Assessing the equity implications of Public-Private-Partnerships in health in Africa

Today, there continues to be question marks around the real impact of Public-Private-Partnerships (PPPs) - especially what they mean for more vulnerable, lower income groups across African countries.

Evidence suggests that the private sector’s imperative to maximise profits tends to be incompatible with the ambition to provide healthcare to all as a public good. Yet, private sector involvement in healthcare delivery in the form of PPPs continues to be heavily promoted by donor countries and international organisations as a way of making available additional resources for healthcare. Research led by Dr Julia Ngozi Chukwuma is looking to provide new insights into the possible dangers associated with PPPs in health, as a strategy to furthering universal access to healthcare in African countries.

Many governments around the world rely on the private sector to both finance and deliver healthcare services. African countries’ healthcare systems have seen an ever-increasing participation of private sector actors, including, crucially, financial institutions such as equity funds or investment banks. Private sector involvement in the form of PPPs is endorsed and encouraged by the World Bank Group and other powerful international institutions and donors. Consequently, PPPs have continued to grow in extent and prominence across Africa, in spite of lack of convincing evidence of their advantageousness over public healthcare service delivery systems. PPPs in health have been associated with unaffordable costs for national governments, a diversion of development aid earmarked for healthcare systems towards the private sector as well as less transparency and accountability.

“Health inequalities are avoidable — they are the result of an unjust distribution of power and resources across the world which can and should be rectified,” highlights Dr Julia Ngozi Chukwuma, Lecturer in Economics at the Open University's (OU) School of Social Sciences & Global Studies.

A widely debated example of the adverse impact on health equity of a PPP project has been the case of a PPP hospital in Lesotho, formerly regarded a flagship scheme by the World Bank Group but prematurely halted in 2021. In 2008, the International Finance Cooperation (IFC), the private-sector financing arm of the World Bank Group, directed the government of Lesotho to enter into a PPP with a private South African healthcare company. However, over the course of its lifespan, the PPP resulted in much higher costs than anticipated and, consequently, a drain of scarce funds from other health priorities in the country.

It is key for us to understand the reasons and implications of the premature termination of the Lesotho health PPP contract, as we are seeing other African countries reform their regulatory landscapes and frameworks in ways that facilitate the implementation of health PPPs.

Open Societal Challenges funding is allowing a team (led by the OU and SOAS University of London, Professor Elisa Van Waeyenberge and Maria Jose Romero and partners in Lesotho and Kenya) to examine the nature and risk associated with PPP arrangements in health in Africa. At the same time, data collection will lead to investigation of the role and ways of working of the World Bank Group in brokering and fostering PPPs in health. Here, a main concern for researchers is to understand the implications on health equity of increasing the involvement of financial (alongside non-financial) private actors in national healthcare systems, alongside the mechanisms which allow for changes made to regulatory frameworks and enable the proliferation of PPPs in health.

The research involves interviewing key stakeholders involved in the planning, implementation and decision-making processes in Lesotho, as well as a second case study country at the forefront of establishing a favourable environment for the proliferation of PPPs, Kenya. The resulting insights are due to be used in collaboration with campaigning groups such as Oxfam, Eurodad and Afrodad for advocacy, pressing home important messages around the importance of robust public healthcare systems as the way forward in delivering health equity and closely related economic and social equalities.

In the future, the research team aims to widen the scope and intensify its work on PPPs in health, looking at the effects and potential risks of privatised and ‘financialised’ healthcare in other African countries’ systems.