The role of the private sector in attaining the objectives of the health sector is gaining increasing recognition, especially in low income countries. Arguably, the private sector is not a new player in health. Indeed, the World Bank has advanced the ideology of private sector provision of health services as far back as the days of structural adjustment policies in the mid- 80s. Of late though, we are witnessing renewed emphasis on embracing the private for-profit sector at global, continental and national levels.
The role of the private sector in universal health coverage (UHC) has been advanced at the UN High Level Political Forum on the Sustainable Development Goals; within the UHC 2030 partnership and during the World Economic forum; and in relation to SDG3 during WHO deliberations at the Executive board level. Strong support for embracing the private sector has also been garnered from the UN Economic commission for Africa and Harmonisation for Health in Africa (HHA). On the African continent, we have witnessed the birth of the Africa Healthcare federation with similar structures at the country level – national federations currently in 18 countries. These organizations provide platforms for the private for-profit and public sector to effectively engage.
Furthermore, the advance in innovation, development of new products – diagnostics, medical devices, digital solutions, medicines; efficient options in the distribution of medicines – by the private sector is fascinating. These developments present both opportunities and challenges. While the former relates to improving access to quality services the latter relates to irrational introduction of innovations with financial implications, potential distortion to service delivery and fragmentation of national health system.
Why the renewed focus?
We recap on recent advances that seem to have provided impetus for strengthening public private partnerships – the Universal health coverage agenda, the commitment to integrated people-centered care, and attaining the sustainable development goals targets which necessitate having a healthy and productive population. Do these aspirations challenge the public sector beyond its capacity to deliver? Inadequate funding for health coupled with fiscal space constraints and weak health systems, inadequate and inequitably distributed human resources are an old story plaguing service delivery in low income countries. Indeed, of late statements like “the public sector cannot go it alone” are resounding.
The private sector is perceived to be more efficient, more innovative and offer better quality services than the public sector. In as much they are a potential resource, the lengthy licensing processes and the weak regulatory capacity of governments limits the extent to which their potential can be harnessed. Statements like “systems must be in place”, “we must cultivate the market place” are common in several dialogues. At present, the partnership is fraught with mistrust and divergent objectives with a sense of being stuck in the rhetoric phase. Although some feel that it is more of a mindset issue, especially of public sector officials, as opposed to divergent objectives. Some have referred to this phase as “deepening the dialogue” whatever this means.
The symposium organized by the Africa Health Business Forum in Addis Ababa, Ethiopia 7th – 9th October 2019 engaged in a frank dialogue. The symposium was attended by over 35 private health enterprises active in Africa, ministers of health, multilateral agencies, the African Union and civil society. The spirit of partnership was evident in the dialogue as remarked by participants “in partnership, we will not only go far, but we will make sure we leave no one behind”, “the dialogue is becoming robust”. Frustrations were also echoed regarding the several dialogues with no concrete results, private sector being labeled as profiteers and the varied appreciation of who is actually private sector in the different contexts.
Can countries foster a meaningful public private partnership?
Trust and ensuring a win-win situation in strengthening public private partnership cannot be over emphasized. The patient should be the center where the public sector fulfils its commitment to the population and the private sector contributes to the objectives of the health sector and realize some profit. These win-win options need to be identified and fostered.
Are conditions favorable for the private for-profit sector to flourish? Can African countries guarantee sizeable markets for private manufactures of medicines and medical products? Certainly not, but the ongoing discussions regarding pooled procurement around regional economic blocks and small Island states offer a favorable option. While this will stimulate the interest of private investors with possible job creation on one hand, countries will be able to negotiate fair prices on the other. The recent ratification of the free trade agreement by 25-member states of the African Union offers an additional opportunity.
Opportunities not-withstanding, innovations from the private sector are numerous and good as they are, not everything that is good is needed or is affordable. In the face of weak enforcement of standards, countries have witnessed an enormous amount of pilot projects that have not been scaled up. Some have referred to this phenomenon as “pilotitis”
The role of the private for-profit sector in fragile and conflict settings has been debated with more inclination towards the negative. However, as we learn from Somalia, some participants in the Africa Health Business forum stated that “such settings do not present impossible situations, but just call for doing things differently”. Although in the case of Somalia, the solidarity culture might explain the realized contribution of the private sector where health care costs are a communal responsibility.
Partnerships in achieving SDGs in general and UHC are inevitable and we argue that in as much as the public sector is challenged beyond capacity, the timing is right.