Maureen Mackintosh

What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries

Private health care in low-income and middle-income countries is very extensive and very heterogeneous, ranging from itinerant medicine sellers, through millions of independent practitioners-both unlicensed and licensed-to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors. In this report, we propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. We develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sectors structure and behaviour, and vice versa.

Flexible Contracting? Economic Cultures and Implicit Contracts in Social Care

Drawing on case studies from two local authorities, this article identifies two distinct economic cultures in social care contracting. An arms-length contracting culture was emerging in interaction with risk-averse commercial suppliers, while a ‘partnership’ contracting culture was developing in association with non-profit providers who actively sought risk and responsibility. The article explores the discursive construction of the distinct implicit contracts associated with the two economic cultures, showing that ‘flexibility’ had become a key trope in contracting debate, carrying complex meanings of both responsiveness and control. The article thus unpacks the notion of ‘soft’ contracting in social care, and argues that social care contracting should be understood as a process of mutual shaping of both a divided care industry and an internally divided local authority economic culture. The article then draws out a series of implications of the research for policy and regulation in care contracting.

Gender and Health Sector Reform: Analytical Perspectives on African Experience

Health systems are gendered institutions. That is, their organization reflects and responds to gender inequalities in the wider society. The hierarchy among health care staff places doctors, policy-makers and administrators — predominantly male — above nurses, paramedical staff and orderlies who are more likely to be female.

Health Systems and Commercialization: In Search of Good Sense

It is the argument of this book that health systems exist to fulfil purposes, including protecting and improving health and the provision of professional, ethical, accountable and accessible health care for all. Therefore policies that influence the nature and extent of health care commercialization should be designed to further those purposes. To achieve this, better economic, social and technical analysis of health care commercialization is required as a foundation for effective health policy.

Inequality and redistribution in health care: analytical issues for developmental social policy

This chapter1 contends that there is a need for more and better political economy of social policy in the development context, and seeks to contribute to its development. Specifically, the chapter discusses the problem of achieving and sustaining redistributive health care in contexts of inequality and low incomes. Much of our evidence and specific argument are drawn from the health sector in Africa, and in particular from recent research2 on health care markets in Tanzania. We believe, however, that our arguments have wider resonance for the effort to create effective, context-specific developmental social policy.

Agricultural marketing and socialist accumulation: A case study of maize marketing in Mozambique

This article analyses maize marketing and its implications for producers, traders and consumers in one area of Mozambique before and after Independence. On the basis of this case, it discusses some of the policy problems encountered by the Mozambican government between 1977 and 1983 in planning agricultural marketing in the context of the wider objective of socialist transformation and development of agriculture.

A perverse subsidy: African trained nurses and doctors in the NHS

Published without an abstract. From the introduction: What would constitute an ethical policy towards the recruitment of African-trained health professionals for the NHS? The story goes that there are more Malawian doctors in Birmingham than there are in Malawi. Gareth Thomas (international development minister) and Rosie Winterton (health minister). They say we don’t need to hire overseas any more. We have trained enough British doctors and nurses and they have to have jobs. NHS manager, in conversation, 2006 In recent years there has been increasing concern about the ‘poaching’ of African doctors and nurses by UK health services. The scale of emigration undermines health care in very poor countries with very severe health problems. 2 The UK government’s response was to institute an ‘ethical’ recruitment policy that banned active recruitment by UK health service employers in staff-short African countries. Public debate about this policy response, including commentary from politicians, journalists, trades unions and also the World Health Organisation (see the latest World Health Report 2006: Working Together for Health WHO, Geneva), has thrown up some complicated ethical and political issues. In this extremely unequal world, there are conflicts between the human rights of African health workers, of British health services users and the African populations who need health services. Migration undermines health services in African countries of origin. Blocking migration by African health professionals however undermines their right to move away from their country of origin; it also plays into the prejudices of anti-immigration lobbies in Britain. Employment by the NHS of doctors and nurses trained in Africa constitutes a ‘perverse subsidy’ to British health service users - that is, a flow of subsidy from poor to rich. The movement from Ghana to the UK alone subsidises the UK health services to the order of £39 million per year. Yet ‘ethical recruitment’ policy solutions lack a sound ethical basis and are potentially discriminatory in their effects, since they focus on restricting mobility rather than ensuring equality of health care. A recent sharp and unheralded switch in immigration policy that phases out training opportunities for migrant overseas-educated doctors and limits entry of all but the most highly qualified doctors has been the latest (and perhaps the most significant) change in this respect. And it has been played out in the fertile territory of debates around ethical health provision. In this article we unpack some of the ethical, political and economic issues that surround this debate and map out some possibilities for picking our way through this troubled terrain.

People and Teams Matter in Organizational Change: Professionals’ and Managers’ Experiences of Changing Governance and Incentives in Primary Care

OBJECTIVES To explore the experiences of governance and incentives during organizational change for managers and clinical staff. STUDY SETTING Three primary care settings in England in 2006-2008. STUDY DESIGN Data collection involved three group interviews with 32 service users, individual interviews with 32 managers, and 56 frontline professionals in three sites. The Realistic Evaluation framework was used in analysis to examine the effects of new policies and their implementation. PRINCIPAL FINDINGS Integrating new interprofessional teams to work effectively is a slow process, especially if structures in place do not acknowledge the painful feelings involved in change and do not support staff during periods of uncertainty. CONCLUSIONS Eliciting multiple perspectives, often dependent on individual occupational positioning or place in new team configurations, illuminates the need to incorporate the emotional as well as technocratic and system factors when implementing change. Some suggestions are made for facilitating change in health care systems. These are discussed in the context of similar health care reform initiatives in the United States.

Accumulation, social services and socialist transition in the third world: Reflections on decentralised planning based on the Mozambican experience

The purpose of this article is to argue for the viability, and the logic, of a distinctive approach to planning economic development and socialist transition in poor economies. The components of this distinctive approach are: more decentralised, and popularly‐based, planning and control of accumulation; the close interlinking of investment in social services and in rural production; and an emphasis on intervention in the market as a tool of socialist planning. The article therefore presents an argument about economic planning intended to be relevant to a range of countries with similar general aims and problems. However, the ideas are developed here, as they were in practice, through a reflection on our own understanding of planning andits problems in Mozambique during the first ten years of that countrys independence.1

Commercial Influence and Global Nongovernmental Public Action in Health and Pharmaceutical Policies

Nongovernmental public action has been effective in influencing global agenda-setting in health and pharmaceutical policies, yet its record in influencing solutions to the problems identified has been notably more limited. While trade policies have been particularly resistant to change, more substantial changes are observable in global health policies and global health governance. However, some of the directions of change may not be conducive to the democratic accountability of global health governance, to the wise use of public resources, to health systems development, or to longer-term access to health care within developing countries. The authors argue that observed changes in global health policies can be understood as accommodating to corporate concerns and priorities. Furthermore, the changing global context and the commercialization of global public action itself pose sharp challenges to the exercise of influence by global nongovernmental public actors. Nongovernmental organizations not only face a major challenge in terms of the imbalance in power and resources between themselves and corporate interest groups when seeking to influence policymaking; they also face the problem of corporate influence on public action itself.