How effectively have governments and NSPs (non-state providers) of healthcare co-operated in developing countries? What government strategies and policy approaches might improve non-state provision of healthcare? This paper from Public Administration and Development investigates the relationships between governments and NSPs in Bangladesh, Malawi, Nigeria, Pakistan, South Africa and India. It argues that, while successful small-scale projects exist, improved non-state healthcare requires more trust between governments and NSPs, better state monitoring of NSP performance and more comprehensive government policy towards NSPs.
NSPs provide the majority of healthcare services in low-income countries. With slow progress in developing public health systems, government and donor policy statements increasingly refer to “public private partnerships” in healthcare, although the extent of implementation is variable.
NSPs include for-profit providers, ranging from corporations running hospitals, to traditional healers, and not-for-profit organisations and NGOs, which also vary in size and formality. Data on NSPs in developing countries is poor, but estimates indicate that most healthcare expenditure goes to the private sector and most practitioners work in private healthcare.
Interaction between governments and NSPs is examined under three headings: dialogue, regulation and contracting. Various patterns emerge:
- Dialogue between government and NSPs varied in effectiveness. In Bangladesh, there was good NSP involvement during nutritional policy formulation, but little engagement during implementation. In Nigeria and South Africa, NSPs are increasingly consulted, although initiatives are still at an early stage. In India and Malawi, there is little meaningful NSP involvement.
- Regulation is divided between two approaches: the “stick” (a “command and control” approach) and “carrot” (based on incentives). The “stick” strategy has suffered from inadequate government monitoring of small, scattered, often illegal NSPs – although better state capacity in South Africa has promoted government and self-regulation. The “carrot” approach has improved some services, but questions remain over the resources involved in monitoring and operating accreditation systems, and the difficulty in scaling up projects.
- Contracting involves more formal relationships between governments and NSPs or NGOs. A South African government project to fund private GPs promoted healthcare access but was poorly monitored and open to fraud. NGOs tended to have more capacity and will to operate in remote areas but partnerships between under-resourced governments and well-funded NGOs could be unbalanced.
Ineffective monitoring by governments and poor compliance by NSPs, as well as suspicion felt by governments towards private providers, should be redressed by various measures:
- Trust must be fostered between governments and NSPs through the establishment of forums for NSPs to be consulted at national and local levels.
- Government engagement with NGOs and coalitions of smaller NSPs should be facilitated through local consultation and better geographical mapping of NSPs.
- The difficulty of monitoring small, far-flung NSPs should be addressed by investing in appropriate human resources, transport, technical capacity and investigating the possibility of decentralising monitoring.
- Governments and donors should devote resources to formulating a comprehensive, scaled-up policy towards non-state healthcare, rather than continuing the current ad hoc, fragmenting initiatives.
