Zimbabwe's health sector has been under-funded for some time causing public health service providers, including Chitungwiza Central Hospital (CCH), to operate below capacity despite the increasing patient demand. CCH entered into a Public Private Partnership (PPP) agreement, now a Joint Venture Partnership, to upgrade quality and availability of health services. However, in this report the authors argue that the intended benefits of the PPP are not being realised because the poor people face increasing fee barriers due to the demand for upfront payment. A survey in 2016 included key informant interviews, client interviews and focus group discussions. It found that the majority of respondents have below poverty monthly household incomes. Most users did not understand the PPP model, and indicated that the hospital did not consult residents on the adoption of the PPP model. Two thirds of respondents felt that services were better before the adoption of the PPP model. Poorer respondents mainly raised the fact that they could not afford services after the PPP due to fee charges, while those with higher incomes felt services had improved due to improved availability of medicines and other supplies. The respondents perceived that not accessing services due to cost barriers for example violated their right to health. The authors note that while there are opportunities to adopt PPP models in sectors such as transport for the construction of roads, rails, and toll gates, these models should not be used in health sectors and other essential services where commoditisation of public services affects access.
Public-Private Mix
Bowling Alone. The collapse and revival of American community. RD Putnam. New York: Simon & Schuster, 2000, pp.544, ISBN: 0 684 83283 6. Carles Muntanera, Department of Behavioral and Community Health, and Department of Epidemiology and Preventive Medicine, University of Maryland-Baltimore, USA. John Lynchb, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor Michigan, USA. International Journal of Epidemiology Vol;31:261-267 - 2002. The authors present an overview of Putnam's claims, their supporting evidence, and several consequences of the BA hypothesis for epidemiology and public health. They argue that the omission of class, race and gender relations and political variables from research on community trust and norms of reciprocity limits the usefulness of social capital as framework for social epidemiology. Next, they link the current theoretical emphasis on social cohesion to earlier social science attempts at advancing the beneficial effects of lack of conflict in Europe and the US.
Carles Muntaner, John Lynch, and George Davey Smith, International Journal of Health Services Volume: 31 Issue: 2, May 2001
The construct of social capital has recently captured the interest of researchers in social epidemiology and public health. The authors review current hypotheses on the social capital and health link, and examine the empirical evidence and its implications for health policy.
The construct of social capital employed in the public health literature lacks depth compared with its uses in social science. It presents itself as an alternative to materialist structural inequalities (class, gender, and race) and invokes a romanticized view of communities without social conflict that favors an idealist psychology over a psychology connected to material resources and social structure. The evidence on social capital as a determinant of better health is scant or ambiguous. Even if confirmed, such hypotheses call for attention to social determinants beyond the proximal realm of individualized sociopsychological infrastructure. Social capital is used in public health as an alternative to both state-centered economic redistribution and party politics, and represents a potential privatization of both economics and politics. Such uses of social capital mirror recent "third way" policies in Germany, the United Kingdom, and United States. If third way policies lose support in Europe, the prominence of social capital there might be short lived. In the United States, where the working class is less likely to influence social policy, interest in social capital could be longer lived or could drift into academic limbo like other psychosocial constructs once heralded as the next big idea.
Debates about the roles of public and private healthcare sectors reflect the experiences of advanced market economies. But in many developing countries, the boundaries between public and private sectors are blurred. Strategies towards private providers must address the context of local relationships between the state, market and civil society. A paper from the UK Department for International Development's Health Systems Resource Centre aims to help the development of a common understanding of the reality of countries where most poor people live and of practical strategies for meeting their needs.
