In this paper, the authors examine government resource contributions (GRCs) to providers in Uganda focusing on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for government resource contributions (GRCs) and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders. Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB initiation, rapid increase in GRCs, and declining GRCs. The main factors affecting the relationship’s evolution were: financial deficits at private-not-for-profit (PNFP) facilities, advocacy by PNFP network leaders, changes in the government financial resource envelope, variations in the “good will” of government actors, and changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The authors argue that the Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. They further suggest that governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.
Public-Private Mix
This case study examined government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders. Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship’s evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the “good will” of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. The authors concluded that GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC.
Richard Smith and colleagues are forceful advocates for a greater role for the private sector in the health systems of low-income countries. Unfortunately, as they also recognise, the evidence to support their position is limited. First, Smith and colleagues pay insufficient attention to the diversity of the private sector in developing countries. Second, they place considerable weight on the proportion of private spending in total health financing. However, this is an imperfect measure of the size of the private sector. Third, it is not true to say that governments and donors have completely ignored the private sector. What is needed is for the global public health community to commit to developing a strong evidence base on private sector engagement so that future debates can be grounded in better understanding.
Health care systems can embed and reinforce inequality within societies or, conversely, can be a platform for the public combatting of poverty and inequality. The objective of the paper is to argue that the process of health care commercialisation - a marked trend across the world since the 1970s for reasons that are explored - and the associated process of globalisation of both health care and health policy, changes the terms of these interactions. Commercialisation, sometimes discreditably sold as a policy for increasing equity, has generally acted to embed inequality in new forms.
Sara Bennett, Lucy Gilson
DFID Health Systems Resource Centre
UK Department for International Development, 2001
Health financing reforms are a core part of health sector development in low and middle income countries.The current focus of the international debate is on the need to move away from excessive reliance on out-of-pocket payment towards a system which incorporates a greater element of risk pooling (for example through health insurance) and thus affords a greater protection for the poor. This paper summarises what is known about the effects of the main health care financing systems, and how they can be designed and implemented to be 'pro-poor'.
At the World Economic Forum, held from 26-29 January 2011 in Davos, Switzerland, the debate on health centred on combating chronic or non-communicable diseases (NCDs), such as diabetes, heart disease and obesity. A panel was held to discuss the issue, where speakers highlighted the need to redefine ‘global health’ to include not only infectious diseases such as HIV and AIDS, malaria and tuberculosis, but also NCDs. NCDs were noted to cause more than 60% of deaths around the world, of which 80% are in the developing world, yet only about 3% of developmental assistance goes specifically towards chronic disease. The panel discussed the potential of technologies to improve health, such as cellphone technology in monitoring patients’ health. The private sector was argued to have a role in implementing workplace policies to support employees’ health and well-being. The panel called for a diagonal approach blending disease specific programmes with health system strengthening, through specific priorities being used to drive general improvements and to build capacity of the public health sector to meet both current and future health challenges.
The International Finance Corporation (IFC), a member of the World Bank Group, the African Development Bank, the Bill & Melinda Gates Foundation and the German development finance institution, Deutsche Investitions und Entwicklungsgesellschaft (DEG), announced that it has created a new private equity fund that will invest in Africa’s health sector. The Health in Africa Fund, managed by Aureos Capital, will invest in small- and medium-sized companies in sub-Saharan Africa with the goal of helping low-income Africans gain access to affordable, high-quality health services. The fund will be measured not only by fiscal performance but also by its ability to cultivate businesses serving the poor. It will target commitments between US$100 to 120 million over two closings. The fund will make long-term equity and quasi-equity investments in socially responsible and financially sustainable private health companies with the aim of scaling up successful businesses, taking proven business models into new regions, and identifying and investing in areas where there are critical gaps. It will invest in a wide range of companies that deliver, among others, health services (clinics, hospitals, diagnostic centres and laboratories); pharmaceutical and medical-related manufacturing companies; medical education; and providers of medical education.
