Public-Private Mix

In responding to the goal of rapidly increasing access to antiretroviral treatment (ART), the government of Botswana undertook a major review of its health systems options to increase access to human resources, one of the major bottlenecks preventing people from receiving treatment. In mid-2004, a team of government and World Health Organization (WHO) staff reviewed the situation and identified a number of public sector scale up options. The team also reviewed the capacity of private practitioners to participate in the provision of ART. Subsequently, the government created a mechanism to include private practitioners in rolling out ART. At the end of 2006, more than 4500 patients had been transferred to the private sector for routine follow up. It is estimated that the cooperation reduced the immediate need for recruiting up to 40 medically qualified staff into the public sector over the coming years, depending on the development of the national standard for the number and duration of patient visits to a doctor per year.

The Health Sector Strategic Plan (HSSP) aims to ensure access to basic health care by the Ugandan population through the delivery of the National Minimum Health Care Package (NMHCP). This requires availability of well-trained health professionals. This study demonstrates that the Private-Not-For-Profit (PNFP) Health Training Institutions - the majority in Uganda - have remained grossly under-funded, which poses a threat to achievement of the HSSP. They are faced with decreasing income from fees, dwindling donor support and over-dependence on government grants which are both uncertain and erratic. Consequently, vital activities for students' training such as field trips, teaching and reading materials are left unsatisfied as a copying mechanism, but not without negative implications for quality. It is recommended that government increases and guarantees its support to these Health Training Institutions as a way of maintaining quality of health worker training. At the same time, the training institutions need to diversify their funding options to include designing short tailor-made courses, mobilising alumni contributions, research and consultancies, self-help projects like farming, canteens and stationeries as well as fund-raising activities as a way of bridging their funding gap. This should be coupled with more efficiency mechanisms and prudent management to avoid wastage of the already scarce financial resources.

Health equity remains a major challenge to policymakers despite the resurgence of interest to promote it. In developing countries, especially, the sheer inadequacy of financial and human resources for health and the progressive undermining of state capacity in many under-resourced settings have made it extremely difficult to promote and achieve significant improvements in equity in health and access to healthcare. In the last decade, public-private partnerships have been explored as a mechanism to mobilise additional resources and support for health activities, notably in resource-poor countries. While public-private partnerships are conceptually appealing, many concerns have been raised regarding their impact on global health equity. This paper examines the viability of public-private partnerships for improving global health equity and highlights some key prospects and challenges. The focus is on global health partnerships and excludes domestic public-private mechanisms such as the state contracting out publicly-financed health delivery or management responsibilities to private partners. The paper is intended to stimulate further debate on the implications of public-private partnerships for global health equity.

This paper traces the history of the public-private partnership for health (PPPH) in Uganda, giving its justification and mandate. It also gives its current state of the art, outlining the successes scored, the challenges still faced in its implementation and current efforts being made to make it comprehensively institutionalised. The successes include the bilateral acceptance of the principle and need for partnership by both the public and private partners, the overt gestures by the public partner through direct funding of the private providers, the ceding of some responsibilities to private players, the acceptance by the private players to take on some public responsibilities using their own resources etc. The challenges include the slow formalisation of the partnership, scepticism about autonomy, the stagnation of government funding, the poor understanding of the partnership at sub-national levels and poor sharing of information, among others. These challenges are now further compounded by the recent introduction of new policy reforms like fiscal decentralisation to the same local officials who do not fully appreciate the partnership and are therefore not likely to support it. The paper concludes with some useful suggestions on how these challenges may be tackled.