Public Sector Delivery Research Articles

A Comparison Study of Risk-based Auditing in Four Developed Countries

Purpose: This study aimed to identify and compare the best practices of a risk-based audit (RBA) approach used in four developed countries. Design/ Methodology/ Approach: A thorough library search and examination of the literature on the RBA approach was conducted. Denmark, Australia, Canada, and the United Kingdom were selected based on their excellent positions in the Corruption Perception Index 2022 ranking. Findings: The four countries adopted the Institute of Internal Audit standards in conducting their RBA. All four countries, except Denmark, used the ISO 31000:2018 as a guidance framework. Furthermore, the four countries used comparable risk determination, assessment, and control techniques. Additionally, the RBA risk governance structure of the four countries is based on the Three Lines of Defence concept. Research Limitations/ Implications: Most of the data were from secondary sources. Only four countries were compared and were selected using only one index. Additionally, the study focused on internal auditing practices as a public governance tool. Practical Implications: The results presented the opportunity for government internal auditors to reconsider and enhance auditing procedures to increase public sector delivery system efficacy. Originality/ Value: This article covers the RBA used by internal auditors in four developed countries. The results could catalyse investigations into the efficacy and best practices of additional elements in public sector governance. Keywords: Risk-based audit, internal audit, public sector, governance, risk management.

A Comparison Study of Risk-based Auditing in Four Developed Countries

Purpose: This study aimed to identify and compare the best practices of a risk-based audit (RBA) approach used in four developed countries. Design/ Methodology/ Approach: A thorough library search and examination of the literature on the RBA approach was conducted. Denmark, Australia, Canada, and the United Kingdom were selected based on their excellent positions in the Corruption Perception Index 2022 ranking. Findings: The four countries adopted the Institute of Internal Audit standards in conducting their RBA. All four countries, except Denmark, used the ISO 31000:2018 as a guidance framework. Furthermore, the four countries used comparable risk determination, assessment, and control techniques. Additionally, the RBA risk governance structure of the four countries is based on the Three Lines of Defence concept. Research Limitations/ Implications: Most of the data were from secondary sources. Only four countries were compared and were selected using only one index. Additionally, the study focused on internal auditing practices as a public governance tool. Practical Implications: The results presented the opportunity for government internal auditors to reconsider and enhance auditing procedures to increase public sector delivery system efficacy. Originality/ Value: This article covers the RBA used by internal auditors in four developed countries. The results could catalyse investigations into the efficacy and best practices of additional elements in public sector governance.

Embedding The Fourth Industrial Revolution (4IR) in South African Municipalities: Challenges and Prospects

In South Africa, the current technology has brought multitudes of changes and transformations to the public sector and service delivery. The current state of technology allows municipalities to carry out their duties using ICT platforms successfully. E-participation, e-services, citizen portals, digital city services and goods, broadband fibre rollouts, CCTV networks, data center infrastructure, and private cloud solutions are just a few of these endeavours. The lack of integration of the smart city plan into the IDP, insufficient internal ability to support and sustain projects, and other issues may prohibit most municipalities from effectively adopting 4IR programs. limited support from a broader range of stakeholders, such as workers, communities, labourers, and businesses Among municipal departments, there is a lack of linked and coordinated thinking and activities. This study aims to assess how well the 4IR has worked to improve municipal service delivery. It is concluded that towns may be able to fully integrate modern technologies with the incorporation of 4IR technology into municipal IDP. In order to do this, a number of strategies are suggested, and a theoretical framework for the phenomena is investigated, with the goal of addressing the issues that prevent the proper application of 4IR technologies in South African Municipalities.

Cost and outcomes of routine HIV care and treatment: public and private service delivery models covering low-income earners in South Africa

BackgroundWhile South Africa’s national HIV program is the largest in the world, it has yet to reach the UNAIDS 95–95-95 targets. To reach these targets, the expansion of the HIV treatment program may be accelerated through the use private sector delivery models. This study identified three innovative non-governmental primary health care models (private sector) providing HIV treatment, as well as two government primary health clinics (public sector) that served similar populations. We estimated the resources used, and costs and outcomes of HIV treatment across these models to provide inputs to inform decisions around how these services might best be provided through National Health Insurance (NHI).MethodsA review of potential private sector models for HIV treatment in a primary health care setting was conducted. Models actively offering HIV treatment (i.e. in 2019) were considered for inclusion in the evaluation, subject to data availability and location. These models were augmented by government primary health clinics offering HIV services in similar locations. We conducted a cost-outcomes analysis by collecting patient-level resource usage and treatment outcomes through retrospective medical record reviews and a bottom-up micro-costing from the provider perspective (public or private payer). Patient outcomes were based on whether the patient was still in care at the end of the follow up period and viral load (VL) status, to create the following outcome categories: in care and responding (VL suppressed), in care and not responding (VL unsuppressed), in care (VL unknown) and not in care (LTFU or deceased). Data collection was conducted in 2019 and reflects services provided during the 4 years prior to that (2016–2019).ResultsThree hundred seventy-six patients were included across the five HIV treatment models. Across the three private sector models there were differences in the costs and outcomes of HIV treatment delivery, two of the models had results similar to the public sector primary health clinics. The nurse-led model appears to have a cost-outcome profile distinct from the others.ConclusionThe results show that across the private sector models studied the costs and outcomes of HIV treatment delivery vary, yet there were models that provided costs and outcomes similar to those found with public sector delivery. Offering HIV treatment under NHI through private delivery models could therefore be an option to increase access beyond the current public sector capacity.

