Public-Private Mix

Achieving universal health coverage in East and Southern Africa: what role for for-profit providers?
Doherty J: Paper presented at the Panel session T03P13: Private sector and universal health coverage - examining evidence and deconstructing rhetoric International Conference on Public Policy, 1-4 July 2015, Milan, Italy

This paper considers evidence on the effectiveness, equity and sustainability of for-profit private provision, and the effectiveness of government’s stewardship of the sector, in East and Southern Africa. It draws conclusions about policy and regulatory requirements to encourage for-profit providers to make a more useful contribution towards achieving universal health coverage in the region. The author observes a recent increase in the size of a formerly relatively small for-profit private sector in some countries in the region, but also the emergence of 'boutique’ hospitals (targeted at the high-income local market, expats and foreign NGO workers, as well as medical tourism) in otherwise underdeveloped settings. As warned by the international literature that critiques the commercialisation of health care, such developments could worsen inequity and destabilise national health systems if inadequately regulated.

Differences in essential newborn care at birth between private and public health facilities in eastern Uganda
Waiswa P; Akuze J; Peterson S; Kerber K; Tetui M; Forsberg BC; Hanson C: Global Health Action 8(10), March 2015, doi: 10.3402/gha.v8.24251

In Uganda and elsewhere, the private sector provides an increasing and significant proportion of maternal and child health services. However, little is known whether private care results in better quality services and improved outcomes compared to the public sector, especially regarding care at the time of birth. This study described the characteristics of care-seekers and assess newborn care practices and services received at public and private facilities in rural eastern Uganda. The authors collected data from mothers with infants at baseline and endline using a structured questionnaire among private and public health facilities. Private health facilities did not perform significantly better than public health facilities in terms of coverage of any essential newborn care interventions, and babies were more likely to receive thermal care practices in public facilities compared to private (68% compared to 60%). Babies born at public health facilities received an average of 7.0 essential newborn care interventions compared to 6.2 at private facilities. Women delivering in private facilities were more likely to have higher parity, lower socio-economic status, less education, to seek antenatal care later in pregnancy, and to have a normal delivery compared to women delivering in public facilities. In this setting, private health facilities serve a vulnerable population and provide access to service for those who might not otherwise have it. However, provision of essential newborn care practices was slightly lower in private compared to public facilities, calling for quality improvement in both private and public sector facilities, and a greater emphasis on tracking access to and quality of care in private sector facilities.

The Access to Medicine Index and Accountability of Pharmaceutical Companies
de Felice D; Edwards D: Health and Human Rights Journal, September 2015

The UN post-2015 development agenda includes 17 Sustainable Development Goals (SDGs) and a “revitalized” Global Partnership to ensure their implementation. Formal inclusion of the private sector (in addition to governments, civil society, the UN system and other actors) is one of the defining features of this Global Partnership. Plenty of studies have shown how corporate actions can have significant impacts, positive and negative, for vulnerable people and for marginalised communities. However the author argues that it also raises an important question. How will the private sector be held accountable for its contribution to the Global Partnership? The latest draft of the 2030 Agenda for Sustainable Development provides that a High Level Political Forum (HLPF) under the auspices of the General Assembly and the Economic and Social Council will have the central role in overseeing follow-up and review at the global level. Interestingly, the HLPF will be tasked to carry out regular reviews that will include relevant stakeholders, including the private sector. The author argues that measuring businesses is as fundamental as measuring governments and that rigorous benchmarking of pharmaceutical companies will be crucial.

CSOs voice concerns over corporate takeover of WHO
Raja K: Third World Resurgence, 298/299, 35-37, 2015

At the World Health Assembly in May, civil society organisations criticised the rich countries for refusing an increase in their assessed contributions to WHO and opposing actions by the agency which would be contrary to the interests of their corporations. THE Framework for Engagement with Non-State Actors (FENSA), initiated to safeguard the independence, integrity and credibility of the World Health Organisation (WHO), now seems to bear the threat of facilitating and legitimising corporate capture of the organisation, civil society groups have charged. 'Many proposals by rich countries in draft FENSA text [are] promoting corporate capture of WHO in the name of promotion of engagements without discussion on any comprehensive mechanism to avoid conflict of interest. These proposals, if accepted, would institutionalise the undue corporate influence on WHO,' said Lida Lhotska of the International Baby Food Action Network (IBFAN) in a press release. Over the last 20 years, the proportion of WHO's budget which is met through mandatory assessed contributions has fallen from 75% to 20%. This is a consequence of continuing new functions being added to the organisation and a continuing freeze on assessed contributions. The remaining 80% is met by voluntary donations, including from the rich countries, the World Bank and the Bill & Melinda Gates Foundation.

