Public-Private Mix

Combatting Substandard and Falsified Medicines: A View from Rwanda
Binagwaho A, Bate R, Gasana M, Karema C, Mucyo Y, Mwesigye JP et al: PLOS Medicine 10(1371), 2 July 2013

Substandard and falsified medicines are major global health challenges that cause unnecessary morbidity and mortality around the world and threaten to undermine recent progress against infectious diseases by facilitating the emergence of drug resistance. According to this study, Rwanda has the lowest prevalence of poor quality tuberculosis drugs among African countries. This positive finding may be associated with Rwanda's efforts to ban the sale of monotherapies, ensure that private sellers of important medicines are qualified, and prioritise the prevention of falsified medicines entering the country, the authors argue. As policymakers in, and researchers of, Rwanda's health sector, they argue that the improvement of the country's supply chain and drug surveillance systems, combined with equity-oriented strategies for increasing geographic and financial access to high quality drugs through the public sector, has played an important role in the country's steep declines in mortality due to tuberculosis and malaria. In scaling up pharmacovigilance for malaria and tuberculosis, they call for a global treaty and leadership by the World Health Organisation to address manufacturing and trade in substandard and falsified medicines.

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.

Commercialisation and Globalisation of Health Care: Lessons from UNRISD Research
United Nations Research Institute for Social Development, Social Policy and Development, December 2007

Using market mechanisms in the provision of health services and seeing health care as a private good are approaches that have featured prominently in health sector reforms across the world. The UNRISD research on global and local experiences of health care commercialization challenges this framework. It calls for reclaiming public policies that promote the purposes that health systems are set up to serve: population health and the provision of care for all according to need.

Commission hears data on WHO report on high price of hospital care in SA
Pitso R: BusinessDay, August 2016

The South African Competition Commission’s healthcare market enquiry on Tuesday convened a special session in Pretoria, at which stakeholders were due to give oral presentations in response to a report by the World Health Organisation (WHO). The report, contested by the private actors, concluded that the cost of hospital care in SA was high when measured against GDP per capita and that the driving forces were in-house hospital and specialist fees. The Organisation for Economic Co-operation and Development (OECD) collected the data and conducted the study, which compared the prices of South African private hospitals to those of 20 OECD countries. The health market inquiry was established to determine why medical inflation has historically risen faster than consumer price inflation, and whether there are barriers to effective competition in the private healthcare sector. The public hearings aim to explore the relationships among different players.

Common Declaration for Responsible Partnerships
International Forum on Public-Private Partnerships for Sustainable Development, December 2015

In the context of the 2015 Paris Climate Conference, COP 21, an International Forum on Public-Private Partnerships (PPPs) for Sustainable Development has been held in Annemasse. Within this framework and in view of the Sustainable Development Goals defined by the UN, the Cité de la Solidarité Internationale organised on October 30 2015 a collective intelligence workshop gathering representatives from the civil society as well as public and private stakeholders. The assembly called for PPPs that guarantee access for all to common goods and the respect of Human Rights to foster an economy of human dimension. They recommended to: Include the civil society in the entire process of public-private partnerships, upstream to downstream, by identifying the genuine needs, promoting the general interest as the final goal and avoiding conflict of interest and controlling the services of which they are the main beneficiaries. They argued that it is necessary to create a legal framework and appropriate tools to strengthen civil society legitimacy, to guarantee co-construction of equal win partnerships with general interest as a common objective to avoid an unbalanced or competitive approach and to consider alternative approaches and initiatives of collaboration (such as social and solidarity-based economy) as an evolution towards more balanced and inclusive partnerships favouring a participatory democracy.

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?
Shah NM, Wang W and Bishai DM: Health Policy and Planning 26:163–171, March 2011

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. The authors of this paper propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. They applied this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing independent private sector providers; social franchises of private providers; non-government organisation (NGO) providers; and government providers on these three factors. They found that franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. These results suggest that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific, the authors conclude.

Competing for business? Improving hospital services in Zambia with market forces

Does competition improve hospital services? Do market forces in healthcare benefit the poorest members of society? Reforms which involve exposing hospitals to market forces are being introduced in many developing countries. However, very little is known about how these markets operate, particularly in developing countries. The University of Zambia, together with the London School of Hygiene and Tropical Medicine, considered the effect of competition among hospitals in Zambia. The study concludes that there is potential for competition in the hospital market to have beneficial effects in terms of prices, quality and efficiency. However, there is also the risk that faced with this competition, hospitals will be less able to charge private prices which allow them to cross-subsidise public patients.

Competing for business? Improving hospital services in Zambia with market forces

Does competition improve hospital services? Do market forces in healthcare benefit the poorest members of society? Reforms which involve exposing hospitals to market forces are being introduced in many developing countries. However, very little is known about how these markets operate, particularly in developing countries. The University of Zambia, together with the London School of Hygiene and Tropical Medicine, considered the effect of competition among hospitals in Zambia. The study examined hospitals in Lusaka, Central and Copperbelt provinces. Data on hospital use, revenues and expenditure, and charges for services were collected for the period 1996 to 1999 from each hospital using routine hospital records. In addition, a patient questionnaire was used in facilities to elicit patients’ views of the quality of services. As well as private for-profit and mine hospitals (facilities operated by the mining industry), "private" services included the private fee-paying services provided in government hospitals (known in Zambia as "high cost" services").

Competition Commission may probe healthcare
Visser A: Business Day, 30 December 2011

South Africa’s Competition Commission is considering initiating a market inquiry into the private healthcare industry reminiscent of its probe into the banking sector a few years ago, which recommended lower banking costs. Health Minister Aaron Motsoaledi has condemned high healthcare costs and accused the private health sector of engaging in "uncontrolled commercialism" and "destructive, unsustainable practices". Tembinkosi Bonakele, deputy commissioner of the Competition Commission, said that the commission was "likely" to commence with an inquiry because of growing concern about the high cost of private healthcare and the effect this had on the public healthcare system.

Conceptualising the impacts of dual practice on the retention of public sector specialists - evidence from South Africa
Ashmore J; Gilson L: Human Resources for Health 13(3), 2015,

‘Dual practice’, or multiple job holding, generally involves public sector-based health workers taking additional work in the private sector. This form of the practice is purported to help retain public health care workers in low and middle-income countries’ public sectors through additional wage incentives. There has been little conceptual or empirical development of the relationship between dual practice and retention. This article helps begin to fill this gap, drawing on empirical evidence from a qualitative study focusing on South African specialists. Fifty-one repeat, in-depth interviews were carried out with 28 doctors (predominantly specialists) with more than one job, in one public and one private urban hospital. Findings suggest dual practice can impact both positively and negatively on specialists’ intention to stay in the public sector. This is through multiple conceptual channels including those previously identified in the literature such as dual practice acting as a ‘stepping stone’ to private practice by reducing migration costs. Dual practice can also lead specialists to re-evaluate how they compare public and private jobs, and to overworking which can expedite decisions on whether to stay in the public sector or leave. Numerous respondents undertook dual practice without official permission. The idea that dual practice helps retain public specialists in South Africa may be overstated. Yet banning the practice may be ineffective, given many undertake it without permission in any case. Regulation should be better enforced to ensure dual practice is not abused. The conceptual framework developed in this article could form a basis for further qualitative and quantitative inquiry.

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