Public-Private Engagement for Better Health in Africa
Editor’s Note: This is the second in a two-part series about public-private partnerships to improve health care. Click here to read the first post about MOTECH, a mobile platform for prenatal mothers in Ghana.
African governments do not ignore the private sector, as a rule. In Lesotho, the main national hospital is run by a private organization, publicly funded at 80 percent of its budget, provided that it submits health data monthly and follows Ministry of Health accreditation procedures. In Ghana, private providers are paid by the government for care they provide to members of the National Health Insurance Scheme.
Indeed, these are a few examples of many models for successful engagement between governments and private health providers in Africa. However, a new report by the World Bank Group finds that public-private engagement is less than systematic. The Healthy Partnerships report evaluates country engagement with private providers in 45 African countries. Lead author Connor Spreng, an economist at the World Bank, talked with me about the findings.
Gina Lagomarsino: Your report was conducted on the premise that health in Africa needs to improve, that the private sector is too large to ignore, and that government engagement with private providers can improve health outcomes.
Connor Spreng: Africa’s health systems are not currently performing as well as they could and should. But most improvement efforts are directed primarily at government health facilities. In many countries, public providers account for only about half of health care provision. For example, of 6,000 doctors in Kenya, only 1,000 are said to work strictly in the public sector. Ignoring the other 5,000 in health systems planning is like working with one hand tied behind your back.
GL: What are some of the ways that governments can engage with private providers?
CS: We focused on five areas of potential engagement: policy and dialogue, information exchange, regulation, financing, and public provision of services, where governments provide key drugs, supplies or training to private providers.
We found that all governments engage at some level and there are good examples of engagement in most countries. But these efforts are not systematic. No country is working successful across all five dimensions, and where there are good examples of engagement, they are often only around specific disease programs. We hope that defining these five domains for engagement and assessing how countries are doing within each domain will motivate governments to more systematically consider all the potential ways they can engage.
GL: How did you measure how well countries are performing across these five domains?
CS: With a team of three doctors and three lawyers to address both medical and legal issues, we conducted 750 interviews in 45 countries with key experts from the public and private sector, as well as with independent experts.
We also learned from what we were not able to collect. For instance, we weren’t able to develop standardized measures for how much time it takes in each country to open a private sector clinic. In several countries, barely anyone knew what the exact procedures were, and many health facilities were never formally registered. This, in and of itself is an important finding and wake-up call about the need for streamlined regulations.
GL: What countries are particularly successful at engaging with private providers?
CS: Like many countries, Ghana had long been stating that the public sector will work with private care providers to meet national health priorities. But with the expansion of national health insurance, which allows for care at private facilities, Ghana is now in intense dialogue with a newly-formed umbrella alliance of private sector providers.
On the financing dimension, we found that Rwanda contracts with a number of private facilities. This is made possible through decentralized public sector budget management, as well as Rwanda’s national insurance expansions.
Expansion of national health insurance is a very exciting trend. In many countries, the insurance authority has become the de facto regulator of providers because it has the power to exclude facilities from payment. This sets up strong incentives for private facilities to comply with regulations.
GL: What were some surprising findings?
CS: Swaziland is now starting to incorporate traditional practitioners-those without formal training- into its AIDS program. They will be trained to identify AIDS patients and refer them to providers who can prescribe ARVs. The traditional providers are now supposed to stop giving herbal remedies for identified HIV/ AIDS patients.
There are fewer than 200 medical doctors in Swaziland and 11,000 traditional medical practitioners. Can any public health program be even marginally successful by excluding 11,000 providers and focusing on less than 200? You don’t have to be a health planner to realize that’s not going to work.
GL: CHMI has launched a series of studies on informal providers because in so many parts of the world they are the first point of contact for care. We are interested in how health systems can better leverage these providers, even as they try to transition people to seek care at more formal delivery outlets.
What reaction are you hoping for with this report?
CS: This research is only worthwhile if it leads to concrete changes on the ground. The Health in Africa initiative has a team in Nairobi focusing on supporting engagement between the public and private sectors in seven African countries. With the toolkit we have created for policy makers, we hope to support engagement in a broader set of countries-namely by sharpening the conversation about what the role of governments should be in mixed public-private health systems.
It’s not just what governments should do more of but what they should also scale back. Some countries would actually benefit from fewer, more effective policies, less frequent, but more meaningful meetings with private providers, and less heavy-handed regulation. There should be fewer raids and more constructive inspections focused on coaching and improvement. In addition, the private sector must do a better job of self-regulation. Only 19 of 45 African countries have an organized private sector.
The application of the framework we propose, and the implementation of changes in policy and practice, will come with many technical as well as political challenges. We hope that African governments will embrace these challenges.