Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review
Source: PLoS Medicine
Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.
Methods and Findings
Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.
Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.
New ACLU Report Documents Destructive Impact of Prison Privatization
Source: American Civil Liberties Union
The American Civil Liberties Union today released a new report providing the first comprehensive analysis of the destructive impact of prison privatization.
The report, “Banking on Bondage: Private Prisons and Mass Incarceration,” traces the rise of the for-profit prison industry over the past three decades and shows how private prison companies have capitalized on the nation’s addiction to incarceration to achieve gigantic profits. All the while, the report shows, mass incarceration wreaks havoc on communities by unnecessarily depriving individuals of their liberty, draining government resources and bringing little or no benefit to public safety.
Committee Report: TSA Ignores More Cost-Effective Screening Model
Source: U.S. House of Representatives, Transportation and Infrastructure committee
Airport passenger screening with private security screeners under federal supervision is dramatically more efficient and less costly than the all-federal screening model, according to a Transportation Committee investigative report.
The report, entitled “TSA Ignores More Cost-Effective Screening Model,” compares costs for the two passenger screening models. A private-federal screening option, known as the Screening Partnership Program (SPP), was established in the Aviation Transportation Security Act (ATSA) after September 11, 2001. This program enabled airports to “opt out” and request the use of private screening contractors under federal Transportation Security Administration (TSA) standards, supervision and oversight. Beginning in 2002, five airports operated under the private-federal screening model. That number has increased to 16, with many other airports requesting to utilize this option.
In January, TSA concocted a decision to pull the plug on allowing more airports to opt out, despite the law and Congress’ intent that airports have the legal right to utilize the private-federal screening model. “This comprehensive report clearly debunks TSA’s position and efforts to undermine this cost-effective program,” said U.S. Rep. John L. Mica (R-FL), Chairman of the Transportation and Infrastructure Committee.
“The report clearly demonstrates that screening under the private-federal model is dramatically more cost-effective compared to screening conducted by TSA,” Mica said. “If the nation’s top 35 airports opted out, we could save taxpayers $1 billion over the next five years.
+ Full Report (PDF)
Insourcing Functions Performed by Federal Contractors: An Overview of the Legal Issues (PDF)
Source: Congressional Research Service (via Federation of American Scientists)
Recent Congresses and the Obama Administration have taken numerous actions to promote “insourcing,” or the use of government personnel to perform functions that contractors previously performed on behalf of federal agencies. Among other things, the 109th through the 111th Congresses enacted several statutes requiring the development of policies and guidelines to ensure that agencies “consider” using government employees to perform functions previously performed by contractors, as well as any new functions. These statutes also require that “special consideration” be given to using government personnel to perform certain functions, including those functions (1) performed by government employees in the recent past, (2) closely associated with the performance of inherently governmental functions, (3) performed pursuant to a contract awarded on a non-competitive basis, or (4) performed poorly by a contractor because of excessive costs or inferior quality. The Obama Administration has similarly promoted insourcing. Among other things, on July 29, 2009, the Office of Management and Budget directed federal agencies to conduct a pilot human capital analysis of one program where the agency has concerns about its reliance on contractors, as a prelude to potentially insourcing functions performed by contractors.
These recent insourcing initiatives raise several legal questions, including whether agencies complied with their own guidelines when insourcing particular functions. Because the Administrative Procedure Act (APA) allows challenges to agency actions that are “arbitrary, capricious, an abuse of discretion, or otherwise not in accordance with the law,” contractors may have standing to challenge insourcing determinations that are contrary to guidelines based in statutes, regulations, or policy documents that the agency intended to be binding or has employed in such a manner that they are binding as a practical matter. However, it is presently unclear whether the federal district courts or the U.S. Court of Federal Claims have jurisdiction over such claims. The district courts have reached differing conclusions as to whether a contractor challenging an insourcing determination is an “interested party” within the meaning of the Administrative Dispute Resolution Act (ADRA) of 1996, and whether an insourcing determination is made “in connection with a procurement or proposed procurement” under this act. Assuming that contractors are interested parties and insourcing determinations are made in connection with proposed procurements, the U.S. Court of Federal Claims would have exclusive jurisdiction under ADRA. If not, the district courts would have jurisdiction under the APA.
While the APA would not prohibit insourcing per se, it could constrain whether and how agencies proceed with insourcing in particular circumstances, as could other provisions of law. For example, the terms of certain requirements contracts could potentially require agencies to delay insourcing so as to allow current contracts to expire, or face the prospect of liability for constructive termination for convenience. Similarly, limitations on “direct hires” under civil service law could prevent agencies from hiring, on the spot, the person currently performing a function under a contract, although no provisions of federal law appear to prevent the government from hiring the employees of its contractors. Federal ethics and conflict of interest laws and regulations could also result in certain narrow limitations on the official duties or conduct of former contractor employees in matters in which that employee may have a continuing or current personal financial interest, or which involve a former employer of that individual as a direct party to a governmental transaction or other such matter.
The 112th Congress is considering legislation that could constrain insourcing initiatives by requiring agencies to conduct a public-private competition and determine that provision of goods or services by federal employees provides “best value” prior to insourcing (H.R. 1474, S. 785).
Report: Privatization of State Economic Development Agencies Can Undermine Integrity and Accountability
Report: Privatization of State Economic Development Agencies Can Undermine Integrity and Accountability (PDF)
Source: Good Jobs First
Transferring state business recruitment functions from government agencies to private entities is not the panacea that its proponents suggest, and the track record of those few states that have taken the step is filled with examples of misuse of taxpayer funds, political interference, questionable subsidy awards, and conflicts of interest, according to a report published today by Good Jobs First, a non-profit, non-partisan research center based in Washington, DC.
“Rather than making economic development activities more effective, privatization is often little more than a power grab by governors and politically connected business interests,” said Philip Mattera, research director of Good Jobs First and principal author of the report.
Interest in economic development privatization has surged recently. It is being promoted by newly elected governors in Wisconsin, Ohio, Iowa and Arizona who are urging that state commerce or development agencies be replaced by public-private partnerships (PPPs).
“Turning economic development over to PPPs is fool’s gold,” said Good Jobs First executive director Greg LeRoy. “What really matters is business basics: strategic public investments in skills, infrastructure, and innovation—not privatized smoke-stack chasing.”
+ Full Report (PDF)