Open Access 01.12.2020 | Commentary
The role of public-private partnerships in extending public healthcare provision to irregular migrants: stopgap or foot in the door?
Erschienen in: Israel Journal of Health Policy Research | Ausgabe 1/2020
Abstract
In this commentary to the paper “Ensuring HIV care to undocumented
migrants in Israel: a public-private partnership case study” by Chemtob et al. we
discuss the role of public-private partnerships (PPPs) as a mechanism for
integrating previously excluded groups in public healthcare provision. Drawing on
PPP case-studies as well as on Israel’s pandemic preparedness policies during the
Covid-19 outbreak, we examine potential implications for the populations in question
and for health systems.
In our view, Chemtob et al. describe an exceptional achievement, where a
PPP served as a stepping stone for the subsequent integration of irregular migrants’
in publicly funded HIV care. However, we argue that in many other cases PPPs are
liable to undermine public healthcare and inclusionary claims. This view is informed
by the fundamentally different concepts of healthcare that underlie PPPs and public
healthcare provision (namely, health care as a commodity vs. access to healthcare as
a right) and existing evidence on PPPs’ role in facilitating welfare retrenchment.
In contexts that are dominated by an exclusionary stance toward irregular migrants,
such as contemporary Israel, we believe that PPPs will become stopgaps that
undermine health rights, rather than a first foot in the door that leads toward
equitable provision of healthcare for all.
In many welfare states, so-called “irregular migrants” remain excluded
from public healthcare provision, despite governments’ commitments to universal
health coverage and the Sustainable Development Goals’ pledge to “leave no one
behind” [1]. “Irregular migration”
denotes human mobility outside those migration channels that are foreseen and
authorized by states, such as bilateral labour migration arrangements. Being an
“irregular migrant” is thus the outcome of interrelations between human movement
across social spaces and states' enactment of policies within the same spaces
[2].
The question of irregular migrants’ access to public healthcare
epitomizes a tension inherent to the national welfare state-concept: On the one
hand, the welfare state is an instrument for the realization of social and health
rights and inclusion. On the other hand, it safeguards the nation’s public resources
by distinguishing between the “deserving” and the “undeserving”, for example, along
the lines of national citizenship, and by excluding the latter from benefits
[3].
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The Covid-19 pandemic reminds us, however, that health in a globalized
world transcends national frameworks. Exposure to hazardous living and working
conditions and exclusion from health services jeopardizes not only the health and
lives of the excluded, but of all. Therefore, several states have included irregular
migrants in their Covid-19 response. For example, in the UK, uninsured migrants
diagnosed with Covid-19 are exempt from charges for medical treatment (to which the
NHS visitors and migrant cost recovery programme would otherwise apply)
[4]. The Berlin Senate has
established a temporary arrangement for anonymous and gratis ambulatory care for
uninsured migrants [5, 6]. Portugal went so far as to endow all migrants
with temporary citizenship, including eligibility for the National Health Services
[7]. The Israeli government stated
that there was “no choice” but to expand preparedness measures to irregular migrants
[8]. It thus reaffirmed its
exclusionary stance, while expressing the exigence to provide Covid-19-related
healthcare for all [9]. The Covid-19
pandemic is an exceptional situation. But as such it helps understand “the
normal”.
Governments always have a choice whether or not to include formerly
excluded groups in public healthcare provision. And they have a choice regarding the
mechanism of inclusion. This raises several interrelated questions, which ultimately
touch on our understanding of what public health is: Which situations compel
governments to expand public healthcare provision? What mechanisms do they choose?
And what are the implications? In this commentary on the paper “Ensuring HIV care to
undocumented migrants in Israel: a public-private partnership case study”
[10] by Chemtob et al., we discuss
the implications of public-private partnerships (PPPs) as a mechanism of inclusion
for the population in question as well as for the respective health system. We also
briefly relate to rationales for expanding public healthcare provision.
Chemtob et al. describe a PPP that was established to provide HIV
treatment for undocumented migrants in Israel. They note that “this is the first
example of a PPP with state partnership in a high-income country to address an
extreme need among the undocumented community” [10, p. 8]. They further describe as the initiative’s major
success that the service was eventually integrated into the Israeli healthcare
system, with costs covered by the Ministry of Health.
We could not agree more about the idea that the initiative merits
praise for obtaining universal HIV treatment from the Israeli government. What makes
this an exceptional accomplishment is that it expanded coverage in the most unlikely
political context; namely, to undocumented migrants and thus to a population for
whose health needs the Israeli government does not usually consider itself
responsible [11, 12].
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However, can this PPP case-study be a role-model for other populations
and for other health needs? Are PPPs a desirable strategy for extending public
healthcare provision to marginalized groups? Can they be a first “foot in the door”
to be incrementally turned into inclusion? We think that the answer is “no”, the
success of this case notwithstanding.