Nurses who moonlight strain the health system
Rispel L: Business Day Live (BDLive), July 2015

Between 2009 and 2010, the author reports that the South African government spent about R1.49bn hiring nurses for the public health sector from nursing agencies. In that period, the provincial spending on agency nurses ranged from a low of just under R36.4m in Mpumalanga to a high of R356.4m in the Eastern Cape. In that financial year, this article reports that more than 5,300 registered nurses could have been employed by provincial governments instead of agency nurses, according to the published research. The government’s spending on agency nursing is argued to be a result of nursing vacancies, poorly managed staff absenteeism, sub-optimal planning for patient loads and not involving nurses in decisions on their shifts or how best to cover hospital wards. Nursing agencies provide a vehicle for nurses to moonlight, as they could be employed concurrently in a public or private sector hospital as well as the agency. These agencies are not obliged to ask nurses whether they have concurrent employment. The author argues that the nursing agency spending is, however, an indication of the bigger crisis in South African nursing.

Private healthcare is ‘wasteful’
Culling K: Health-e News, 28 July 2014

Private healthcare is wasteful and over-dependent on hospitals, which makes it too expensive for a large group of working people to join medical schemes, Health-e news reports. As a result, scheme membership has stagnated at around 8,5 million people and is skewed towards older, sicker members. This was the assessment of healthcare consultant Dr Brian Ruff, speaking at the opening day of the Board of Healthcare Funders (BHF), the group that represents medical schemes and administrators in South Africa. Ruff said that families with an income of R7000 to R12000 a month may be able to afford membership of around R300 a month, yet no medical scheme could provide such a cheap service.

WHO reform: opening the floodgates to the private sector?
Richter J: Third World Resurgence 298/299, 20-23, 2015

The author presents in this paper how in the name of 'reform', against a backdrop of a funding crisis, a greater collaboration between WHO and big business is being justified. She provides a historical overview of the process which began in 1992 with the drive for UN 'reforms', naming it as a euphemism for the neoliberal restructuring of the world body. Both the idea of attracting more funding from private foundations and the commercial sector and the notion of dealing with global health and nutrition matters through multi-stakeholder approaches are argued to carry major risks to WHO's role as the highest authority in international public health. Even though the regular World Health Forum is abandoned at the moment, the notion of greater involvement of the private sector as legitimate 'stakeholders' in public health affairs is not. She calls for an urgent reflection on whether this path should be pursued, noting that the 'privatisation' of public agencies and spaces increases the reliance on private sector funding, as well as inviting profit-motivated actors into public decision-making forums, and sometimes removing specific public issues from the public sphere altogether. This is seen to be the opposite of ensuring financial independence of public institutions and safeguarding and enlarging of spaces for public debate.

Modern African Remedies: Herbal Medicine and Community Development in Nigeria
Africa Research Institute, April 2015

Pax is a private sector rural manufacturing enterprise in Edo State Nigeria that is a joint endeavour of the monastic and local communities. It has professionalised the production of traditional natural remedies to demonstrate that herbal medicines can be a force for innovation and progress in health care. An estimated two-thirds of Nigerians are reported in this paper to use these products, often in tandem with other medicines. The company holds that open dialogue, scrutiny and regulation are crucial if the economic potential of the sector is to be realised, and that traditional medicine must be modern, professional and based on science if it is to contribute to improving health systems and outcomes. More than 30 Pax products are reported to be government-certified. The paper argues that traditional medicine and pharmaceutical industries could be fostered in Nigeria; but that indigenous knowledge, resources and enterprise still remain under-exploited.

Malawi govt backtracks on hospital user fees
Chauwa A: Nyasa Times April 5 2015

The Malawi government has said that medical services in all public health facilities will remain free. Minister of Health spokesperson Henry Chimbali told Nyasa Times that government has introduced by-pass fees [and not user fees] in referral hospitals in order to decongest the facilities. He also noted that the ministry will review the current arrangement between the Ministry and Christian Health Association of Malawi (CHAM) saying the current Memorandum of Understanding (MoU) dates back to 2002, is well overdue for review and needs to take into account some of the emerging issues that have taken place such as the passing into law of the new Act on Public Private Partnership Agreements (PPPs) which is the basis of the arrangement between the Ministry of Health and CHAM. The proposal is to work out a mechanism that will see greater access to quality health services by all Malawians especially those in rural and hard to reach areas. He also noted that the Ministry of Health seeks to establish a Health Fund to support health service delivery and widen coverage of medical insurance for those who can afford it.

Conflicts of interest and global health and nutrition governance - The illusion of robust principles
Richter J: BMJ, doi:, 2015

This is a response to a BMJ paper 'Do the solutions for global health lie in healthcare?' where in the run-up to the Second International Conference on Nutrition (ICN2), the author warned against downplaying the fundamental differences between the commercial interests of multinational food companies and those of public sector agencies. If public health officials do not acknowledge the divergent interests, he suggested, they risk harming their public health mission, institutional integrity and ultimately public trust. In the response, the author suggests that the current discourse ignores the problem of involving food transnational corporations in public decision-making processes, acceptance of funds and resources in the name of partnership or stakeholder engagement. The trend to increase such engagement reduces and almost eliminates public policy spaces without corporations. The author argues that that robust, comprehensive conflict of interest safeguards do not exist with respect to global food and nutrition governance. This obscures the fact that conflicts of interest are an important legal concept and that establishing conflict of interest policies are an integral part of UN agencies’ duty to establish the Rule of Law.