This virtual Civil Society Policy Forum session on 24 March 2021 was sponsored by Afrodad, Development Alternatives With Women for A New Era, Eurodad, GI-ESCR, Initiative for Economic and Social Rights, SID, Wemos

Panellists

• Maria José Romero, Policy and Advocacy Manager, Eurodad
• Allana Kembabazi, Program Manager Initiative for Economic and Social Rights (ISER)
• Adrian Chikowore, Policy and Research Consultant – International Public Finance, AFRODAD
• Masaya Llavaneras Blanco, Executive Committee Member, Development Alternatives with Women for a New Era (DAWN)
• Andreas Seiter, Health, Nutrition and Population Global Lead for Private Sector, World Bank
• Tlaleng Mofokeng, UN Special Rapporteur on the Right to Health, UN Human Rights

Session

Marco Angelo, Global Health Advocate for Wemos

• Research on middle-income countries and healthcare- big discrepancy in the PPP debate between the way they are promoted by global actors including the WB and the way they are perceived in the countries where they are implemented.
• PPPs often more expensive, risky than public healthcare. Commercialisation of healthcare intrinsic to PPPs.
• Launching paper today called ‘Risky business: A position paper on PPPs in healthcare’
• Open letter to the World Bank with 93 countries called on World Bank to focus on public healthcare first rather than private.

Adrian Chikowore, Policy and Research Consultant · ‎African Forum and Network on Debt and Development (AFRODAD)

• Lessons emanate from an Afrodad and Osisa study on the Privatisation of Education and Health Services in Southern Africa
• Raising concerns over the rising trend of PPPs and privatisations in Southern Africa propagated by IFIs in the Global North and reasons they give for governments to support PPPs. Posit it as a resource raising mechanism, instead of other domestic resource mobilisation. Concerns amidst limited understanding and capacity to handle the models especially in the social services
• IFIs posit that: Limited fiscal space for governments to meet development needs; low public sector capacity to increase the level of investment to meet increasing demands for health; Greater efficiency in project execution and service delivery; value for money.
• Panacea for developing PPPs across sectors, not just the financial sector
• Lesson 1: PPPs crowd out expertise and resources from the public to private sector. Rising trend of health sector personnel moving to private sector and or dually working in both private and public
• Lesson 2: PPPs undermine democratic accountability and transparency on agreements and contracts. Government accountability will be diminished due to cover-ups by the private sector e.g. case of Lesotho contract now. Parliaments have lost oversight control over PPPs and privatised services as they (agreements) are governed by corporate institutions. Limited consultation and access to PPP agreements and documents.
• Lesson 3: PPPs limit access to health services as a result of: High user fees out of pocket expenses for health services that culminate into the infringement of basic human rights based access to health – perpetuates inequality especially on women who tend to be the backbone of homebased care of families and communities
• Lesson 4: Contingent liabilities embedded in PPPs play a significant role unsustainable debt accrual. PPPs have become one of the most prominent drivers of debt within southern Africa. PPP transactions are off-budget books thereby giving skewed DSAs. The case of the Queen Mamobato Memorial Hospital is testament to how repayment of the IFC advised loan gobbled at least half of the countries’ Health Ministry’s budget.
• Call to action: Put people first in all development interventions within the health sectors of the region and beyond. Delivery of health services are government obligations and the time is now for governments to reclaim this space. In light of the need of the Covid-19 recovery, we are alive to the temptations to continue engaging in PPPs and as Afrodad we hazard this move and make a clarion call that government should ensure adequate public financing for health by tackling illicit financial flows and continued enhancement

Allana Kembabazi. Program Manager Initiative for Economic and Social Rights (ISER)

