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AbstractBilateral and multilateral donors make frequent reference to collaboration with non‐state providers (NSPs) in the health sector, and the desirability of so‐called public private partnerships. Governments of many low‐income countries are also increasingly committed to this goal in their policy statements. This article presents a range of cases from six countries of how governments, donors and NSPs interact. It describes examples of what type of engagement is taking place between governments and NSPs, highlights some common themes and reflects on common motivations for collaboration and constraints to it. Examples are examined under the original study design headings of dialogue, regulation, facilitation and contracting. These categories were not easy to sustain. Much government support to NSPs was characterised by donor involvement, fostering a 'pilot project' style of approach. In other cases, it was not so much a case of governments pursuing a specific intervention to support or regulate NSPs, as NGOs taking an initiative to fill a gap in government provision. The article highlights the main gap in interaction with NSPs as a comprehensive framework for regulating services provided by small scale, for profit NSPs. This is a serious shortcoming given that they deliver the bulk of basic health care in most of the countries examined. Copyright © 2006 John Wiley & Sons, Ltd.

AbstractContracting out of health services increasingly involves a new role for governments as purchasers of services. To date, emphasis has been on contractual outcomes and the contracting process, which may benefit from improvements in developing countries, has been understudied. This article uses evidence from wide scale NGO contracting in Pakistan and examines the performance of government purchasers in managing the contracting process; draws comparisons with NGO managed contracting; and identifies purchaser skills needed for contracting NGOs. We found that the contracting process is complex and government purchasers struggled to manage the contracting process despite the provision of well‐designed contracts and guidelines. Weaknesses were seen in three areas: (i) poor capacity for managing tendering; (ii) weak public sector governance resulting in slow processes, low interest and rent seeking pressures; and (iii) mistrust between government and the NGO sector. In comparison parallel contracting ventures managed by large NGOs generally resulted in faster implementation, closer contractual relationships, drew wider participation of NGOs and often provided technical support. Our findings do not dilute the importance of government in contracting but front the case for an independent purchasing agency, for example an experienced NGO, to manage public sector contracts for community based services with the government role instead being one of larger oversight. Copyright © 2011 John Wiley & Sons, Ltd.

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.

AbstractWhen the Thai universal coverage (UC) scheme was established, the government decided to exclude renal replacement therapy (RRT) for end‐stage renal disease (ESRD) patients from the benefit package, though RRT was included in two other public health insurance schemes. Access to RRT for UC members thus depended on the ability to pay. This study assessed the economic impact of RRT costs on Thai households of different economic status focusing on three issues: (1) the use of RRT; (2) the financial burden of health care payments and (3) household strategies for coping with RRT costs. In‐depth case studies of 20 households covered by the UC scheme and having ESRD patients were undertaken using three qualitative data collection approaches: semi‐structured and in‐depth interviews, and direct observation. Poorer and richer households in urban and rural areas of Nakorn Ratchasima province, a large province in the Northeast where more than 20 per cent of households live below the national poverty line, were purposively selected. The study was conducted in early 2005 and households were visited every 2 weeks for 3 months. Interviews were transcribed and analysed using a thematic approach. The decision to exclude RRT from the UC benefit package created financial barriers to RRT and had a substantial economic impact on poorer ESRD patients. Inadequate dialyses and erythropoietin injections to correct anaemia appeared to be a major cause of death for poorer patients. Household expenditure on RRT took 25–68 per cent of total income or 31–52 per cent of total expenditure, which meant all poorer patients faced catastrophic health spending. In contrast, richer patients had adequate dialyses, resulting in a higher survival rate and quality of life than poorer counterparts. Various coping strategies were employed by poorer patients; these included reducing frequency of dialyses, reducing food consumption, using public transportation to hospitals and taking high interest loans. The RRT cost burden not only impacted patients but also their household members and relatives who provided financial support. Given the two UC policy objectives of equitable access to health care and financial risk protection, the catastrophic impact of RRT costs on poorer households questions the appropriateness of excluding RRT from the UC benefit package. This issue requires further serious attention by the Thai government. Copyright © 2009 John Wiley & Sons, Ltd.