Africa: Public healthcare and outsourcing – can it work? The Global Review provides some answers

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Universal health coverage – ensuring everyone has access to high-quality, affordable health care When they need it – It is one of the goals Sustainable development goals.

But progress towards this goal has been elusive, especially in developing countries. In recent years, existing vulnerabilities in public health systems have been exacerbated by the COVID pandemic, stressed public budgets, rising public debt and risks associated with climate change.

An increasingly common government strategy for universal health coverage is to contract with private companies or non-profit organizations to provide health care services on its behalf. This is known as ‘contracting out’, and is often seen as a means of bypassing the perceived inefficiencies and inertia of the public sector, and using existing infrastructure and resources in the private sector to expand the delivery of public services.

Some proponents of outsourcing also believe that introducing competition and innovation will improve the quality of health care services. These are the principles that are often associated with the markets.

But how does it work in practice? Does contracting affect opportunities for community participation, which is considered a cornerstone of primary health care and democratic governance?

our A team of researchers in South Africa, Brazil and India Run Global review From the evidence, analyzing more than 80 peer-reviewed studies from around the world. We wanted to understand, first, whether contracting leads to improved access, quality, and equity in primary care. Health systems are based on strong primary care Usually better performance.

Second, we wanted to know whether involving local communities in the management (design and monitoring) of these contracts made a difference.

Our review painted a complex picture. On the positive side, evidence was clear that outsourcing often improved access to primary care. This was especially true in peripheral or remote areas where state influence and resources were limited.

However, the impact on service quality was much less clear.

Regarding the community question, our research has found that when communities have a real say in the design and monitoring of contracts, outcomes are better. This has helped improve access to services and make them more responsive to local needs.

This global evidence has implications for South Africa as it grapples with severe health inequalities and the proposed introduction of the National Health Insurance (NHI) system. This envisions a health care system in which health care is purchased from a mix of public and private providers. Our research indicates what the government will need to achieve for this to work.

Defining and measuring quality – and what we found

The complexity of findings regarding quality is partly due to differences in how it is measured across different studies and programmes.

Ideally, quality should be measured by the effectiveness and relevance of services. In other words, whether they solve the health care problems they intend to solve and address actual needs. But too often, service quality is evaluated on the basis of whether contractors achieve a set of narrowly defined goals, such as the number of patients seen and services provided, rather than on what the services achieve.

Quality can also be defined in terms of cost-effectiveness, rather than public health goals. This can create incentives for contractors to reduce costs and avoid treating the sickest patients.

In some cases in our review, such as in parts of Brazil and India, contracting was associated with impressive improvements in health outcomes, such as reduced infant mortality. In other countries, quality has stagnated or even declined from this perspective.

We also found that profiteering can take hold when for-profit companies take control of service delivery and success is defined primarily in terms of shareholder value. In Brazil, contractors must be non-profit for this reason.

An important influence on the quality of service is the state’s capabilities in contract management. Are they able to design good contracts, quality indicators, payment systems and incentives? How successful is it in managing relationships and enforcing conditions?

Benefits of community participation

The most convincing evidence came from Brazil. It has established legally mandated health councils composed of community members and health workers. They have powers to veto health plans and budgets.

Councils have often helped nonprofit health providers understand local needs, remove access barriers, and anticipate service delivery challenges.

Similar successes were observed in Iran. The country established “people’s boards of trustees” in health centres. These contribute to planning and awareness.

In Bolivia and India, initiatives involving community participation in the management of services provided by non-profit organizations have been associated with improved maternal and child health outcomes.

However, effective participation requires resources, and the political will to ensure participation enables real impact.

States must provide transparent, high-quality data on contractor performance, and invest in improving the skills of community partners to interpret complex contractual terms.

Community actors may also lack the trust necessary to engage with government officials and companies, who are usually more powerful. Too often, participation is thwarted by technical glitches in fragmented reporting systems, a lack of cooperation by officials, and a focus on auditing finances rather than health outcomes.

What does this mean for National Health Insurance in South Africa?

the NHI Bill It envisions the state as the sole purchaser of health care services, purchasing care from a mix of public and private providers. This is, in essence, a massive nationwide contracting exercise.

Our research indicates that its success requires two basic things: state capacity must be built; Public participation must be included in the system.