Public-Private Mix

Can private equity deliver on equity?
Cometto G and Brikci N: Bulletin of the World Health Organization: 87(10), October 2009

In June 2009, a new Health in Africa Fund was launched by the International Finance Corporation (IFC), the branch of the World Bank group mandated with supporting and expanding the private for-profit sector. This Fund will be managed by Aureos Capital, a private equity fund manager focusing on emerging markets. Through investment in small- and medium-sized private providers, the Fund will attempt to’[help] low-income Africans gain access to affordable, high-quality health services.’ The Fund targets initial commitments of US$ 100–120 million and intends harnessing private capital and private sector providers to improve quality and coverage of health services. But it is unlikely to improve access or quality of care unless it is complemented by initiatives to strengthen the public sector capacity to regulate, train, oversee and sub-contract (where appropriate) private providers. In addition, the Fund would also require the development of risk-pooling and subsidy mechanisms, so that privately-provided services can be offered free at the point of delivery. If it fails to do so, there is a concrete risk that, contrary to its objectives, it will contribute to the entrenchment of two-tier health-care systems and to a further concentration of human and financial resources in services catering to affluent urban dwellers.

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.

Can the private sector help overcome nursing shortages?
Resyst project: LSHTM, 2013

The demand for nurses is growing and has not yet been met in most low and middle-income countries. In India, Kenya, South Africa and Thailand, there has been a rapid proliferation of private training institutions to increase the supply of nurses. This infogram summarises evidence from RESYST research examining the role of these private institutions, their contribution to the wider health systems, and how governments in these countries have managed the opening of markets to the private sector. Private nurse training institutions are reported to be playing an increasingly important role in producing nurses in many low and middle income countries. Governments need to ensure that graduates from both private and public institutions are of sufficient quality to meet the health needs of their populations, and that training institutions have the capacity to train more nurses. In some countries including India and Kenya, the benefits of expanding nurse production through the private sector have been hindered by high levels of international migration. A balance needs to be struck between producing nurses for export, and ensuring sufficient supply and skill-mix for domestic markets.

Can working with the private sector improve access of the poor to quality health services?
Hanson K: World Institute for Development Research (WIDER), 2006

In recent years there has been increasing interest in the role played by the private sector in providing health services in low- and middle-income countries. Many countries have a vibrant and growing private sector, which is perceived by some to respond to the failures of the public sector to provide affordable, accessible, convenient and high quality services. There has been little investigation, however, of the extent to which interventions can be successful in expanding access to those who are difficult to reach and to provide services that are 'genuinely pro-poor'. This chapter offers a systematic review of the literature on the equity impact of private sector interventions.

Can working with the private sector increase ART coverage?
England R: DFID Health Resource Centre/ Eldis, 7 July 2006

This paper reviews the experiences of franchising and discusses the opportunities and implications for governments and donors of franchising for HIV and AIDS services. The author details how the private sector can offer huge potential to extend and maintain anti-retroviral therapy (ART) coverage. The author outlines how franchising may offer a way of meeting known challenges and thus, increasing the prospects for universal access to HIV and AIDS services.

Changes in utilization of health services among poor and rural residents in Uganda: Are reforms benefitting the poor?
Pariyo GW, Ekirapa-Kiracho E, Okui O, Rahman MH, Peterson S, Bishai DM, Lucas H and Peters DH: International Journal for Equity in Health 8(39), 12 November 2009

This paper describes the changes in utilisation of health services that occurred among the poor and those in rural areas in Uganda between 2002/3 and 2005/6 and associated factors. Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset-based index derived from principal components analysis (PCA). The study found that the rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access. The risk of not seeking care due to high costs did not change significantly. Poor people, females, rural residents and those from elderly headed households were more likely to use public facilities relative to private for-profit (PFP) providers. Although overall utilisation of public and private not-for-profit (PNFP) services by rural and poor populations had increased, PFP providers remained the major source of care. Policy makers should consider targeting subsidies to the poor and rural populations. Public-private partnerships should be broadened to increase access to health services among the vulnerable.

Changing roles - responding to health sector transformation in developing countries

Many low and middle-income countries (LMICs) have experienced changes in the provision of healthcare services. Services are now provided by a variety of sources under market conditions. In response to this shift, how have the roles of healthcare providers changed? How have households adapted to these changes in order to meet their health needs? What should governments do to provide good healthcare in these conditions? Research by the UK's Institute of Development Studies highlights that over the last few decades there have been profound changes in the ways that health goods are produced and consumed in LMICs. This change is due to economic and political factors, such as crises in public sector financing and governance, that have reduced governments’ capacity to fund infrastructure, supplies and salaries and competently manage healthcare. The result in many countries is that it is difficult to maintain the distinction between public and private in the health sector.

Civil society health caucus at the WSSD

The Civil society health caucus at the WSSD Global Forum hosted a Commission to discuss the Role of the of the state and water, sanitation and primary health care in the context of globalisation. The discussion included analysis of the situation which raised the following points.

• Debt and globalisation impact negatively on the distribution of all resources, including environment and health through their destruction and privatization.
• Environmental degradation increases the burden of ill health
• Lack of knowledge about environment and health and hygiene are sorely lacking amongst many citizens, especially children.
• Environmental services are a basic right which every citizen should enjoy
• Privatisation of services, including through public private partnerships, has been a very negative experience for many poor people, especially women and children, in countries as diverse as the UK and Argentina
• War and military occupation both severely restrict access to health and basic services, and conflict and psychological stress are also increasingly a result of struggles for access to these services.

Further details: /newsletter/id/29330
Clinical social franchising: An annual compendium of programmes, 2009
Global Health Group: 2009

Social franchising is argued to be a way of rapidly scaling up clinical health interventions in developing countries. Building upon existing expertise in poor and isolated communities, social franchising organisations engage private medical practitioners to add new services to the range of services they already offer. Specific examples are provided, such as the Confiance programme in the Democratic Republic of the Congo that provides a toll-free hotline for answering family planning-related questions and making referrals. It is reported to have been effective in addressing family planning concerns raised by men. This paper argues that standardisation, quality monitoring and scalability make social franchising one platform for the expansion and improvement of a wide range of medical services.

Closing the access barrier for effective antimalarials in the private sector in rural Uganda: consortium for ACT private sector subsidy (CAPSS) pilot study
Talisuna AO, Daumerie P, Balyeku A, Egan T, Piot B, Coghlan R et al:Malaria Journal 11(356), 29 October 2012

Between August 2007 and May 2010, the Uganda Ministry of Health and the Medicines for Malaria Venture conducted the Consortium for ACT Private Sector Subsidy (CAPSS) pilot study to test whether access to artemisinin-based combination therapy (ACT) for malaria in the private sector could be improved through the provision of a high level supply chain subsidy. Four intervention districts were purposefully selected to receive branded subsidised medicines, while the fifth district acted as the control. Researchers analysed the intervention's impact on: ACT uptake and price; purchase of ACT within 24 hours of symptom onset; ACT availability and displacement of sub-optimal anti-malarial. At baseline, ACT accounted for less than 1% of anti-malarials purchased from licensed drug shops for children less than five years old. However, at evaluation, it accounted for 69 % of anti-malarial purchased in the interventions districts. Purchase of ACT within 24 hours of symptom onset for children under five years rose from 0.8 % at baseline to 26.2 % at evaluation in the intervention districts. These data demonstrate that a supply-side subsidy and an intensive communications campaign significantly increased the uptake and use of ACT in the private sector in Uganda.

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