Public-Private Partnerships in Middle-Income Countries - Literature review Example

? Provision of healthcare by private sector in low and middle-income nations is often argued to be resourceful, responsible and sustainable compared to the public healthcare delivery systems. However, the public sector is often considered to be able to offer more equitable as well as evidence-based care thus, the literature review evaluates the performance impact of the partnership between private and public health sectors within low and middle-income nations. The past three decades have seen a steady growth in private sector’s role in the health care system in high-income nations within commonwealth; moreover, studies clearly show that private sector plays an essential role in of financing and producing healthcare in low and middle-income countries. As well, theoretical as well as empirical studies point to the potential contribution of private sector to reforms aimed at improving the quality and accessibility of health systems. The focus of the study is the increased focus of public-private partnerships (PPP) as a way of increasing capital finance as well as improving the efficiency and quality of service provision in low and middle-income countries. The partnership involves the public sector entering into long-term contract with private sector in order to enable the public sector access private capital for building and renovating health facilities and agreeing to deliver services over the contract period. Such contracts are designed and agreed upon some pre-determined specifications of the required outputs and define the financial, working and clinical standards, which the private sector has to meet. In low and middle-income nations, governments remain the ultimate funder of health care by making periodic payments to private sector in return for services delivered (Hellowell, 2012 p.71). Public-private partnership is an institutional arrangement built on foundation of fresh public management that claims objectives such as improved efficiency, quality as well as competition of public sector services. In striving to achieve these objectives, PPP aims at achieving value for money while reducing the demands on the state budget by involving the private sector in provision of traditional infrastructure services like health care. Adoption of PPP policy within industrialized nations is often viewed as a tool for further development of public services, while its application in developing nations is a way for reducing poverty and improving the service offered to citizens in such nations. Early 1990s PPPs policy was widely adopted in industrialized nations like USA, UK and Australia; nevertheless, this policy has been diffused in developing nations (Appuhami, Perera & Perera, 2011, p.431). The approach of PPP is attractive to developing countries that often experience macro-economic problems like poor infrastructure that burden the government budgets and excessive government budget. State-based healthcare service provision and private sector health services have existed together in various low and middle-income nations for decades with many nations having a huge portion of healthcare spending paid by the state. Private providers are heterogonous made up of formal business entities like independent hospitals, informal entities that include unlicensed providers as well as non-profit and non-governmental organizations (Basu, Andrews, Kishore, Panjabi & Stuckler, 2012, p.3). Various studies have disaggregated consumption of health care by income levels and appeared to show that the private sector mainly provide health services to more affluent populations. In the emerging economies, some nations are taking bold steps with the PPP’s by indulging the private sector in both infrastructures renewal and delivery of clinical services in the integrated partnership. Health care is a labour-intensive industry where clinical and ancillary services absorb most the expenditure allotted to many health systems; therefore integrating clinical services with provision of capital infrastructure in PPP offer unique opportunity for high efficiency gains in low and middle-income nations. The model is appropriate in circumstances where prevailing health care provision seems to be inadequate with regard to productive efficiency or quality; therefore, the partnership offers a bundled solution where the private sector gets involved in all aspects of healthcare production process that range from designing, building, financing and maintaining healthcare facilities for delivery of clinical services. Generally, the PPP is essential for enhancing health care system performance within low and middle-income nation by ensuring that procurement processes as well as structure of contracts produce the correct incentive framework. The private sector in developing nations has a growing contribution to healthcare influenced by various factors that include counterbalance between supply and demand heavy influences of private healthcare in developing nations. Physicians within low and middle-income countries frequently move abroad because of the meagre incomes and insufficient funds available in the nations and the superior professional prospect and high standards of living abroad; since, there are considerable recruitments of physicians in high-income nations. This emigration of physicians from many low and middle-income nations drains accomplished personnel from the pathetic health system, which in return reduces the accomplishment of existing main health care which often tend to public health