• ISER report: World Bank funded $17.3 million Uganda reproductive health voucher PPP fails to reach the poorest women
• We’re seeing PPPs purporting to target the poor. Uganda has a PPP law, in line with the World Bank
• World Bank has been financing reproductive health voucher projects – poor people buy and pay for voucher. Use market theories of supply and demand. The theory is giving people choice of providers. “Here in the private, it is those with means that come to the private facilities. Those poorest can’t come here. You have to look for them in the villages, that is where you will find them. And if you say you will wait from here, you will not get them. Those ones do not even have the transport to come here”- private provider.
• NGO was middleman, vouchers distributed through village health teams. Why is there this mismatch? Project design was to not use the public health system, instead we will charge a ‘nominal’ amount. One dollar seems little to us but for someone poor, it isn’t something can afford. Then transport costs etc. Cost was a significant barrier
• Fees in public healthcare in Uganda was banned and then so many more used the healthcare e.g mothers giving birth in hospital instead of at home and pressure mothers into having C sections
• Project teaches us that PPPs won’t reach poorest, especially women administrations costs were huge. You have a public health sector that is struggling. Only 30 per cent of what is needed is financed. This year they were talking about cutting the public health budget. Need to stop ideological dogma and look at the evidence, look at what is happening on the ground in remote villages in Uganda tells a different story.
• One clear message for the World Bank: finance the public health sector. During Covid, doctors were drying because there were not enough ICU beds and mothers dying because facilities too far during lockdown.

Masaya Llavaneras-Blanco, Development Alternatives with Women for a New Era

• New DAWN report: PPPs & women’s human rights: Feminist analysis from the Global South
• Why are using a feminist lens? Women’s centrality in care provision. The sexual division of labour assigned them the role of caregivers. Women are the default buffer for deficiencies in health care provision and other forms of care at the household and community levels. Poorly paid health and social care workers. Lower paid labour participation. Lower income.
• PPPs reduce women’s ability to access health. Out of pocket service create a heavier burden on women, especially poor women. The Mbuya Nehands Maternity Hospital PPP at the Parienyatwa Group of Hospitals (Zimbabwe) implemented a dual service model where the same hospital provides public and private services. For 2019, 89.6 per cent of deliveries were provided publicly, while only the remaining 10.4 per cent were private patients. Reports of harassment of women when unable to pay our of pocket fees after delivering their children. Women also report unexpected fees in the MBPMJ insurance scheme in Chattisgarh, India.
• PPPs create negative incentives that affect survival and quality of life. In the case of the MBPMJ insurance scheme in India, we observed a rise in cases of unnecessary c-sections and hysterectomies booked under the insurance scheme. Mostly for-profit private hospitals, which targeted women of lower socio-economic strata without being offered any alternative treatment. Most were (illegally)charged additional money for the operations even though they had been treated under the PPP insurance scheme which should cover the full treatment.
• Women workers bear the brunt of privatisation schemes such as PPPs. In the Dual service at the Mbuya Nehanda Maternity Hospital in Zimbabwe, ward nurses are attending to both public and fee-paying patients while being only paid for by the public sector (this is not the case for the physician, the surgeon , the anaesthetist and operating theatre nurse, who are also paid privately). Nurses’ unions are at often at the forefront of Fiji’s Nurse Association and different unions in Peru have been at the forefront public demands for informed consultation with affected communities, as well as the disclosure of contracts that sustain the PPs at Lautoka and Bank public hospitals, and the Red Asistencial Sabogal of Alberto Baron-Callo Hospital III in Peru.
• Beyond adding gender and stir: the need for public services: We welcome improvements in production of sex improvements of the specific needs of women and girls. The RIGHT TO Health is a human right which is a duty of the state to protect and provide. Public health provision is a cornerstone of a fairer social organisation of care and thus a central intersectional feminist demand.
• Poor health outcomes, accounts from Zimbabwe where the divide incentivises workers to be more available in private ward rather than public ward and a lack of consultation

