@gawain I disagree—the essay begins by arguing that natural disasters and outbreaks are matters of major social concern, and that fee-for-service health systems often respond poorly to them. While I’d like to see more evidence or statistics with respect to this point, it is a very substantive point and such evidence exists in more long-form documents like Oxfam’s report Blind Optimism (on the shortcomings of for-profit health care). Does healthy skepticism of for-profit care providers mean that the government has to own and control everything unilaterally? Not necessarily, and I found it helpful that the author drew on his own experience with Possible to make the case for PPPs.
If you didn’t understand the article the first time, perhaps you should read it a second time.
That said, I would like to have seen a ‘to be sure,...’ illustration of how PPPs can go wrong, and how to distinguish the good from the bad. For example, if the World Bank co-funds a hydroelectric dam in Haiti, and the contracting company is highly accountable to the many urban dwellers who will pay for its electricity, does it matter that some subsistence farmers are displaced when the new dam floods an old farming community? Perhaps there wasn’t space to discuss it in this article, but I’d be interested in hearing about PPPs that have gone wrong, and whether the binary distiction of private and for-profit versus private and not-for-profit is helpful for future PPPs.
Thanks Isaac for the notes. I very much agree that this piece could be more well-referenced; as you mentioned, there is a wealth of literature on this topic (including the Lancet’s excellent Universal Health coverage series from 2012). Indeed, part of our group’s goal over the long-term is to contribute to that evidence based around what works for particular interventions and ideas with public sector healthcare delivery. I also agree that, when we consider the broad term “PPP”, or specific instances here, such as our population-based financing approach, we have to be cautious about over-reaching or over-generalizing with our conclusions. Any intervention must be understood, and is prey, to local, national, and global hierarchies and institutions of power. The conception and the devastating environmental and human rights effects of the failed hydroelectric projects reflect the long-lasting effects of power structures. Certainly in Possible’s case, we must continuously be assessing those dynamics, reflecting on them, and iterating to mitigate their effects in our work in Nepal. We do feel that an “outsourced” approach is one worth testing to see if we can bring greater quality and accountability to the public sector and compete against—and eventually push the system to better regulate—the unregulated fee-for-service system with its attendant large out-of-pocket expenditures, iatrogenic excesses, and restrictions in access. The endeavor, and the ideas put forth in this piece, are very much a hypothesis relevant to a particular moment in Nepal’s democratic governance and health sector trajectory. This hypothesis, and our experiences, are likely to be of use to other countries and communities, but only time will tell on the effectiveness of our approach, the results of our hypothesis, and the generalizability of any conclusions to other settings.
COMMENTS
BY gawain
ON October 11, 2015 02:56 PM
this is really incoherent. could be something valuable in it, but nothing comes through this essay.
BY Isaac Holeman
ON October 13, 2015 05:33 AM
@gawain I disagree—the essay begins by arguing that natural disasters and outbreaks are matters of major social concern, and that fee-for-service health systems often respond poorly to them. While I’d like to see more evidence or statistics with respect to this point, it is a very substantive point and such evidence exists in more long-form documents like Oxfam’s report Blind Optimism (on the shortcomings of for-profit health care). Does healthy skepticism of for-profit care providers mean that the government has to own and control everything unilaterally? Not necessarily, and I found it helpful that the author drew on his own experience with Possible to make the case for PPPs.
If you didn’t understand the article the first time, perhaps you should read it a second time.
That said, I would like to have seen a ‘to be sure,...’ illustration of how PPPs can go wrong, and how to distinguish the good from the bad. For example, if the World Bank co-funds a hydroelectric dam in Haiti, and the contracting company is highly accountable to the many urban dwellers who will pay for its electricity, does it matter that some subsistence farmers are displaced when the new dam floods an old farming community? Perhaps there wasn’t space to discuss it in this article, but I’d be interested in hearing about PPPs that have gone wrong, and whether the binary distiction of private and for-profit versus private and not-for-profit is helpful for future PPPs.
BY duncan.maru, Possible
ON October 14, 2015 03:27 PM
Thanks Isaac for the notes. I very much agree that this piece could be more well-referenced; as you mentioned, there is a wealth of literature on this topic (including the Lancet’s excellent Universal Health coverage series from 2012). Indeed, part of our group’s goal over the long-term is to contribute to that evidence based around what works for particular interventions and ideas with public sector healthcare delivery. I also agree that, when we consider the broad term “PPP”, or specific instances here, such as our population-based financing approach, we have to be cautious about over-reaching or over-generalizing with our conclusions. Any intervention must be understood, and is prey, to local, national, and global hierarchies and institutions of power. The conception and the devastating environmental and human rights effects of the failed hydroelectric projects reflect the long-lasting effects of power structures. Certainly in Possible’s case, we must continuously be assessing those dynamics, reflecting on them, and iterating to mitigate their effects in our work in Nepal. We do feel that an “outsourced” approach is one worth testing to see if we can bring greater quality and accountability to the public sector and compete against—and eventually push the system to better regulate—the unregulated fee-for-service system with its attendant large out-of-pocket expenditures, iatrogenic excesses, and restrictions in access. The endeavor, and the ideas put forth in this piece, are very much a hypothesis relevant to a particular moment in Nepal’s democratic governance and health sector trajectory. This hypothesis, and our experiences, are likely to be of use to other countries and communities, but only time will tell on the effectiveness of our approach, the results of our hypothesis, and the generalizability of any conclusions to other settings.