providers. The trouble of prolonged non-contagious illness has been increasing in low and middle-income countries (LMICs) as well as tenacious contagious diseases, deprived maternal health and fragile health systems (Berman, 2001). Non communicable diseases in LMICs account for a lot of premature mortality in many LMICs whose costs overwhelm health systems and national economies. Health care sic ire responsibility of national governments nevertheless, many developing nations face the challenges of sheer inadequacy of financial and human resources that hamper governments to deliver healthcare all people who need such service in their nations. Inefficient public sector undermine effective delivery of healthcare even in countries endowed with resources because of inequities in accessing healthcare and essential medicines facilitating the necessity of additional resources and efficient delivery strategies (Asante & Zwi, 2007, p.176). For instance, access to efficient HIV/AIDS treatment remains very inequitable all over the world even though India supplies about half of developing nation’s HIV-positive people with the life-saving generic antiretroviral drugs; nevertheless, access to treatment is between 6% and 15%, which is below 28% the average for Low and middle income nations (Celentano & Beyrer, 2008). Moreover in many sub-Saharan African nations that include Ghana, Tanzania and DRC (Demographic Republic of Congo), their access to antiretroviral drugs despite recent improvements they remain below 20% (Raman, & Bjorkman, 2009). Public-private partnerships have been under scrutiny as mechanisms through which LMICs can mobilize additional resources as well as support for health activities essentially in under-resourced and developing nations. Many partnerships that exist focus on combating neglected diseases or are engaged in developing drugs or vaccines with the UN and its agencies being at the forefront of engaging with private sector in trying to foster collaboration that would deliver resources for health in developing nations. For instance, WHO identified collaborations with civil organizations, philanthropic establishments as well as the private sector as an essential way to the prospects of global health (Yong, 2010). The burgeoning collaborations with the private sector comply’s with UN’s global impact that seeks to improve and distribute benefits of global economic developments through actions in human rights and good governance. According to Asante and Zwi (2007, p.176), enthusiasts of public-private partnership like World Bank believe the partnerships help address cost and investment challenges faced by governments in LMICs in improving efficiency and quality health services. Nevertheless, others like WHO as well as other pharmaceutical companies consider public-private partnership to be able to contribute to the improvement of equity in access to crucial drugs at the time enhancing research into some of the world’s ignored diseases. Even though public-private partnerships are conceptually appealing the approach faces many concerns because the structure and governance arrangements where the partnerships operations are critiqued as well as their potential impact on healthcare delivery in health governance. However, there is not much debate on how the partnerships influence or undermine global health based on viability of public-private partnership for improving health equity and key prospects as well as challenges (World Bank, 2011). According to a study by Basu et al (2012, p.4), there was significant proportion of outpatient services in LMICs that were accessed from private sector; even though, the percentage differed from nation to nation and across income levels. The study showed that in Vietnam the private sector offered 60% of outpatient services in the country while in India in excess of 90% of children suffering from diarrhoea were taken to private healthcare providers; even though income levels were not recorded in the study. Moreover, among accomplices surveyed for HIV testing within 12 African nations, the percentage of patients utilizing the private health sector for testing varied from 3% to 45%. Nevertheless, other studies disaggregated utilization by income levels that tend to show that private sector predominantly serves affluent populations as indicated by the World Bank study in 22 LMICs utilizing Demographic and Health Surveys. Even though various analysis of the World Bank study vary, Basu etal (2012) found that 19 of the studied nations that had both wealthy and poor families the private sector was utilized more compared to the public sector. Basu et al (2012), identified that the private sector included drug shops and any other informal providers; however, when the composition of private sector narrowed down to licensed and certified healthcare personnel, then the public sector offered majority of healthcare in LMICs. In the study, Basu et al (2012) indicated that three countries were exceptional because even when narrowed down to the licensed personnel majority providers of healthcare remained in the private sector, the exceptional countries include Tanzania, Zambia and Namibia. In the study, accessibility of the healthcare services was considered and it was revealed that wait time was consistently short in private sector compared to the public sector. In Ghana it was revealed that waiting time within the public sector was longer even if it was for an identical condition in the private sector. Patients tended to report bad hospitality from providers in the public compared to private facilities; for