ daily professional work which negatively impacted on patient care due to unmet needs. Six such projects were included with personnel from psychiatry, psychology, occupational therapy and nursing. Each project group was formally mentored as part of the initiative, with mentors being senior professionals with expertise in psychiatry, public health and nursing. Participants acquired both skills and the confidence to sustain the changes that they themselves had initiated in their institutions. The initiative gave impetus to the inclusion of public mental health as part of the curriculum for specialist training.

Commercial determinants of health - the role of governments remains crucial
The Graduate Institute: GI, Geneva, 2017

A multi stakeholder panel on “Governing Non-Communicable Diseases - Addressing the Commercial Determinants of Health” was held as a side-event during the 70th session of the World Health Assembly. It explored the commercial determinants of health, their links to the political determinants of health and how to navigate the narrow space to create both health and wealth, not just the latter at the expense of the first. The panel identified that government has a central role in taking the lead in policy formulation and in creating a political space for this. Rocco Renaldi from the International Food and Beverage Alliance highlighted the need for governments to create a regulated space and to encourage systemic change within the private sector which will allow them to adjust their strategies to meet the challenge. of chronic conditions. NCD Alliance Executive Director Katie Dain raised in contrast that the private sector has no role in policy development as this remains the responsibility of governments. The event made a case for enhanced engagement between different sectors of government to build systems of accountability, monitoring and implementation to manage the private sector in health.

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.

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