A new, pernicious epidemic is stalking the health care systems of the world, according to this book: the rampant spread of neoliberal, pro-market “reforms,” devised and promoted by a narrow policy-making academic and political elite in the wealthiest countries. The author argues that it can only be eradicated by the spread of information, political campaigning and critical thinking, with regular injections of evidence and social solidarity. The so called “reforms” are driven not by evidence, but by ideology – and behind the ideology is a massive material factor: the insatiable pressure from the private sector to recapture a much larger share of the massive $5 trillion-plus global health care industry, much of which only exists because of public funding. Since 1980 global agencies like the World Bank, new powerful players like the Gates Foundation, and even at times the World Health Organisation, have played a role in promoting these changes, along with academics whose loyalty appears to be to the giver of the research grant rather than to the evidence. Market-style reforms result in systems more unequal, more costly, more fragmented and less accountable – but which offer more profits to the private sector. The policies can be rejected and defeated by mass political action, argues the author. The question is to develop a political leadership with the courage to embrace them and fight for them.
Public-Private Mix
Public-private partnership (PPP) has been suggested as a tool to assist governments in lower to middle income countries fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level – which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP. This case study was conducted in the Bagamoyo district of Tanzania, and employed 30 in-depth interviews, document reviews, and observations methods. A stakeholder analysis was conducted to understand power distribution and the interests of local actors to engage non-state actors. The study findings reveal several forms of informal partnerships, and the untapped potential of non-state actors. Lack of formal contractual agreements with private providers including facilities that receive subsidies from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. Furthermore, findings highlight weak capacity of governing bodies to exercise oversight and sanctions, which is acerbated by weak accountability linkages and power differences. Disempowered Council Health Services Board, in relation to engaging non-state actors, is shown to impede PPP initiatives. Effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Orientation towards collaborative efforts that create value and enable its distribution is argued to facilitate healthy partnership, and in return, strengthen a district health system. This study highlights a need for new social contracts that will support integrative collaboration at the local level and bring all non-state actors to the centre of the district health system.
Low-income African populations continue to suffer poor access to a broad range of medicines, despite major international funding efforts. A current wave of pharmaceutical industry investment in SSA is associated with active African government promotion of pharmaceuticals as a key sector in industrialisation strategies. The authors present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. Key policies are identified that can ensure that local health systems benefit from the investments. The authors argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. This local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.
A current wave of pharmaceutical industry investment in sub-Saharan Africa is associated with active African government promotion of pharmaceuticals as a key sector in industrialization strategies. The authors present evidence from interviews in 2013–15 and 2017 in East Africa that health system actors perceive these investments in local production as an opportunity to improve access to medicines and supplies. The authors identify key policies that can ensure that local health systems benefit from the investments. They argue for a ‘local health’ policy perspective, framed by concepts of proximity and positionality, which works with local priorities and distinct policy time scales and identifies scope for incentive alignment to generate mutually beneficial health–industry linkages and strengthening of both sectors. This local health perspective represents a distinctive shift in policy framing: it is not necessarily in conflict with ‘global health’ frameworks but poses a challenge to some of its underlying assumptions.
What role can non-state providers play in scaling up healthcare delivery to meet the Millennium Development Goals? A policy briefing paper for the UK Department for International Development addresses this question using case studies in Bangladesh, India, Malawi, Nigeria, Pakistan and South Africa. Non-state providers (NSPs) of healthcare, whether philanthropic or commercial, exist outside the public sector. Research by the London School of Hygiene and Tropical Medicine found evidence that NSPs provide the majority of primary contacts with the health system in all six countries, except possibly South Africa. This is true for poor and rich alike. Poorer households are likely to spend a higher proportion of their income on private sector care than the rich, while the rich tend to access higher quality services. For successful and sustainable collaboration between governments and NSPs, the author recommends that donors should: encourage trust between state and non-state sectors; enable smaller providers, which may have greatest coverage of the poor, to come together to interact with governments and donors; and invest resources and expertise to develop human, transport and technical monitoring capacity; support policy formulation, management and research.
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.
This report explores evidence on the private sector in delivery of health care services for public health goals particularly in the areas of MNCH and SRH. It finds that there is a considerable body of evidence on the private provision of healthcare in low- and middle-income countries, often focusing on SSA, but that the evidence base is not robust. The arguments in favour of private healthcare suggest it is more responsive and efficient, while arguments in favour of public services suggest they are more equitable and better equipped than the market to respond to health needs. Some studies find that the private sector is unregulated, has financial incentives for inappropriate healthcare, and is expensive. There is very little evidence on the comparative cost-effectiveness of the private sector. This varies considerably across country contexts and types of services. There is no conclusive evidence that the private sector is more cost-effective or more efficient than the public sector. The literature warns that increased use of private services may crowd out or decrease the funding available to the public sector. The major criticism of private sector services is that their higher user fees create inequality of access, limiting their use by the poor. The literature is quite clear that private for-profit health services create inequality. Private non-profit, or services run by NGOs, appear to mitigate some of the inequality effects. In practice, boundaries can be blurred between public and private; both formal and informal cost recovery schemes operate at public facilities. NGOs providing healthcare are generally seen as private, although they may not charge for their services. The difference between free-at-the-point-of-use NGOs and out-of-pocket-expenditure on private doctors can be enormous, and it is important to differentiate between the types of providers when reviewing the evidence on private services.
Between 6.5 and 11 million people are in need of antiretroviral therapy (ART) in developing countries. Only 1.3 million are receiving it. With the public sector struggling to expand coverage, how can the private sector play a more significant role? This paper reviews the experiences of franchising and its potential for HIV and AIDS services.
This report focuses on the contribution of AIDS-related public-private partnerships to the six building blocks of health systems: service delivery; human resources; information; medicines and technologies; financing; and leadership. A desk review and interviews were conducted with representatives of private and public organisation stakeholders, as well as development partners. Interviewees identified mutual understanding as an important precondition for the implementation of efficient and successful partnerships. The private sector at times lacks profound knowledge of the complex stakeholder landscape in the HIV response and health care provision. To develop flourishing partnerships, honest and wide-ranging dialogue to inform and secure agreement in joint planning is essential from the very earliest stages. Such planning will of course consider issue such as sustainability, follow-up, and monitoring, essential to flourishing partnerships. Health financing mechanisms, HIV and tuberculosis treatment and mobile health technology are areas which are of interest to the private sector and which require further technical expertise and promotion.
This report focuses on the contribution of AIDS-related public-private partnerships to the six building blocks of health systems: service delivery; human resources; information; medicines and technologies; financing; and leadership. A desk review and interviews were conducted with representatives of private and public organisation stakeholders, as well as development partners. Interviewees identified mutual understanding as an important precondition for the implementation of efficient and successful partnerships. The private sector at times lacks profound knowledge of the complex stakeholder landscape in the HIV response and health care provision. To develop flourishing partnerships, honest and wide-ranging dialogue to inform and secure agreement in joint planning is essential from the very earliest stages. Such planning will of course consider issue such as sustainability, follow-up, and monitoring, essential to flourishing partnerships. Health financing mechanisms, HIV and tuberculosis treatment and mobile health technology are areas which are of interest to the private sector and which require further technical expertise and promotion.