Is there a reason to scale up public-private engagements in the South African health system?

By Lucy Gilson

The South African health system is a plural health system, with a strong private sector – encompassing private-for-profit providers of various forms of health care, private health insurance companies, commercial companies providing a range of services to all parts of the health sector, and others, such as mining companies, providing health care to their employees. For over a decade national economic policy has encouraged public-private partnerships across sectors, and the National Treasury has a special unit to support their development. In addition, a range of specific health policy initiatives have sought to regulate, encourage and manage public-private interactions.

Nonetheless, before we rush into scaling up new public-private arrangements in South Africa, I think we need to stop and ask, why? Why would we encourage more such interaction, and what are the trade-offs involved in doing so?

In their recent paper, Kula and Fryatt present a careful and systematic review of available South African evidence on public-private interactions. The authors are less clear, however, in defining what ‘success’ means for such interactions, or why they should be implemented on a wider scale. In the face of the recognized inequities within the health system, with six times greater expenditure on those served predominantly by the private sector than those served by the public sector, Kula and Fryatt recognise that significant concerns exist around expanding the role of the private sector. As they also note, it is, therefore, important to consider what is needed to ensure that the developing National Health Insurance system works towards creating a more equitable and high quality health service from the foundation of the current public-private mix in the health system. But the range of possible public-private interactions is wide – are all worth pursuing?

In thinking further it is always important to recognize:

1) The trade-offs involved in developing the specific capacity needed to manage private sector health agents, against developing the capacity to manage the health system as a whole.

2) That commercial interests inevitably largely, if not entirely,  drive private-for profit sector agents.

While there is room to learn from the South African private sector, for example, about aspects of contract management or about reimbursement mechanisms, what does it offer in terms of managing the broad array of goals – a much more complex set of goals than exists in the private sector – that we, as citizens, have for our health system as a whole? Or for managing the different forms of accountability, and related actor relationships, that we demand of public health managers? Furthermore, given the high costs of South African private provider fees, highlighted by Kula and Fryatt, there are clear reasons to be cautious in any expansion of private sector provision over improving public provision.

In South Africa, as elsewhere, I think we need to pause and reflect on whether and when to encourage public-private interactions. Yes, there is willingness on the part of the private sector to engage further, and yes, there are opportunities to learn from private sector experiences. However, the questions we need to ask are not just ‘how do we do it better?’, but also ‘when should we do it at all?’ and ‘if and when does encouraging public-private interactions limit the possibilities of strengthening the public sector that serves the majority of the population?’ Current UK debates about the growing role of the private sector within the NHS, for example, and particularly the evidence about its negative consequences (such as fragmenting primary health care services and risks for the financial viability of hospitals), should lead to careful and thoughtful reflection in South Africa.

The existence of a strong private sector and the wider discourse – inside and outside the health sector, at national and international levels, about the need for the public sector to work with the private sector – do not themselves provide the rationale. Neither does knowing more about what makes interactions work. Government stewardship of the health system in every setting is always based on values and in pursuit of expressed and agreed political objectives. Evidence does not replace politics in policy making, it is always only one input to the process. The critical first question, therefore, is surely not ‘how do we scale up public-private engagements?’ but rather, ‘what sort of a health system do we want in terms of access, coverage and quality?’ – and only second, ‘can private sector agents support this goal’?


Lucy Gilson is Health Policy Editor of Health Policy and Planning and Professor of Health Policy and Systems at the London School of Hygiene and Tropical Medicine and the University of Cape Town.


1 comment

  1. Bob Fryatt

    Lucy raises valid concerns about the role of the private sector and how much effort should policy makers put into expanding public-private interactions. In response I would like to raise a few points:

    1) Since the onset of democracy in South Africa there has been considerable debate about the future of the country’s health sector and this continues today. The Green Paper on National Health Insurance has raised a considerable range of views, which is feeding into a new national policy on National Health Insurance. The government has recently launched a competition commissin enquiry into the high costs of private health care. The main focus of the Department of Health is improving the quality of services in the public sector – whether it be national priority programmes, such as for HIV /AIDS, TB, MCH or Mental Health, or for improving management and service delivery in primary care and Hospitals. Our focus on public-private interaction is not taking place in a vacuum – is it not just one element of a much larger discourse on the future of South Africa’s health system.

    2) The private-for-profit health sector currently utilises a high level of the health workforce and of health technology for a relatively small, and wealthy group of the population. In the longer term, a well run, and well resourced public sector with a higher overall level of health workers will help redress this imbalance, but will take many years to develop. Is it not worth looking for short and medium term solutions to addressing inequities is still worth doing, keeping in mind that this should not impair the longer term objectives?

    3) Despite the extensive number of reports, reviews and pilots of public-private interaction, the number of rigorous evaluations was small. This was despite some being recognised by the Treasury, and some parts of the public sector moving forward with explicity partnerships and collaborations with the private sector. We argued that many of the current collaborations may seem to be in line with national goals, but without some independent rigour to assessing their impact, this area will remain open to conjecture.

    4) Whilst there will no doubt continue to be two different camps in South Africa – those in favour of the private health sector, both in terms of financing and provision, and those against it – there does need to be a continual look for a middle path. There are many reasons for this not least the limited level of health workers and medical specialists in the country. The case studies in our paper gave some examples of this and there may be more, especially if the not-for-profit sector is included. The potential positive outcomes of these interactions, in terms of improved access to quality services for those currently under-served, as well as any unintended consequences, do require more attention from the the evaluation and research community.


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