Andreas Seiter, Health, Nutrition and Population Global Lead for Private Sector

• World Bank Been involved in many discussions on PPPs and where IFC has supported them as ‘positive learning experiences’ – we fully acknowledge this
• But it is often coming from the country, from the minister. All the examples we recall, we advised against it.
• When we go back to what we do – in most countries there in a private sector in health, some countries dominant in terms of service delivery. Countries should start a dialogue with private sector, govern private sector. The more successful areas we work is where we encourage and facilitate public private sector dialogue. Health federations which encourage their working together.
• In boardroom this all makes sense, but you see in reality, there is a lot of factors you weren’t considering. You feedback is helpful to us.
• What shocks me is the administration costs. Bring in an international agency – their costs for their systems are much higher. Without the administration, these are dilemmas we haven’t seen – just have a dialogue.
• Areas where you could start contracting out non-clinical services. Specialised clinical services e.g. IFC contracting out dialysis services.
• This all is messy and it takes much longer than we think. Yes, public sector is underfinanced. Do you want to spend it all in a public health system? Show we where there is quality, transparency and good pay for workers, supply chains where drugs arrive at facilities. Muddled grey on both sides – difficult where on one side a money driven system, on other side, we want it to be a free service for everyone, including the poor.
• I would like CSOs to keep going in and doing what you are doing and show us what you find, But also being open to peer reviews.
• It’s shades of grey, not black and white. Useful to get your detailed country level data.

Tlaleng Mofokeng, UN Special Rapporteur on the Right to Health, UN Human Rights Committee on Economic Social and Cultural rights 

• The obligation to fulfil the right to health lies on the state – can’t delegate or sub-contract to other players. The right to health in policy and legal frameworks remain the function and responsibility of the state. Minimum core obligations, include non-discrimination and equal treatment
• Often lead to continued discrimination
• We know we cannot hold other parties and players in the same way we can hold government and parties to account for equal treatment
• Obligation is on states to move expeditiously to right to health
• For me, an ultimate question is when will private players invest in improving public health – rather than coming in to take leadership – who sets the agenda, who decides what is the priority? Often leaves communities out of discussions – perpetuates hierarchy, not designed to bring in or for communities to have buy in. Communities on the ground set the agenda, navigate struggles on a daily basis.
• Any PPP must come with enough guarantees of the respect to the right to health. Private providers are not absolved of this. With a strong regulatory framework, monitoring. Especially with SRHR, we should be doing monitoring evaluation and learning and then budgets after learning. We can’t do this without thinking about the impact of colonialism and racism on the right to health.
• Why is it that we need private players to supplement the public health system? We can’t have this conversation without being honest. Being intersectional in the approach – if there is any negative outcome, can’t continue to affect women, migrants, LGBT people.
• Need to provide remedies that can settle grievances, rights violations, where processes are impartial and transparent. Many pharma companies have made countries sign non-disclosure agreements. Lack of transparency leads to more distrust.
• It’s humans first that we need to save.

Questions and final remarks

• Roosje Saalbrink (Womankind and co-chair Global Alliance for Tax Justice tax and gender working group): Importance of not leaving behind LGBT groups but also thinking about maternal health, which can lead to disabilities after giving birth which is avoidable with good healthcare.
• Andreas Seiter: public first, people first so that we leave no one behind
• Masaya Llavaneras-Blanco: full study published later this year about the Kenya case. The central issue is the responsibility to provide and protect the right to health, which is on the state. It needs to be based on the common good. Problem is where the incentives are placed- negative health outcomes. Limitations in access to health, loss of human lives when these incentives are nit rightly placed. The WBG and IMF are central in shaping the ground for the application of the model. Be creative in how we finance these processes – tax systems – alternatives to find resources that are not limited to PPPs
• Andreas Seiter: – most countries that reached universal healthcare did this through the public system Because the WBG often promotes a private first approach – we need a public first approach instead.
• Anna Marriot (Oxfam GB): interested in hearing from the Bank on what their lessons are – if they will be doing a review into what went wrong to learn those pertinent lessons? Recently hearing reports that just in the last week, over 300 nurses sacked in Lesotho PPPs because the private sector wasn’t keeping salaries equivalent to public.
• Allana: a lot of this detracts from what we should be doing in public sector. Want to underscore message on accountability – this is the state’s role – there is a contract between citizens and state that is not their for private citizens.
• Andreas Selter: Need to check on Lesotho example with IFC colleagues. MFD from 2017 is across all sector which says if you have private capital tat can use for infra projects where government money isn’t there, but not for health sector. Be aware of private sector because it can grow to undermine public sector
• Tlaleng Mofokeng: discussion of how richer countries are recruiting healthcare workers creating massive gaps but safeguarding against privatisation of health.