Achieving universal health coverage in Africa: is there a role for formal for-profit providers?

Here is the link for a blog post that has just been published on Oxfam’s Global Health Check – it summarises the recommendations of the paper in my previous post.

Doherty J. 2015. Achieving universal health coverage in Africa: is there a role for formal for-profit providers? Global Health Check. Available at:

Will for-profit private providers help low- and middle-income countries reach universal health coverage?

Doherty J. 2015. Achieving universal health coverage in East and Southern Africa: what role for for-profit providers? Paper presented as part of Panel Session T03P13: Private sector and universal health coverage – examining evidence and deconstructing rhetoric. DOI: 10.13140/RG.2.1.1993.9682. The International Conference on Public Policy, Università Cattolica del Sacro Cuore, Milan, Italy, 1-4 July 2015.

This paper cautions that regulatory frameworks governing the behaviour of the for-profit private health sector in Africa are weak.

These frameworks need to be strengthened before promoting the growth of the for-profit private health sector.

This is because, if poorly regulated, the behaviour of the for-profit health sector can lead to health system distortions that undermine progress towards universal access to affordable, quality health care.

More detail on legislation in the region can be found in:

Doherty J. 2015. Regulating the for-profit private health sector: lessons from East and Southern Africa. Health Policy and Planning; 30(3); i93-i102. doi: 10.1093/heapol/czu111.

Universal health coverage assessment: South Africa

If anyone missed this in an earlier blog, I’ve posted a preliminary assessment of South Africa’s progress towards universal health coverage here.

The purpose of the assessment is to use what data are available to analyse the extent to which South Africans are enjoying financial protection against the costs of using health care services, and accessing the services they need.

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



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

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:


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:


Can the private health sector fix the failings of public health systems?

My latest book chapter has just been published:

Doherty J, McIntyre D. 2013.  Addressing the failings of public health systems:  should the private sector be an instrument of choice?  In:  Surender D, Walker R (eds). 2013. Social policy in a developing world.  Cheltenham, UK:  Edward Elgar.

Research on the for-profit health sector in Africa

I would like to get into contact with researchers, policy-makers and legal experts working on appropriate policies and legislation governing the for-profit private health sector in Africa.

Or perhas you do work on other low- or middle-income countries that might be relevant to the African situation?

On the ‘About Jane Doherty’ tab above you will find my e-mail address if you want to let me know about the work you are doing or have research or reports to share.

On the ‘Private health sector’ tab you will find my own work on the private sector (with links to the electronic versions where available). Of particular interest might be:

  • FORTHCOMING: A situation analysis of private sector legislation in East and Southern Africa which is still in an early draft form
  • FORTHCOMING: Doherty J, McIntyre D. (2013)  Addressing the failings of public health systems:  should the private sector be an instrument of choice?  In: Surender R, Walker R.  (2013)  Social policy in a developing world.  Cheltenham, UK:  Edward Elgar
  • Doherty J.  2011. Expansion of the private for-profit health sector in East and Southern Africa. EQUINET with HEU, UCT and TARSC Policy Brief 26. Harare: EQUINET.
  • Doherty J.  2011.  Expansion of the private health sector in East and Southern Africa.  EQUINET Discussion Paper 87.  EQUINET:  Harare.
  • A report summarising research on the for-profit private health sector in South Africa from the 1980s to 2003:  Doherty J, Steinberg M.  2003.  Priority health care information needs for reform:  what role for BHF?  Johannesburg:  Board of Healthcare Funders.

NHI Snippets (6): The high cost of private health care in South Africa

So, I’ve elaborated a little on the poor health of South Africans relative to the country’s level of economic development and wealth.

The second major point I made at the beginning of this blog series was that a huge proportion (43%) of all the money spent on health care in South Africa is paid as premiums by people on medical aid (medical aid is what is know internationally as ‘voluntary private health insurance’).  In fact, the proportion is so huge that South Africa tops the list of countries around the world in this regard, even outdoing the United States.

If you want to see this point displayed graphically, click on this link – Proportion of spending on health insurance – for a slide by Prof. Di McIntyre of the Health Economics Unit at UCT.1   On the extreme right of the graph are South Africa and the United States, each spending a large amount on voluntary private health insurance (the red section of the bars).  The other countries shown in the graph have health systems which are getting close to achieving universal health care coverage (in a later blog I’ll explain this term but in broad terms it means that most citizens are able to access and afford adequate health care).  You’ll see that, for these countries, the red section of the bar is very small.

The last bit of information you need to know to appreciate this graph is that ‘the big red bit’ of South Africa’s bar is spent by only 16 percent of the population.2  So the following picture emerges:

1.  Only a very small proportion of South Africa’s population has access to high quality care (this is assuming that lots of resources translates into good quality, which isn’t wholly true, so I’d like to qualify this statement in a later blog as well as note that good quality care is also available in the under-resourced public sector);

2. Private health care is very expensive and funding this care places a very high financial burden on those who can afford it.

3. Countries achieving universal health care coverage have not relied on private voluntary health insurance to do so (I’ll elaborate this point later and, of course, we need to have the discussion about why universal health care coverage is desirable.)



1. McIntyre D.  2011.  Options for South Africa:  Financing.  Presented at National Department of Health Consultative Conference on “National Health Insurance:  Lessons for South Africa”, Gallagher Estate, Midrand, 7-8 December 2012.  Available at:

2.  McIntyre DE, Doherty JE, Ataguba JE. (forthcoming). Health care financing and expenditure – progress since 1994 and remaining challenges. Health and health care in South Africa (2nd edition). Van Rensburg H. Pretoria: van Schaik Publishers.

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).