The Importance of Project Management in Public Sector Delivery

The Importance of Project Management in Public Sector Delivery

Universal health coverage and public-private arrangements within Sri Lanka's mixed health system: Perspectives from women seeking healthcare

Universal health coverage (UHC), a target of the United Nations' third Sustainable Development Goal on health, refers to people having access to essential healthcare services without suffering financial hardship. The World Bank and other leading global health actors champion mixed health systems—in which government and privately-financed market delivery coexist—as a sustainable model for UHC. Yet, little is known about what these public-private arrangements mean for women, a crucial partaker of UHC in low- and middle-income countries (LMICs). Using a critical feminist approach, this study explores how women negotiate access to public and private healthcare services within Sri Lanka's state-dominant mixed health system. Data were generated through focus group discussions and interviews with women residents of an urban division in Kandy, a city seeing rapid private healthcare expansion in central Sri Lanka. Notwithstanding policies of universality guiding public sector delivery, out-of-pocket payments burden socially and economically disadvantaged women. They use private services to fill gaps in the public system, and consult dual practitioners privately, to pave way for better (public) care. By contrast, wealthier women opt for private outpatient care, but capitalize on the dual practitioners to obtain priority access to oversubscribed services at public hospitals. Most women, regardless of social location, combine public with private, albeit to varying degrees, to save on household expenses. Relying on women's invisible care work, these public-private “hybrid” routes of access within Sri Lanka's poorly regulated mixed health system, reinforce social inequalities and individualize the responsibility for healthcare. The article throws light on the messiness of access within mixed systems and demands closer scrutiny of calls for private sector engagement in the quest for UHC in LMICs.

Institutional Arrangements for Providing HIV and AIDS Services in Uganda: A Transaction Cost Economics Analysis.

Transaction cost economics (TCE) theory predicts that features of institutional arrangements determine the intensity of their governance instruments. Consequently, institutional features link to transaction costs, but the linkages have received little attention in the public health literature. This study sought to address this gap. It examined the governance features of institutional arrangements and their transaction cost implications for providing HIV prevention and social support services in Uganda. The analysis was based on 4 proposed TCE governance instruments: administrative controls, adaptation, incentives and contract laws. These governance instruments were assessed in 3 modes of delivery( institutional arrangments) for HIV and AIDS Services in Uganda: Contracting-Out – the case of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe); a Public-Non-Governmental Organisation (NGO) partnership – the case of the CHAI (Community-led HIV/AIDS Initiative); and direct Public Sector Delivery. These assessed delivery modes follow Williamson’s TCE framework of 3 institutional arrangements to deliver goods and services, notably market, hybrid (partnership) and internal (hierarchy) delivery, with related governance features. Within this framework, the discriminating alignment hypothesis guided the analysis. According to the hypothesis, the delivery modes of goods and services result in smaller transaction costs when their governance features are as predicted by TCE. The hypothesis was assessed by analysing, with qualitative methods, the differences in HIV and AIDS services characteristics across the 3 arrangements and their differences with theory prediction, and hence the difference in transaction cost implications. The study found that the delivery arrangements that minimised cost are those whose HIV and AIDS services were aligned with the TCE theory prediction. The aligned ‘public-NGO partnership’ arrangement (CHAI) had fewer sources of transactional costs than the misaligned arrangements – ‘contracting-out’ (DREAMS) and ‘public sector’. The analysis revealed that the DREAMS and public sector delivery models suffered some flaws in efficiencies. DREAMS had high administrative controls, high-powered tangible incentive intensity and intensive monitoring mechanisms for performance adaptation due to the lack of ‘trust’ on the part of the financing agency, contrary to the TCE prediction. In contrast with the TCE prediction, low administrative controls in the public sector arose from the failure to invest in performance monitoring systems. The high-powered incentive intensity and low administrative controls observed in the CHAI arrangement primarily stemmed from the reliance on informal institutions (trust, social expectations and reputation) rather than principal-agent arms-length sanctions. These results suggest that the level of transaction costs is associated with features of institutional arrangements. The valuable insights from TCE could contribute to policymaking during the design of institutional arrangements to efficiently deliver HIV and AIDS services.

