This issues paper, published by the DFID Health Systems Resource Centre (HSRC), was one of several feeding into Department for International Development (DFID) policy discussions in mid-2004. It examines evidence on the impacts of user fees for primary health care, evaluates the cost implications of abolishing user fees, and considers what line donors should take on the issue. The paper argues that the case for abolishing user fees is strong: they raise little money, rarely meet their stated efficiency and equity goals.
Public-Private Mix
The case for abolition of user fees for primary health services
The case for public intervention in financing health and medical services
Mathonnat J: Bulletin of the World Health Organization 86(11) November 2008
This article reviews Klarman’s classic article ‘The case for public intervention in financing health and medical services’. Government intervention still plays an essential role in most public health actions but the links between public health expenditure and health improvement are tenuous and econometric analyses have yielded widely divergent results, leading us to the highly consensual formula that ‘it is not enough merely to increase expenditure on health’. Contemporary analyses agree that efforts to strengthen health systems or to control neglected diseases are underfunded. Increased expenditure on health will be a source of employment for the surplus workforce of the manufacturing sector and the health industry will be the driving force of tomorrow’s economy.
The Charter of the Public and Private Health Sectors of The Republic Of South Africa
Department of Health, South Africa
Access to health care is a complex issue of constitutional significance. There are significant numbers of people in South Africa who do not have adequate access to health services due to geographical, financial, physical, communication, sociological (such as unfair discrimination and stigmatisation)and other barriers. Access to medical schemes is diminishing in real terms. Medical schemes provide financing for almost 7 million people but over the years membership figures have declined as a percentage of the general population. This is due in part to major increases in non-health expenditure by medical schemes on items such as administration and brokers fees. This Charter commits to move towards a coherent, unified health system offering financial protection for all the population in accessing a nationally affordable package of health care at the time of need and to improve access to health care services.
The child health implications of water privatisation in Africa
Kosec K: Stanford University, March 2009
Each year, diarrhoeal diseases claim the lives of nearly two million people – 90% of them children under the age of five. The problem is especially critical in Africa, a continent that contains 10% of the world's population, but accounts for 40% of the deaths of children under age five. This paper uses panel data on the sub-national regions of 26 African countries over 1985-2006, a period of expanded private sector participation in water supplies to explore the impact on child health. Using a fixed effects analysis the author suggests that an expansion in piped water after PSP was associated with a 5% decrease in diarrhoea in children under-five. The author notes, however, that PSP In Africa was often pursued as a remedy to a severely distressed water sector with government under-investment for years.
The Competition Commission’s Market Inquiry into the Private Health Care Sector
Section27: April 2014
On 6 January 2014, South Africa’s Competition Commission began a market inquiry (an investigation)into the private health sector. The Commission was concerned about high prices in private health care and will use its wide powers to investigate the general state of competition in this sector to determine what can be done to achieve accessible, affordable, high quality and advanced private health care in South Africa. According to the Commission, there are indications that the private health care market is not working well for consumers. The market inquiry will examine the causes of why the market may not be working effectively, and will make recommendations as to how they might be made to work better in order to promote and protect consumer interests, while ensuring that markets
are fair and competitive. As such the Commission will specifically look into the increases in prices in private health care and determine the factors that are driving prices. This fact sheet outlines the terms of the Commission inquiry. It points to the opportunity to address inequality in the health system in South Africa. SECTION27, together with its partners, report that they will closely monitor the inquiry and ensure that the voice of ordinary users of private health services.
The creation of the health consumer: Challenges on health sector regulation after managed care era
Iriart C, Franco T and Merhy EE: Globalization and Health 7(2), 24 February 2011
In this study, the authors examined how economic reforms, like structural adjustment programmes that were developed and implemented in the 1990s, have affected the health sector. They report that these policies facilitated reforms in the health sector that facilitated the entry of multinational financial (insurance) and pharmaceutical capital. This redefined both the health-ill-care model and converted patients into consumers being pressured to buy products, largely via the media and the advertising industry.