This report reviews the progress made in the health sector in Africa over the last 50 years, in terms of health outcomes, and particularly in the
utilization of, and access to, healthcare services. The current challenges faced by the health sector are assessed, and the discussion lays the groundwork for projections regarding the future of healthcare in Africa over the next 50 years. The authors outline that the private sector has been playing an increasingly important role in health financing in Africa, and that in some countries, such as Angola and Mali, all private expenditure is direct payments from households. Lack of continuity in policy, lack of resources, poor management of available resources, and poor policy implementation are identified as major impediments to improving the health systems. The private sector is playing a major role in the delivery of health services to citizens, yet dialogue and the sharing of information between the private and public sector is rare. They indicate that in addition to scaling up public spending, there needs to be a drive to ensure better value for money throughout the health system. They also suggest that The health sector will become a labor-intensive industry that can provide an estimated 2–3 million skilled jobs for young Africans and contribute to economic growth on the continent. As the pharmaceutical, medical technologies, and ICT segments develop, there will be more opportunities in research and development, manufacturing, sales and distribution. Within this industry, other opportunities will be driven by the hospital, health insurance, and medical education segments.
The South African private healthcare sector comprises a complex set of interrelated stakeholders that interact in markets that are not transparent and so not easily understood. This report highlights key features that describe how the private healthcare sector operates. The author identifies features of the private healthcare sector that, alone or in combination, prevent, restrict or distort competition. The report presents recommendations to remedy these adverse effects on competition. Overall, the market is characterised by high and rising costs of healthcare and medical scheme cover, highly concentrated funders’ and facilities’ markets, disempowered and uninformed consumers, a general absence of value-based purchasing, ineffective constraints on rising volumes of care, practitioners that are subject to little regulation and failures of accountability at many levels. An incomplete regulatory regime is attributed to a failure in implementation on the part of regulators and inadequate stewardship by the Department of Health over the years. Intrinsic and extrinsic incentives in the market have promoted over-servicing by medical practitioners which include increased admissions to hospitals, increased length of stay, higher levels of care, greater intensity of care or use of more expensive modalities of care than can be explained by the disease burden of the population. The report presents We evidence of supply induced demand. Various marketing choices are reported to leave consumers confused and disempowered, compounding their inability to use choice as a pressure on schemes. The market is characterized by a dominance of a few schemes and by an absence of effective direct competition between the three big hospital groups. The report recommends changes to the way scheme options are structured to increase comparability between schemes and increase competition in that market; a system to increase transparency on health outcomes to allow for value purchasing and a set of interventions to improve competition in the market through a supply side regulator.
This article raises that the four-year long Competition Commission Health Market Inquiry’s findings reveal what Health Minister Dr Aaron Motsoaledi says he already knew – that South Africa’s private healthcare has become so expensive that even those on medical aid can’t afford it. The article reports that the inquiry singled out the dominance of Discovery Health among medical schemes, and Netcare, Mediclinic and Life Healthcare among hospital groups, as illustrations of competitive market failure. The commission found that the market was characterised by high and rising costs of healthcare and medical scheme cover, by disempowered and uninformed consumers, and by a general absence of value-based purchasing. According to the inquiry’s chair, former Chief Justice, Sandile Ngcobo – who presented the executive summary of the report – the private healthcare sector market displayed consistently rising medical scheme premiums accompanied by increasing out-of-pocket payments for the insured, almost stagnant growth in covered lives and a progressively decreasingly range and depth of services covered by scheme options. Although there were 22 open schemes, two medical schemes constitute 70% of the total open scheme market and Discovery Health Medical Scheme comprised 55% of the open scheme market. The Government Employees Medical Scheme (GEMS) was the second largest restricted scheme. There were 16 medical scheme administrators and Discovery Health and Medscheme accounted for 76% of the market based on gross contribution income. The inquiry also found that there was a failure by practitioners to explore multi-disciplinary models of care and that the fee-for-service model of remuneration stimulated oversupply, and incentivised practitioners to provide more services than needed. The inquiry was also reported to raise the issue of an incomplete regulatory regime in the private healthcare sector: Medical facilities were not regulated beyond the requirement to have a licence to operate and practitioners licensed to practice by the Health Professions Council of SA but little more. The report is open for comments until 7 September 2018 and the final report is expected to be released on 30 November.