Legislation on the for-profit private health sector in East and Southern Africa

Here is some information on my latest policy brief, as well as the report on which it is based:


EQUINET Policy Brief 35: Legislation on the for-profit private health sector in East and Southern Africa

Doherty J (2013) with UCT HEU, TARSC. Wemos Foundation,  Policy brief 35, EQUINET, Harare

At http://www.equinetafrica.org/bibl/docs/Pol%2035%20finregs.pdf


While the private sector contributes new resources to the health system, international evidence shows that if left unregulated it may distort the quantity, distribution and quality of health services, and lead to anti-competitive behaviour. As the for-profit private sector is expanding in east and southern African (ESA) countries, governments need to strengthen their regulation of the sector to align it to national health system objectives. This policy brief examines how existing laws in the region address the quantity, quality, distribution and price of private health care services, based on evidence made available from desk review and in-country experts. It proposes areas for strengthening the regulation of individual health care practitioners, private facilities and health insurers.  A more detailed discussion paper (#87) on the laws and information in the brief is available at www.equinetafrica.org/bibl/docs/EQ%20Diss%2087%20Private%20HS.pdf.

Regulating the for-profit private health sector in Africa

EQUINET (the Network on Equity in Health in Southern Africa) have just published an editorial and report on legislation governing the for-profit private health sector in east and southern Africa. To access these publications, click on the links below:


Doherty J. 2013. We cannot afford to leave the for-profit private health sector unregulated in Africa (editorial). EQUINET Newsletter 150: 01 August 2013. Available at: http://www.equinetafrica.org/newsletter/


Doherty J. 2013. Legislation on the for-profit private health sector in east and southern Africa. EQUINET Discussion Paper 99.  Harare: HEU, EQUINET. Available at: http://www.equinetafrica.org/bibl/docs/Diss%2099%20privsector%20laws%20Aug2013.pdf


Developing clinical leadership in support of rural health systems

My colleagues – Ian Couper, David Campbell and Judi Walker – and I have just published a new article in Rural and Remote Health.

It is called “Transforming rural health systems through clinical academic leadership: lessons from South Africa.”

Here is the PDF version:  RRH article_clinical academic leadership.

Will mid-level medical workers address staff shortages in public hospitals?

Here is my latest article on clinical associates:

Doherty J. 2013. Addressing staff shortages at public hospitals: a role for clinical associates? Public Health Association of Southern Africa Newsletter February 28. Available at: http://www.phasa.org.za/articles/addressing-staff-shortages-in-public-hospitals-a-role-for-clinical-associates.html

Mid-level medical workers in South Africa

I have just published the following open source article on mid-level medical health workers (Clinical Associates) in South Africa:


Doherty J, Conco D, Couper I, Fonn S. (2013) Developing a new mid-level health worker: lessons from South Africa’s experience with Clinical Associates. Global Health Action; 6: 19282. Available at: http://dx.doi.org/10.3402/gha.v6i0.19282

NHI Snippets (6): NHI and staff shortages: how can clinical associates help?

South Africa has begun producing a new type of health professional – a clinical associate.

You can read a bit more about clinical associates here but, in brief, they are people ideally suited to working in hospitals, helping doctors carry out some of their tasks – like dealing with emergencies and doing procedures.

Clinical associates don’t replace doctors or nurses  – they work with them, sharing some of their workload, and allowing them to concentrate on the tasks for which only they are qualified.

There is no doubt that more doctors and nurses need to be trained and recruited into the South African health system. But will this alone solve the country’s staff shortages? Realistically, how many decades will it take to fill all the country’s vacant posts? Can the country afford a system exclusively based on doctors and nurses? Is this even necessary?

It takes less time to train a clinical associate. They can become very good at what they do because they focus on a special set of skills and are supervised by doctors. They are recruited from rural and disadvantaged communities. Health workers a bit like them have made an enormous difference to many health systems around the world, especially in Africa but even in the United States.

So clinical associates could do a lot to address staff shortages in the public sector, especially in district hospitals. They could help bring good quality care closer to communities in a way that is affordable for the country. Along with other initiatives – such as strengthening hospital management – they could help produce public services that live up to the aspirations of the NHI policy.

So why isn’t there more excitement about this new category of health professional? Why don’t we hear about them in the press or from government spokespeople?

Clinical associates are noted as a priority in the latest government human resource strategy but the future of clinical associates and the strategy of NHI need to become much more closely intertwined.

NHI Snippets (3): Will NHI lose jobs?

Today I read an article in The Star’s business report entitled Private hospitals highlight danger of job losses (page 15 with a follow-up on page 16).

One of the points made is that the private hospital industry makes a large contribution to the economy, both directly and indirectly, through job creation and tax contributions.  If patients who were formerly privately insured were no longer able to afford private cover (and use private hospitals) because they were obliged to pay mandatory NHI contributions, this could result in job losses, at least according to the article.

I think it is valid to explore the impact of any proposed reform on the economy (as long as one balances this against other benefits) and I would be very interested in seeing modelling exercises that attempt to estimate this impact comprehensively.

Off the top of my head, though, I question the logic of the article on the following grounds:

1. The public health sector is already a massive employer, far larger than the private sector, and is set to grow under NHI.  This is because NHI is intended to expand health care coverage dramatically.  This will require an expanded workforce, especially in the public sector but quite possibly also in the private sector, especially at the primary care level.

2. As the article states, only a quarter of those who gain employment because of the existence of private hospitals are directly employed by those hospitals.  The other three-quarters are employed by companies that service private hospitals in some way.  If patients were to shift to public hospitals under NHI, presumably there would be a similar positive knock-on effect for entities (both public and private) that service public hospitals. 

3. NHI is intended to make financial protection for health care more affordable for everyone, including employers who currently pay large subsidies towards workers’ medical scheme cover.  This should make it cheaper for employers more generally to take on additional staff and boost employment.   

3. In the long term, improving the health of a country’s population leads to economic growth (at some stage I’ll haul out some evidence for this).  

So I can’t see NHI damaging employment, at least if it is designed and implemented well.  In any case, I think the heart of the affordability problem is really the high cost of private care, especially in hospitals.  We can talk later about the reasons for this but, in the meantime, you might like to read some facts about the efficiency of the private sector in a related post (click here).

Decentralised financial management capabilities for pilot hospital sites in South Africa

I have finally uploaded scanned copies of the last few annexures from the 1996 Hospital Strategy Project’s analysis of decentralised financial management issues.

Annexure F is very relevant to the current debate on readying public hospitals for National Health Insurance as it presents recommendations for decentralised financial management capabilities in pilot hospitals. 

Look on one of my ealier posts, entitled Decentralised Financial Management of Hospitals, for the uploaded files.

Guidelines for measuring the critical areas for financial management

I have just uploaded a scanned copy of another annexure (Annexure B contd.) from the 1996 Hospital Strategy Project’s analysis of decentralised financial management issues.

This annexure presents useful guidelines for measuring the critical areas for financial management.

Look on one of my ealier posts, entitled Decentralised Financial Management of Hospitals, for the uploaded files.  You can find it under ‘Categories’ to the right of the screen – under ‘Financing,’ ‘Hospitals’ or ‘Management and leadership.’

More information on financial management in public hospitals

I have just uploaded scanned copies of the conclusion of the 1996 Hospital Strategy Project’s analysis of decentralised financial management issues, as well as Annexures A and B.

Look on one of my ealier posts, entitled Decentralised Financial Management of Hospitals (and available under the Hospitals category to the right of the screen), for the uploaded files.