This House believes that private sector involvement is necessary to improve healthcare in Africa

The commitment to improving healthcare can be seen by the prevalence of health indicators in the Millennium Development Goals (MDG). This has resulted in innovative models, and thinking, on healthcare. The MDG provide a means for monitoring national progress in tackling multiple dimensions of poverty[1]. The defined goals encourage intervention to enable equality in health care, ensure a healthy population, and promote healthy environments. However, Sub-Saharan Africa continues to be far from reaching the MDG targets (UNDP, 2013).

In seeking to achieve the predefined goals the role of the private sector[2] has received increasing attention. Questions have been raised as to what the private sector can do to assist in eradicating poverty; how the private-sector is enticing innovative models of care; and why targeting the goals need to move beyond state intervention. The private-sector has played a key role within the distribution, and provision, of health care in Africa(McKinsey, 2007). Further, the rise of an urban middle class has encouraged a new market towards care. Willing to pay for care and demanding better care, the middle-class are encouraging a shift towards continuing privatisation.

This debate focuses on the relation between health and privatisation. With the public-sector underfunding health care, and a rise in consumers opting for private healthcare, what conclusions can be made? The debate returns to the issue of social policy in Africa - its importance and the need for new ideas.

[1] The MDG incorporate eight goals (see UNDP); recognising ‘poverty’ is not simply measurable in economic terms, but as freedom and social. ‘Health’ remains explicit in three goals; and implicit in the remaining five. The goals applicability has been widely criticised; however, in this case, the focus is on the process of achieving them. 

[2] The private-sector includes a broad range of actors, ranging between formal and informal, for-profit and non-profit, insurers and manufacturers.

 

Title 
Funding solutions to combat disease
Point 

Sub-Saharan Africa accounts for 24% of the global disease burden; but only 1% of global health expenditure and 3% of the world’s health workers (McKinsey and Company, 2007). $25-30bn is required to invest in healthcare assets in the next decade to meet needs (McKinsey and Company, 2007). Public resources are not available, so the private-sector is critical.

The private sector can help fill this funding gap; private-sector actors - including Actis - are planning to invest $1.2bn into Adcock Ingram to provide and supply drugs[1]. The investment will provide key funding to enable research; and the availability for ART[2] within Adcock Ingram’s Anti-Retroviral Portfolio. To combat HIV, and other diseases, investors are required for R&D and the distribution of drugs. In 2012, only 34% of the people living with HIV in low and middle-income countries had access to ART showing how necessary such investment is[3]. Furthermore, the private-sector have established partnerships to implement training programmes, improving qualified treatment for HIV, TB and malaria[4].

[1] See further readings: Private Equity Africa, 2013.

[2] ART (Anti-Retroviral Treatment) involves drugs which prevent the progression of HIV; reduce transmission and mortality.

[3] According to the WHO 2013 guidelines of people eligible for ART. See further readings: UNAID, 2013.

[4] See further reading: AMREF USA, 2013; AMREF, 2013.

Counterpoint 

In order to combat disease equality needs to be a central component. Drug distribution, new training schemes, and facilities, targeting disease prevention and treatment are influenced by market economics and feasibility. Treatments by Anti-retrovirals should not just be for those who can afford private healthcare.

Further, when considering health care private actors need to broaden horizons. Although funding remains uneven and below target, the specific inclusion of HIV, TB and Malaria within the MDG has distorted the focus on disease. Investment is required in neglected tropical diseases and non-communicable diseases something the private sector has yet to be willing to invest in.

Title 
Improving health care for mother and child
Point 

Private-sector investment will provide crucial training for health professionals, infrastructure, and resources to improve maternal and child health care. Providing affordable maternal care acts as a means for promoting gender equality, and empowerment.

Jacaranda Health[1] operate on a business model, meeting the demand, and need, for affordable and high-quality maternal care in East Africa. Through mobile clinics and new maternity hospitals Jacaranda Health is empowering women and children. Within the first year Jacaranda Health provided care for 4,000 women, and changed the lives of 20,000 families.