As mechanisms for delivering health services, public healthcare
provision and PPPs reify fundamentally different conceptualizations of healthcare:
The welfare state provides healthcare as a right. PPPs provide healthcare as a
commodity. While public participation in PPPs aims to assure universal access, the
involvement of for-profit organizations in the provision of services make market
considerations the dominant variable in decision-making - with far-reaching
implications: First, for-profit organizations will prioritize profits over issues of
accessibility, quality and patient empowerment. Second, understanding healthcare as
a commodity essentially influences the approach to public health issues by narrowing
public health down to the delivery of (mainly biomedical) services that can be
quantified and priced; for instance, vaccinations or screening. Such commodification
of public health practices, however, does not allow addressing the social
determinants of health; because that requires intersectoral action on population
level, which cannot be easily quantified and priced. Third, it is the exception and
not the rule that a service that began as a PPP is subsequently transformed into a
state responsibility.
Examples of PPPs worldwide - such as the British Private Finance
Initiative [13] and the Spanish Alzira
experiment [14, 15] - suggest that PPPs are in fact often a form
of subtle privatization of healthcare. In most cases, they fill voids where welfare
states retreat from responsibilities. PPPs alleviate the worst impacts of cutbacks
in public healthcare provision in the short term. In the long run, they normalize
and solidify privatization by making market considerations the central criteria for
decisions, for example, over which types of health services to develop (such as the
expansion of services aimed at lucrative “market shares” like, for example, vaccines
for travellers) and over their geographical distribution (for instance,
concentration in high-income areas versus equitable access across central and
peripheral regions). Eventually, PPPs are thus liable to expedite the erosion of
public healthcare systems [16‐18]. The risk of PPPs facilitating neoliberal welfare
retrenchment has been described for the Israeli case [19, 20]. Hence, in
those cases in which PPPs emerge as stopgaps for public healthcare provision, they
may undermine the concept of health as a universal and indivisible right, rather
than help realize health rights.
The primary rationale for providing treatment to a population that
otherwise remains barred from public healthcare, both in the case of HIV and
Covid-19, is apparently fear of contagion. The logic that works for the success of
Chemtob’s et al. case-study of HIV treatment for undocumented migrants is the same
“Us vs. Them”-logic that undergirds the exclusion of this population. The state
provides treatment when indispensable to protect “us” from the risks “they” embody
[21, 22] – and only then. Without the risk of contagion (for example,
in case of non-communicable diseases or injuries), the same logic does not work.
Moreover, from an “Us vs. Them”-perspective, governments will favour solutions that
allow providing just enough healthcare to reduce risks to the majority population,
while avoiding challenges to the welfare state’s boundaries. PPPs offer a convenient
way to add on solutions that provide excluded populations with a minimum level of
healthcare, instead of making systemic changes toward universal health coverage and
the highest attainable standard of health (also) for migrants, as is advised, inter
alia, by the WHO constitution, the International Covenant on Economic, Social and
Cultural Rights, and the recent WHO action plan “Promoting the health of refugees
and migrants” [23]. We claim that PPPs,
in most cases, will not work as stepping stones toward these visions. The
PPP-inherent commodification of healthcare, in combination with an “Us vs.
Them”-logic, is liable to generate a very limited conception of public health.
Instead of a holistic approach that addresses the social determinants of health,
entrenched in an ethics of solidarity, social justice, and human rights, public
health is conceived as a set of interventions that ensure “protection from”, rather
than “protection of”. Within such conceptual framework, the health of marginalized
migrants is a means, not the goal.
In the Israeli context, the latest manifestation of such a stance is
the government’s response to the Covid-19 pandemic. In a laudable move, it decided
to provide free testing and treatment for all irregular migrants. However, in a
context where the Covid-19-related lockdown left many irregular migrants without any
income and pushed families into absolute destitution, a broader perspective of
public health would have required taking into consideration also the social
determinants of health such as livelihoods. The “Deposit Law” offered an easy way
out: By this law, 20% of asylum-seekers’ wages are deducted as a deposit, payable
upon their departure from Israel. Local and international agencies (including the
UNHCR) urged the government to disburse the retained amounts to needy households as
an economic relief. However, the government disbursed the deposits only after the
Supreme Court’s intervention [9]. Beyond
the duration of the outbreak and beyond Covid-19-related treatment, irregular
migrants remain without access to many of the social determinants of health. The
patchy inclusion necessitated by the pandemic must therefore be understood as the
exception that proves the rule: a tenaciously exclusionary approach toward irregular
migrants [9].
Privatization, welfare retrenchment and ethno-national exclusion form
the backdrop against which migrants’ health rights are claimed, contested and
re-negotiated in Israel. In this context, we caution against using PPPs as a
strategy for extending healthcare provision to marginalized groups. Even though it
resulted in inclusion in Chemtob’s et al. case-study, in many other cases PPPs are
fraught with the risk to become stopgaps that undermine health rights, rather than a
first foot in the door that leads toward equitable provision of healthcare for all.
Hence, when considering expanding public healthcare provision to previously excluded
groups, policymakers ought to be aware that the seemingly technical choice of a
mechanisms for inclusion has far-reaching consequences, for the group in question,
for the health system, and the public. As the Covid-19 pandemic requires
policymakers to formulate and revise public health policies and solutions -
including access to healthcare, testing and other interventions for a variety of
different groups - in a rush, such awareness will be all the more important to avoid
eroding public health systems from the margins.
We want to thank the IJHPR editors for inviting this commentary and for
their valuable feedback on earlier versions of this work.
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Not applicable.
The authors declare that they have no competing interests.
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