instance, in Bangladesh public providers ranked low compared to the private providers in scale based surveys. Moreover, analysis of the study reveals that many patients preferred private sector facilities because of the short waiting time, long and flexible opening hours and availability of workers. Quality of healthcare According to Busa et al (2012), a cross sectional study was carried out based on survey studies and found diagnostic accuracy as well as adherence to medical management standards were worse in private providers compared to public. In the study, various researches were examined including infectious disease management protocols and diseases like tuberculosis and malaria, with private sector practitioners recording worse results on knowledge, correct diagnosis and treatment. In Nigeria, it was recorded that public health care providers were drastically likely to use fast malaria diagnostics as well as the suggested combination therapies compared to private sector providers. However, parallel results were recorded in analysis of 24 other nations where children with diarrhoea were less likely to be given proper oral rehydration salts and more probable to get needless antibiotics from private providers compared to public health providers. Poor adherence to guidelines in prescription practices and prescribing of unnecessary antibiotics were more likely to appear in private than public health care providers. Moreover, analysis of privatization of health care system in Peru found significant increase in C-sections after privatization of delivery service, which was high than the recommended WHO 10% to 15% since after the reform the rate exceeded 50%. Besides, a cross sectional study carried out documented lack of drugs and service provision in public health facilities since the study revealed that private facilities stocked more drugs than public facilities; even though, it was unclear if the additional forms of drugs were associated with better outcomes or simply additional brands of equivalent medication (Busa et al, 2012; Robinson, 2010). Patient outcomes According to Busa et al (2012, p.8), public sector provision was associated with high rate of treatment success; for instance, in Pakistan study in Karachi showed that tuberculosis patients were highly satisfied in public sector services compared to the private sector. Moreover, in Thailand patients seeking private institutions’ care had low treatment success in tuberculosis, which showed the likelihood of patients being prescribed with non-WHO recommended regimens than in public sector. Similarly high rate of treatment breakdown was observed in the private sector compared to the public sector regarding antiretroviral therapy that is intended for HIV in Botswana (Celentano & Beyrer, 2008). Studies that compared pre- and post-privatization effects often came up with inferior health system performance linked with extensive healthcare privatization schemes. Following major privatization reforms in Columbia in 1993 in vaccine coverage, the coverage of vaccine in the nation declined for various diseases in the country that led to the significant increase of tuberculosis incidences. A study of Brazil’s privatization of fertility management service showed an increase in sterilization, abortions and unacceptable use of oral contraceptives, which eventually linked to high mortality pace in young women. According to Basu et al (2012, p.10), the comparative analyses of public and private healthcare systems in LMICs found strengths and limitations in both sectors for various WHO themes of patient outcome, efficiency, accountability and quality of healthcare. Private sector healthcare providers seemed to lack published data for evaluating their performance, nevertheless, the private sector had great risk of low-quality care and appeared to serve the high socio-economic groups, while the public sector was less responsive to patients and lacked accessibility of supplies. Contrary to many assumptions, the private sector appears to have low effectiveness compared to the public health sector as a result of high drug costs, vicious incentives for redundant testing and treatment, great risk of complications as well as weak regulation. Therefore, both sectors had poor accountability and transparency in all the WHO themes; even though the findings varied considerably across nations and by methods employed. Therefore, international organizations like the World Bank have ended up strongly rooting for public-private partnerships that improve efficiency and effectiveness of the health sector. From the analysis it is clear that regulatory conditions interact with effectiveness in both private and public sector provision; however, regulatory capacity in low and middle income nations is weak. The information reviewed suggests that systems that incentivize extra procedures tend to result in inefficiencies and poor health outcomes. The study has highlighted lack of regulatory infrastructure in the LMICs to monitor performance of private healthcare contractors with the study showing that private is not accountable, more efficient or even medically effective than the public sector. The private sector advantages can accrue from enhanced medical understanding for suitable diagnosis as well as disease management based on specific improvement programs for medical education to serve as models (Smith & Hanson, 2012). Given the current complexity in health challenges in resource-limited settings it cannot be solved by government alone, therefore, Public-private partnership are emerging as an approach for