Finding Middle Ground: Making Better Use of the African Private Health Sector through More Effective Regulations

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Governments in sub-Saharan Africa face many complex and difficult challenges in meeting the health needs of their populations. Although sub-Saharan Africa accounts for 11 percent of the world’s population and 24 percent of the global burden of disease, the region commands less than 1 percent of global health expenditures (WHO, 2006). To improve public health, African governments must marshal all the resources available in the health sector – public and private alike. African governments and donors increasingly recognize that achieving equity in access to health care requires engaging the commercial and non-profit private health sector through partnerships.

Africa’s public and private sectors both have roles to play in expanding access to priority health services to underserved populations. The government must play an active role as a steward, facilitating public- private collaboration through an enabling policy environment. An effective regulatory framework that encourages greater private sector participation in public health is a balancing act: it must consider the market realities of the private health sector while at the same time ensuring expanded coverage of quality health services.

The Africa Bureau for Population, Health and Nutrition of the U.S. Agency for International Development (USAID) funded this report to highlight how changes in the legal and regulatory environment can facilitate expanded access to family planning (FP) and reproductive health (RH) services through Africa’s private health sector. Using laws and regulations from three Africa countries – Ethiopia, Kenya and Nigeria – this report presents a “road map” on how to review the most important laws governing the private sector, as well as key issues to assess. Although the report focuses on policy reforms to increase private sector participation in the overall health system, these changes will also benefit critical health services such as FP, RH, Maternal and Child Health (MCH) as well as HIV/AIDS.


One of the government’s key stewardship functions is to create a supportive environment for public and private health sector collaboration. Policies, laws, and regulations are important instruments for this purpose. However, many underlying factors must be addressed. They include:

  • Mutual distrust between the public and private sectors
  • Outdated, inadequate or counterproductive regulation
  • Ineffective enforcement
  • Little reward or encouragement for higher quality care or better access
  • Lack of understanding of public-sector business requirements by the public sector

The challenge is to find a middle ground that considers both sectors’ perspectives and concerns and imposes the proper degree of regulation. Reaching a middle ground requires consulting all the parties affected by the regulation and integrating their perspective and concerns while ensuring patient safety and protection. Too much regulation can inhibit private sector interest, while insufficient regulatory enforcement can expose patients to dangerous medical care and unsafe medicines. Stewardship entails striking the right balance of the appropriate degree of regulation and adequate enforcement, given institutional capacity and budgetary constraints.