Public-Private Mix

Conceptualizing 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.

Concern over role of private sector in policy development
Conflict of Interest Coalition: February 2012

In this Statement of Concern, the Conflict of Interest Coalition calls for the development of a Code of Conduct and Ethical Framework to guide private sector involvement in public health policy development. The Coalition seeks clarity on the nature of recent government ‘partnerships’ with the private sector, and argues that public-private partnerships run the risk of counteracting efforts to protect and improve public health. The proposed framework should help protect the integrity of the United Nations’ public policy decision-making, to ensure it is transparent and to identify, safeguard against and manage potential conflicts of interest. The Statement argues that a clear distinction must be made between business-interest not-for-profit organisations (BINGOs) and public interest non-governmental organisations (PINGOs) and a clear differentiation between policy and norms and standards development and appropriate involvement in implementation. The Coalition calls on the World Health Organisation (WHO) to develop guidance for Member States to identify conflicts and eliminate those that are not permissible. WHO should perform thorough risk/benefit analyses on partnerships and provide surveillance on those considered acceptable.

Conflicts of interest and global health and nutrition governance - The illusion of robust principles
Richter J: BMJ, doi: http://dx.doi.org/10.1136/bmj.g5457, 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.

Conflicts of interest within philanthrocapitalism
Global Health Watch: 2012

This chapter from Global Health Watch 3 explores the origins of philanthrocapitalism and addresses its increasing influence on global health governance and decision-making. It examines the functioning and priorities of the Bill and Melinda Gates Foundation in order to explore how the alignment of corporate interests and philanthropic investment may be having adverse effects on health policy. It looks at the efforts of the proponents of philanthrocapitalism to challenge progressive tax measures that could generate government revenues earmarked for global health. Finally, the chapter suggests that a focus on conflicts of interest could be a useful starting point for the mobilisation of health specialists who are concerned about the influence of the Gates Foundation on health policy, but who have thus far had difficulty, as a result of the immense scale of the Foundation’s influence, in highlighting some of its controversial policies. Global Health Watch cautions against the new philanthropy’s core idea that private-sector investment fills the void left by cash-strapped governments. A key objective for health activists could be highlighting the ways in which government revenues are strapped through private-sector support and through a reluctance to embrace tax measures that are disparaged by philanthropists who purport to be operating outside the realm of politics.

Considering domestic manufacturing issues
Wanyanga, WO

This report - presented at the African Civil Society Meeting of the Intergovernmental Working Group on Intellectual Property, Innovation and Health in Nairobi, Kenya, 28-29 August 2007 - found that there are over 30 registered local manufacturers in Kenya and at least two others under construction (foreign investments). It also analysed seven private-private partnership (PPP) projects (six in Kenya & one in Tanzania). The first PPP project passed its first inspection in August 2007 and the others are due for inspection by the end of the project. The main outcome of the report was that intellectual property rights do not stimulate research and development for medicines for diseases prevalent in developing countries simply because the market in poor countries is considered to be too small or too uncertain.

Contracting for health service delivery in developing countries
The Lancet, Volume 366, Number 9486, 20 August 2005

To achieve the health-related Millennium Development Goals, the delivery of health services will need to improve. Contracting with non-state entities, including non-governmental organisations (NGOs), has been proposed as a means for improving health care delivery, and the global experience with such contracts is reviewed here, in this Lancet article. The ten investigated examples indicate that contracting for the delivery of primary care can be very effective and that improvements can be rapid. (requires registration)

Contracting out: the case of primary care in South Africa

Contracts can be used to govern the relationship between the public and the private sectors where the private sector delivers services on behalf of the state. On occasion, this allows the state to offer services such as basic medical provision where public sector provision does not reach. Researchers examine the case of primary care in South Africa where such contracts are being utilised. They argue that understanding the relationship between client and contractor requires a thorough understanding of some of the factors that govern the relationship, such as the role played by individual motivation.

Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation
Maluka S; Chitama D; Dungumaro E; et al: International Journal for Equity in Health 17(118) 1-13, 2018

This paper reports on the design and implementation of service agreements between local governments and non-state providers for the provision of primary health care services in Tanzania. The authors used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. The institutional frameworks shaping the engagement of the government with non-state providers are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage non-state providers facilities. Development partners provided significant technical and financial support, signalling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with non-state providers, financing the contracts remained largely dependent on external funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. The authors indicate that Tanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with non-state providers for primary health care services; and that forums for continuous dialogue between the government and contracted non-state providers be fostered to clarify the expectations of all parties and resolve any misunderstandings.

Council for Medical Schemes Annual Report 2012
South African Council for Medical Schemes: 2012

In this annual report, the South African Council for Medical Schemes details its support for the Department of Health in its efforts to strategically review the entire health system of South Africa. Council provided input to the technical sub-committees of the Ministerial Advisory Committee on the proposed National Health Insurance (NHI) system, and submitted a formal document on the NHI policy paper. Ever-escalating costs in the industry, which are driven by private hospitals and medical specialists, have always been one of Council’s concerns, and this financial year proved no different. This worrying trend of inflation-exceeding price increases in the private health sector has serious and negative implications for the well-being and sustainability of the entire health system. Council therefore continued to motivate for the establishment of a regulator to oversee the price determination of private healthcare provision. Council believes that a real need exists for a platform where medical schemes and healthcare providers can meet and negotiate prices for the benefit of all South African consumers. Private healthcare providers should also be regulated, specifically the hospitals and specialists. The practice where beneficiaries are exposed to unfair billing practices must be addressed.

Counting the cost of HIV in Southern Africa

Southern Africa is the region with the highest rates of HIV infection in the world. An estimated 9.4 million of the total population of 97 million were HIV-positive in 1999. What impact will the HIV/AIDS epidemic have on the provision of health services in the region? Is there any scope for improving access to highly active antiretroviral therapy (HAART) in low-income countries? A study by the International Monetary Fund warns that health services in southern Africa are already over-stretched. The current cost of providing health services to HIV patients accounts for a very large proportion of total health expenditure for most countries in the region. As the number of AIDS patients increases, the situation will deteriorate.

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