leveraging the strengths of various sources in order to address health issues in LMICs. Either non-governmental organizations all over the world have for a long period provided public assistance together with government or independently; however, private foundations and academic institutions have come to be involved in social as well as humanitarian efforts in large scale. PPPs often differ in their scope of activities, partners and objectives since some partnerships are formed between huge multinational companies and international agencies while others are modest occurring at the local level (Nakimuli-Mpungu, et al, 2013, p.2). According to CONSTANTINESCU (2012, p.45), constraints on resources impose limitation either explicitly or implicitly of the available medical services that set limits on given benefits in the health sector. The consequence of this effect influences the system of individual and social values as well as some sectors and responsibilities of the professional rank. Therefore, it seems natural for both sectors to identify which medical benefits are essential to a given population and each individual in an attempt to define the basic health service package the public sector can offer. The nations that have national health services with more comprehensive system of social health, a passive approach needs to be generated while decision of rationalizing be left to doctors. Many nations that fit into the LMICs category have citizens who frequently use unofficial payments as means of prioritizing access to health services. In the past implicit rationalization has for a long time being concealed by the medical decision and was maintained that way by lack of knowledge in the huge category of population. It appears there is need for explicit definition of the beneficiary of services delivered by the health system if when the beneficiaries do not always respond to requirements of efficiency and equity. Therefore, the basic package for LMICs healthcare is a tool through which the population’s needs are channelled through certain patterns for medical services and reflect the citizens’ priority in relation to the type as well as the level of services they expect from their preferred health service providers. Therefore, all society members ought to have access to the entire spectre of the health services in relation to terms of quality regardless of the people’s payment capability because of the limitation of funding resources. Partnerships with non-state actors Effective governance for non-communicable diseases at national levels involves development of effective partnerships and coalitions to generate the demand for change and catalyse political action in healthcare sector. Low and middle-income nations may not be well equipped to develop partnerships or engage effectively in such complex and wide ranging actors, which often have conflicting factors. Functional mechanisms for dealing with non-traditional stakeholders like manufacturers are not well developed in low and middle-income nations; therefore, implementation of programs for communicable diseases and maternal and child health in LMICs depends on financial and technical assistance from external donors. Even though, there is increasing international advocacy, the future of international financing for non-communicable diseases still remains unpredictable; hence the state is left with the option of implementing public-private partnership in ensuring that citizens access quality healthcare (Montagu, Anglemy and Tiwari, 2010). According to Rani and Hawken (2012, p.8), in the past numerous global proposals required countries to set up management structures for certain health concerns as a guarantee for receiving assistance. The coordination mechanisms aimed at monitoring and sharing information regarding the implementation of the funded activities instead of engaging with all external partners in harmonizing efforts across them in accordance with national priorities. Response to non-communicable disease in low and middle income countries shows various positive trends that include increased institutional recognition of non-communicable disease programs and an increased inclusion of non-communicable disease in sector-wide health plans. While the population burden of some diseases LMICs is known the causes some times remain unknown; however, rapid socioeconomic growth in many LMICs complemented by the severe economic crisis affecting high income nations generate natural experiments in LMICs health sector. The developments allow investigation of the various risk factors for non-communicable diseases; thus, increasing the need for cooperation between private and public sector players in healthcare (Montagu, 2002). The developments reflect increasing recognition of high burden of no n-communicable diseases as well as other diseases and the explicit acknowledge of the need of multi-sectorial actions by creation of high-level coordination mechanisms. The study shows substantial effect of supranational schemes and processes in governance and policy development that have both opportunities and challenges of PPPs in LMICs. According to Rani and Hawken (2012, p.10), without influences the positive trends, the analysis shows some areas of concern and potential strategies with which to address the concerns. Various strategies for pre-empting the undesirable effects of the various socio-economic impacts on health care in LMICs in the development of PPP is the clear separation of technical, operational and management functions between specific units and sector-wide organizational