Additionally, free maternal care holds negative side-effects. As Burundi shows, the social policy ideas implementing ‘free’ maternal health care resulted in overburdening the health resources and understaffed facilities; and putting vulnerable children at greater risk (IRIN, 2013).

[1] See further reading: Jacaranda Health, 2013.

Counterpoint 

Quercioli et al (2012)’s study on the relationship between investing in private health care and mortality does not come to clear conclusions about the best course[1]. The results show investments in public sector health services is associated with a 1.47% reduction in ‘avoidable’ mortality. Investing in the public-sector is more cost-effective, and achieves faster results. The rate of return from private investment is slower.

Privatisation is not necessarily best for maternal care.

[1] The research was carried out in Italy.

Title 
Alleviating rural-urban disparities
Point 

Private health is enabling improved access to health services in neglected areas and reducing disparities in access to health.

In Sub-Saharan Africa rural-urban disparities in health-care have received increasing attention. Private investment is bringing services to remote locations. The potential role of technology companies bringing healthcare to areas without it is showcased in Samsung’s investment in mobile solar-powered clinics in rural South Africa[1]. Mobile technology is providing crucial innovations[2]; used as tools by private investors, mobiles mean individuals can be updated on health status and preventative practices without physical access to doctors, or nurses.

[1] See further readings: All Africa, 2013.

[2] See further readings: Deloitte, 2013, Graham, 2012; Knapp et al, 2010. 

Counterpoint 

Although mobile technology is introducing innovative approaches, location and physical access is still often required. Disparities cannot be alleviated until the private actors are willing to invest in remote areas. Not all health problems can be dealt with by a mobile conversation with a doctor.

Further, it remains debatable as to whether rural environments receive worse health-care. Debates have been raised as to the extent of an urban bias - do urban populations hold an advantage or penalty in health[1]? Frequently neglected by private-investors, the urban poor have been identified as vulnerable groups. Investment, planning, and intervention, is required within slums and for the urban poor.  

[1] See further readings: Goebel et al, 2010; 

Title 
The missing MDG: inequality
Point 

Privatising health care cannot be discussed without raising concern over inequality. The privatisation of health care promotes exclusive health care, and is failing to bridge the gap between accessible care for low-income groups and the elite. The model remains unaffordable for many, and therefore ineffective. Even where affordable options are available the quality of care deteriorates. Quality assurance, and affordable care, is needed.

For example, taking the case of South Africa. Health care is provided through both public and private systems. However, the pricing of private health care: whereby better facilities and speed of treatment are found, leaves a majority out-of-pocket and excluded (All Africa, 2013). Prices need to be controlled and affordable options made available. Although formal employers have been involved in supporting access and coverage to health insurance schemes, to prevent a two-tier health system, a majority work within formal employment. If everyone has a ‘right’ to adequate health care, privatisation neglects their rights to health[1].

[1] See further readings: War on Want (2013).

Counterpoint 

In seeking to make private health care affordable new models are being introduced. The new models introduced tackle issues over affordability from a demand and supply perspective.

First, multiple health financing schemes have been rolled-out across Sub-Saharan Africa. A range of financing and insurance options are being built, from investing in health providers[1] to including bottom-up approaches. Community based health insurance, as found in Rwanda and Ghana, are ensuring a move towards universal coverage (see USAID, 2012).

Secondly, in tackling supply issues, low-cost private clinics models are being constructed. In Kenya, the Avenue Group provides a positive example working to provide affordable private health care. Risk-pooling, by members, is accepted as a method of payment. Costs are reduced by working with patients, whilst a regular payment source is provided for the caregiver (see Avenue Group, 2013).

[1] The IFC recently announced a $4mn investment in AAR East Africa, expanding out-patient care (see AVCA, 2013).

Title 
Unregulated health-care
Point 

With the incorporation of a diverse range of private actors, both formal and informal, can health-care still be regulated? Quality and staff need to be regulated, with standards and prices set, but who will enforce regulation and how can we ensure rules are followed? Just treatment is required. Public-sector delivery protects patients from poor, dangerous, treatment.

