There remain a number of constraints that still need to be tackled in the area of public-private partnership (MOH 2003a). The TCMP, the PHP and the non-facility based PNFPs have poorly developed structures for adequate representation and dialogue and help is needed to improve their internal organisation.
While the partnership concept has been well received at the national level, there is much less appreciation at the district level, and both public and PNFP district partners have been slow to engage with the partnership process. The main reason behind this divergence possibly lies in the fact that the impetus for partnership originated at the national level and has only slowly been gaining the acceptance of the districts. In many cases, at district level, there remains mutual suspicion between the public and private health facilities with each complaining that the other has secret, non-disclosed sources of funding. The dominant motivation has often appeared to be one of competition (for resources) rather than of coordination (in service delivery).
6,111 6,914 6,026 5,400.00 5,600.00 5,800.00 6,000.00 6,200.00 6,400.00 6,600.00 6,800.00 7,000.00 2000-01 2001-02 2002-03
Figure 3: Total units of output in a sample of 111 UCMB lower level units
Source: UCMB (2004).
Note: The degree of completeness and reliability of data from lower level units prior to 2000/01 were poor.
The administrative partnership arrangements, for example the government grant and the medicines credit line, have used government planning, budgeting, accounting and reporting procedures for both public and PNFP providers. This is seen by many in the PNFP sub-sector as weakening their autonomy and introducing a degree of inflexibility that may lead to loss in value for money. They consider it necessary to introduce contractual arrangements between the government and the private health providers to smooth over administrative differences and to maintain the autonomy of the private sector.
Despite improving remuneration, the PNFPs are still unable to competitively recruit and maintain health workers. Most of the losses of staff from the PNFP are to government employment posts (MoH 2005), due to both pull (higher government salaries) and push factors (e.g. more stringent management practices, fewer opportunities for professional development in the PNFP sub-sector (MoH 2001b)). The human resource constraint is probably the most difficult test for partnership currently. The PNFP units have been working to reduce the salary gap between public and PNFP staff, only to be met with further increases in public wages and increasing staff loss. This is compounded by stagnation in the size of the PNFP grant against a growing health sector budget. Furthermore, in successive government budget allocation forecasts, the size of this grant has been flattening which gives a worrying indication of a decline in emphasis on the partnership on the part of the government (UCMB 2005). For example, in the budget allocation of 2002, the PNFP grant was projected to rise quite steeply over the medium term, while in the latest medium-term budget allocations, the size of the grant is projected to grow much more slowly (see Figure 5). Maintenance of the positive achievements of the partnership will hinge on finding a solution to these constraints.
1,371 1,502 1,439 1,307 1,408 1,130 0 500 1000 1500 2000 2500 3000 3500 4000 97 98 98 99 99 00 00 01 01 02 02 03
Figure 4: Median fees charged per Standard Unit of Output OP in UCMB Hospitals (Not adjusted for time preference)
8. Conclusions
The public-private partnership in the health sector has advanced ahead of many other developing countries and international initiatives. It is clear that in promoting the partnership, the government appreciates the valuable role played by private health providers in the delivery of health services to the population. In particular, there is a clear understanding that the partnership seeks to utilise as much as possible the different capacities of all the partners from policy development through to service delivery.
The current level of partnership has been facilitated by a number of factors. The installation of the new government in 1986 paved the way for wide reforms in all sectors including health. The sector-wide approach, initiated in the year 2000 (see chapter 2), was one of the key reforms that provided an enabling environment for partnership. Due to sustained economic growth and continued financial support from donors, resources for government services have increased over time (see chapter 7), and have thus allowed some contribution towards private sector partners, in particular the PNFP health providers.
In many countries in sub-Saharan Africa, partnership with the private sector is largely understood in terms of a funding contract whereby mainly non-clinical services
0.00 5.00 10.00 15.00 20.00 25.00 30.00 35.00 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 Uganda Shilli n gs Billions BFP end 2002 BFP January 2003 MTEF October 2003 BFP April 04 National BFP 05-6 07-8 PNFP
Figure 5: Projected budget allocations to PNFPs over time
Sources: MOH (2002b); MoH (2003c); MoH (2004); MoFPED (2003); MoFPED (2005). BFP: Budget Framework Paper.
are purchased from the private sector (Verhallen 2001). In contrast, the Ugandan case is seen as a more extensive partnership, with partnership areas ranging from policy development to service delivery. The overall goals and objectives of the government and private health providers, in particular the PNFP providers, overlap significantly, leaving little room for exploitation of either party, and consequently the need for legal structures is limited. Moreover, support of the private sector by the government has been shown to yield very positive results in health sector performance. Financial support to the PNFP sub-sector, equivalent to 30 percent of their budget, led to an increase in outputs of over 50 percent in a set of UCMB hospitals between the years of 1997/98 and 2002/03. Such a significant output improvement over time was achieved despite the growth in the government grant to this sub-sector to only 7 percent of the total health budget by 2002/03.
Finally, the value of the partnership with the PNFP sub-sector goes beyond that of achieving health output improvements, as it has helped this sector to refocus itself on its original mission – to assist the poor and vulnerable in the country in the hope of alleviating poverty and improving equity in the population. While much of this chapter has focused on the PNFP sub-sector, it is possible that similar benefits in terms of improved health sector performance can be achieved as greater partnership at the district level is encouraged, and that with the PHP and TCMP sub-sectors is further developed.
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