units respectively. Therefore, setting partnership outcomes for patients are essential for patients in order to access quality healthcare as well as affordable healthcare while ensuring that the projects are sustainable and commercially viable. Nevertheless, the cost of capital remains high in many LMICS that restrict local enterprises in private sector in any aspect of healthcare from logistics and supplies to broad healthcare delivery. In conclusion, the past few decades have witnessed stable development in relation to the private sector role within the general health systems of LMICs making it clear that the private sector plays a significant role in financing as well as provision of healthcare in LMICs. There has been acknowledgement the private sector and its existence has been accepted and plays a crucial role in healthcare for many people in LMICs. It has been documented that the poor can involve the private sector in reaching public sector goals by including multiple frameworks to evaluate performance with regard to efficiency, quality and access. The accessibility of franchised private clinics to the poor is able to offer services similar to non-franchised private clinics; therefore, through quality enhancements within the private sector can result in access to quality healthcare for the poor. Therefore, it has been shown that the private sector investment can be crucial in sustaining health programmes in LMICs for instance in sub-Saharan countries total resources increased while the out-of-pocket spending decreased in various countries. Nevertheless, various countries have never recognised the private sector through the policy makers thus in such countries the role of private sector in health system is scarce. Nevertheless, the private health sector has moved beyond classifying and counting providers and users to assessing mechanisms of harnessing the private sector as well as identifying conditions for successful application. The analysis offers an important contribution to analysing PPP and developing health systems in various contexts in LMICs. References Appuhami, R, Perera, S, & Perera, H 2011, 'Coercive Policy Diffusion in a Developing Country: The Case of Public-Private Partnerships in Sri Lanka', Journal Of Contemporary Asia, 41, 3, pp. 431-451 Asante, A. D., & Zwi, A. B. (2007). Public-private partnerships and global health equity: prospects and challenges. Indian J Med Ethics, 4(4), 176-180. Basu, S, Andrews, J, Kishore, S, Panjabi, R, & Stuckler, D 2012, 'Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review', Plos Medicine, 9, 6, pp. 1-14, Berman P.(2001) Getting more from private health care in poor countries: a missed opportunity. International Journal of Quality in Health Care;13:279-80 Celentano, D. D., & Beyrer, C. (2008). Public health aspects of HIV/AIDS in low and middle income countries epidemiology, prevention and care. New York, Springer. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=364072. Ha NT, Berman P, Larsen U. ( 2002). Household utilization and expenditure on private and public health services in Vietnam. Health Policy and Planning;17:61-70 Hanson K, Berman P. (1998) Private health care provision in developing countries: a preliminary analysis of levels and composition. Health Policy and Planning;13:195-211 Hellowell, M. 2012 The role of public-private partnerships in health systems is getting stronger. Pp.71-73. Konde-Lule J, Gitta SN, Lindfors A, et al (2010). Private and public health care in rural areas of Uganda. BMC International Health and Human Rights;10:29. Mills A, Brugha R, Hanson K, McPake B.( 2002) What can be done about the private health sector in low-income countries? Bulletin of the World Health Organization 80:325-30. Montagu D, Anglemyer A, Tiwari M, (2010). A comparison of health outcomes in public vs. private settings in low- and middle-income countries. San Francisco, CA: Global Health Sciences, University of California San Francisco; Montagu D. (2002). Franchising of health services in low-income countries. Health Policy and Planning;17:121-30 Nakimuli-Mpungu, E, Alderman, S, Kinyanda, E, Allden, K, Betancourt, T, Alderman, J, Pavia, A, Okello, J, Nakku, J, Adaku, A, & Musisi, S 2013, 'Implementation and Scale-Up of Psycho-Trauma Centers in a Post-Conflict Area: A Case Study of a Private-Public Partnership in Northern Uganda', Plos Medicine, 10, 4, pp. 1-8, RAMAN, A. V., & BJORKMAN, J. W. (2009). Public-private partnerships in health care in India: lessons for developing countries. London, Routledge. Rani, M, Nusrat, S, & Hawken, L 2012, 'A qualitative study of governance of evolving response to non-communicable diseases in low-and middle- income countries: current status, risks and options', BMC Public Health, 12, 1, pp. 877-889, ROBINSON, H. (2010). Governance & knowledge management for public-private partnerships. Chichester, U.K., Wiley-Blackwell. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=477896. SMITH, R., & HANSON, K. (2012). Health systems in low- and middle-income countries: an economic and policy perspective. Oxford, Oxford University Press. World Bank. (2009). Improving effectiveness and outcomes for the poor in health, nutrition, and population an evaluation of World Bank Group support since 1997. Washington, D.C, World Bank. World Bank. (2011). Healthy partnerships how governments can engage the private sector to improve health in Africa. Washington, DC, World Bank. http://site.ebrary.com/id/10476325. YONG, H. K. (2010). Public-private partnerships policy and practice: a reference guide. London, Commonwealth Secretarial. Read More