This paper from the Harvard Health Policy Review examines the ways in which public and private sectors can cooperate to improve the quality and accessibility of primary health care (PHC) to the poor in developing countries. The authors argue that the promise of alternative business models lies in their ability to accomplish several important functions in PHC. Business-style contracts can organise small providers into units that are large enough to yield returns to scale in investments in physical capital, supply chains, and in worker training and supervision. In order to understand the problems that business models can help solve, this paper sets up a simple economic model of public private interests in health care. The model identifies two key social interests in health care markets: quality of service provision and access to care by disenfranchised groups. The authors finish with policy proposals for future consideration which include a recommendation that supporting the coordinating organizations through government revenue is only one option. A more creative approach to supporting the coordinating bodies would be to allow them to exploit their comparative advantage in obtaining capital.
The concept of franchising for health services is similar to franchises in business. A franchiser develops a way to provide health services, and then other franchisees copy the model. Each franchisee has to follow the original model. There is usually specific training, protocols and standards to follow, monitoring, and a brand name or logo that identifies that the provider is part of a franchise. Early work reports that social franchising may improve the spread of health services across low- and middle income countries. The review does not find any rigorous evidence to demonstrate the effect of social franchising on access to and quality of care in low- and middle-income countries. Well designed studies are needed.
Governments and donor agencies increasingly recognise the need to provide protection for the poor against income fluctuations or livelihood shocks. In this context, ‘social protection’ is an umbrella term covering a range of interventions, from formal social security systems to ad hoc emergency interventions to project food aid (e.g. school feeding, public works). This paper synthesises current thinking and evidence on a number of issues around the design and impact of social protection programmes, including: the case for and against targeting resource transfers; alternative approaches to targeting; what form resource transfers should take (cash, food, agricultural inputs); the ‘crowding out’ debate; cost-efficiency of transfer programmes; whether these programmes meet the real and articulated needs of their ‘beneficiaries’; impacts on poverty and vulnerability, and fiscal and political sustainability.
Edited by Alexander S. Preker , David M. Dror, World Bank
Traditional sources of health care financing are often inadequate leaving many of the 1.3 billion poor people in low- and middle-income countries without access to the most basic health services. Governments in these countries have tried to reach these excluded populations through public clinics and hospitals. To help pay for these services, governments often use a combination of broad-based general revenues, contributions from the formal labor force, and user fees, similar to the financing mechanisms used by Western industrial countries. However, these mechanisms are not always effective in many developing countries, leaving many of the poor without essential health care or financial protection against the cost of illness. Social Reinsurance details community-based approaches to insuring people against medical risk not based on individual risk rating as in private insurance, but rather using decentralized social insurance based on the average risk.
Whether via international bodies or by means of bilateral agreements, nationally or in PPPs, the public sector would continue to play the key role in terms of setting strategy and providing funds for access to health. With a view to ensuring that a larger percentage of public funds actually reach their intended beneficiaries, Dr Gwatkin of the World Bank urged NGOs to undertake monitoring of government and donor programmes in individual countries, stressing that together, "civil society and the public sector comprise a powerful force for change". He also mentioned that he would like to see efforts by international bodies, such as the World Health Organization (WHO) (www.who.int), to make their health and funding statistics more user-friendly as a means of improving grassroots use of them to increase global access to health.
The chairman of South Africa’s Parliament’s health portfolio committee, Bevan Goqwana, is lobbying for a new, statutory body to oversee private hospitals. Members of his committee grilled the Hospital Association of SA (Hasa) on the prices charged by its members, which include more than 95% of private hospitals. The Council for Medical Schemes said a lack of competition was partly to blame for rising private hospital fees. They said that, in 1996 half the hospitals in metropolitan areas were independent but by 2006 this figure had fallen to 12,3%, due to market concentration in the hands of a few private health care providers, resulting in an oligarchy of providers. Private hospitals and healthcare professionals have faced constant criticism from the Health Minister, Aaron Motsoaledi, for the role he perceives them to be playing in driving up the cost of healthcare. In their defence, Hasa claims that the real cause of high hospital costs in the private sector is the cost of inputs and the expense of increasing hospital capacity with the purchase of expensive specialist equipment.