The cupboard is full: Public finance for public services in the global South
Lipschutz RD and Romano ST: Municipal Services Project, Briefing Note No 2, 2012
Governments around the world argue that there is no money for badly needed public services. But the author of this briefing note disagrees, pointing to evidence that large pools of public monies exist for investment in public infrastructure, with public pension funds and sovereign wealth funds being two examples. Currently, these funds are being directed toward large-scale, capital-intensive, high-return projects aimed primarily at well-off urban residents and the private sector. Lessons from the financial crisis show that such funds could actually realise greater long-term returns from investment in public service provision, the authors argue, while avoiding the politically controversial and contradictory practice of using public sector funds to support privatisation. They make the case for using public pension funds and sovereign wealth funds for socially responsible investments in the global South, in support of essential public services.
The difficult relationship between faith-based healthcare organisations and the public sector in sub-Saharan Africa
Boulenger D and Criel B: Studies in Health Services Organisation and Policy 29, ITG Press, 2012
In this book, the authors present the principal findings of a study conducted between September 2007 and March 2009 on contractual arrangements between faith-based hospitals and public health authorities in four sub-Saharan African countries: Cameroon, Tanzania, Chad and Uganda. In Tanzania, Christian faith-based organisations were found to be well represented, particularly the Catholic Church. The study focused on the Nyakahanga District Designated Hospital (NDDH), a rural Lutheran hospital located in the north-west of the country. Researchers found that monitoring of the contractual relationship between church and state is not properly done and supervision remains erratic, with frequent stock-outs and lack of capital investment, leading to a negative perception of the relationship by both parties. In Uganda, the faith-based health sector owns about 30% of the country’s health facilities. Field research for the study focused on two faith-based hospitals in Uganda that were involved in contracting agreements with PEPFAR recipients. Restrictive and demanding agreements between PEPFAR recipients and hospitals were identified as problematic, but this was mitigated by the reliability of PEPFAR funding. The authors observe that where the relationship between public and faith-based sectors is not satisfactory, faith-based organisations may opt for more predictable agreements that they can rely on with external organisations like PEPFAR.
the Drugs for Neglected Diseases Initiative: A global initiative to develop drugs for those in need
Recent international efforts to revive pharmaceutical R&D for neglected diseases have focused mainly on malaria, tuberculosis and HIV/AIDS. These have relied heavily on market-based incentive mechanisms, including public-private partnerships. The DND-WG's analysis clearly shows that this strategy will have limited impact for what we describe as the "most neglected diseases". One strategy to address this fatal imbalance that is currently being pursued is the creation of a needs-driven global drug development network - the Drugs for Neglected Diseases Initiative (DNDi). The DNDi is a not-for-profit research and development organisation that will manage global R&D networks with the goal of producing new, effective, affordable and field-relevant drugs for neglected diseases. The Drugs for Neglected diseases Initiative is the brainchild from Médecins Sans Frontières' Drugs for Neglected Diseases Working Group. The DNDi aims to take the development of drugs for neglected diseases out of the marketplace and encourage the public sector to assume greater responsibility.
The effect of an anti-malarial subsidy programme on the quality of service provision of artemisinin-based combination therapy in Kenya: a cluster-randomised, controlled trial
Kangwana BP, Kedenge SV, Noor AM, Alegana VA, Nyandigisi AJ, Pandit J et al: Malaria Journal 12(81), 1 March 2013
To improve the quality of care received for presumptive malaria from the highly accessed private retail sector in western Kenya, subsidised pre-packaged artemether-lumefantrine (AL) was provided to private retailers, together with a one-day training course for retail staff on malaria diagnosis and treatment, job aids and community engagement activities. This study assessed the intervention through provider and mystery-shopper cross-sectional surveys, which were conducted at baseline and eight months post-intervention to assess provider practices. On average, 564 retail outlets were interviewed per year. At follow-up, 43% of respondents reported that at least one staff member had attended the training in the intervention arm. The intervention significantly increased the percentage of providers knowing the first line treatment for uncomplicated malaria by 24.2%; the percentage of outlets stocking AL by 31.7%; and the percentage of providers prescribing AL for presumptive malaria by 23.6%. Generally, outlets that received training and job aids performed better than those receiving one or none of these intervention components.