When looking at regulation in health care, the relationship between private healthcare provision, efficiency and quality is variable. Outcomes depend on the institutional settings (economic, political, and social) and what private actors are involved. Private health providers have a profit incentive to cut corners and provide the cheapest care they can while charging high prices. The theory of a virtuous cycle is far from the reality.

Counterpoint 

Being part of a brand ensures investors maintain a standard, and ensure infrastructure, drugs, and medical practices are met. Building franchises for health-care ensures familiarity and is setting standards to follow. Blue Star is a case in point. The Blue Star Network has been rolled out across Africa, and the franchise provides family planning resources and training on sexual and reproductive health. Once the private clinics have completed training, Blue Star recognition is awarded[1].

Including the private sector in health care provision means a structural shift in the model of care: improved efficiency, quality and methods of care.

[1] See further readings: Marie Stopes International, 2013. 

Title 
Ideas and interests in a neoliberal model
Point 

The ideas driving private health need to be deconstructed. 65% of expenditure received for health care was from the for-profit sector (USAID, 2012). Health care is not a business or market - patients become customers and needs become sidelined by competition when in the private sector. Private health care involves adopting a neoliberal approach to care; competition is central and markets volatile. The market logic focuses on what is a good investment, will the elderly be included when they are a high risk population? This is why even in private systems like in the United States the elderly need public funding.

The privatisation of basic services, across Sub-Saharan Africa, has been shown to be a failure[1]. Access to health care should be based on need, rather than ability to pay.

[1] See further readings: UNDP (2007). 

Counterpoint 

Having the government only paying for some health care for those who can’t afford private healthcare is still better than the government paying for all. Competition between both public and private will help raise standards in both. 

Bibliography 

AfDB (African Development Bank Group), ‘Health Ministers Say Investing in Health is Key to Inclusive and Sustainable Growth in Africa‘, 2012, http://www.afdb.org/en/news-and-events/article/health-ministers-say-investing-in-health-is-key-to-inclusive-and-sustainable-growth-in-africa-9460/

All Africa, ‘South Africa: What’s Driving the High Cost of Private Healthcare in South Africa?’, All Africa, 2013, http://allafrica.com/stories/201310111434.html?viewall=1

AVCA (African Private Equity and Venture Capital Association), ‘IFC Invests in East African Health Services Company, AAR Health Care Holdings’, IFC, 2013, http://www.avca-africa.org/ifc-invests-in-east-african-health-services-company-aar-health-care-holdings/

Avenue Group, ‘Managed Care’, 2013, http://www.avenuehealthcare.com/managed%20care.html

IICD, ‘Mobile Devices Help Monitor Access to Healthcare in Ghana’, IICD, 2010, http://www.iicd.org/articles/pdas-help-monitor-access-to-healthcare-in-ghana

IRIN, 2013. ‘Burundi: Side-Effects of Free Maternal, Child Health Care’, IRIN, http://www.irinnews.org/report/59267/burundi-side-effects-of-free-maternal-child-healthcare

McKinsey and Company, 'Health Care in Africa: A Vital Role for the Private Sector', McKinsey on Society: Global Public Health, 2007, http://mckinseyonsociety.com/the-business-of-health-in-africa/

Quercioli, C., Messina, G., Basu, S., McKee, M., Nante, N., Stuckler, D. ‘The Effect of Healthcare Delivery Privatisation on Avoidable Mortality: Longitudinal Cross-Regional Results from Italy, 1993-2003’, Journal of Epidemiology and Community Health, 2012, http://jech.bmj.com/content/early/2012/09/28/jech-2011-200640.abstract

USAID, ‘The Path to Universal Coverage in Africa: Focus on Community-Based Health Insurance’, Health Systems 20/20: Better Systems, Better Health, 2012, http://www.healthsystems2020.org/content/resource/detail/104166/

UNDP, (United Nations Development Programme), ‘The Millenium Development Goals Report 2013’, United Nations, New York, 2013, http://unstats.un.org/unsd/mdg/Default.aspx

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