Under-Five Mortality and Associated Risk Factors in Rural Settings of Ethiopia: Evidences from 2016 Ethiopian Demographic and Health Survey

Background. Evidence shows that in Ethiopia, a gradual decrease of under-five mortality is observed, but it is still high in the rural settings of the country. We are motivated to investigate the socioeconomic, demographic, maternal and paternal, and child-related associated risk factors of under-five mortality given birth from rural resident mothers. Methods. Demographic and Health Survey data from Ethiopia (2016) were used for analysis. The chi-square test of association and logistic regression were used to determine the associated risk factors of under-five children mortality. Study Settings. Rural Ethiopia. Results. Secondary school and above completed fathers (AOR = 0.77; 95% CI: 0.63–0.94) and primary school completed mothers (AOR = 0.82; 95% CI: 0.72–0.93); multiple twin child (AOR = 4.50; 95% CI: 3.38–5.98); public sector delivery (AOR = 0.65; 95% CI: 0.55–0.76); had working of mother (AOR = 1.28; 95% CI: 1.16–1.42) and of father (AOR = 1.45; 95% CI: 1.25–1.69); mothers aged above 16 at first birth (AOR = 0.41; 95% CI: 0.37–0.45); breastfeeding (AOR = 0.60; 95% CI: 0.55–0.66); birth order of 2-3 (AOR = 1.18; 95% CI: 1.02–1.37); religious belief of Muslim (AOR = 1.20; 95% CI: 1.02–1.41); users of contraceptive method (AOR = 0.80; 95% CI: 0.71–0.90); vaccinated child (AOR = 0.52; 95% CI: 0.46–0.60); family size of 4–6 (AOR = 0.74; 95% CI: 0.63–0.86) and of seven and above (AOR = 0.44; 95% CI: 0.36–0.52); mother’s age group: aged 20–29 (AOR = 3.88; 95% CI: 3.08–4.90), aged 30–39 (AOR = 16.29; 95% CI: 12.66–20.96), and aged 40 and above (AOR = 55.97; 95% CI: 42.27–74.13); number of antenatal visits: 1–3 visits (AOR = 0.50; 95% CI: 0.43–0.58), and four and above visits (AOR = 0.46; 95% CI: 0.39–0.54); and preceding birth interval of 25–36 months (AOR = 0.55; 95% CI: 0.48–0.62) and above 36 months (AOR = 0.30; 95% CI: 0.26–0.34) are significant determinant factors of under-five mortality in rural settings. Conclusions. Differences in regions, educated parents, born in singleton, public sector delivery, nonavailability of occupation of parents, mothers older than 16 at first birth, breastfeeding, use of a contraceptive method, child vaccination, higher number of family size, repeated antenatal visits, and preceding birth interval play a significant role regarding the survival of under-five children. These, among other differences, should be addressed decisively as part of any upcoming strategic interventions to improve the survival of children in line with the target of 2030 Sustainable Development Goals (SDGs).

Lessons learned from a public sector community-based distribution program for scaling up DMPA-SC contraceptive services in Nigeria

Background: From August 2016 to December 2017, the United Nations Population Fund (UNFPA) in Nigeria, through three implementing partners, scaled up the public sector delivery of subcutaneous depot medroxyprogesterone acetate (DMPA-SC, brand name Sayana Press) across 10 states. The public sector program featured a proactive community-based distribution (CBD) model, led by community health extension workers (CHEWs) and supported by community health volunteers (CHVs). Methods: We conducted monitoring and evaluation (M&E) alongside program implementation to understand the program’s reach, particularly in terms of clients served, and their proportions of new users of modern contraception and younger women. Key performance indicators (KPIs) were calculated from end-user data digitized from client registers. To evaluate performance trends over time and understand geographic variation, we analyzed quarterly data in Excel and Stata 15, and complemented these analyses with data from interviews conducted periodically with program staff and performance documentation submitted by implementing partners. Results: The program reached 144,505 clients, of whom 88% (n=127,315) were women. Among women reached, 92% (n=116,614) chose DMPA-SC. The program reached a high percentage of new users of modern contraception: 80% (n=93,075) of DMPA-SC clients were new users, as were 80% (n=111,350) of overall clients. However, only 26% (n=36,313) of clients were under 25. From performance reports and interviews with program staff, many involved credited the CBD model with reaching a client base largely comprised of new users of modern contraception. Conclusions: Our analysis of the Nigeria public sector DMPA-SC program suggests that the combination of DMPA-SC and proactive CBD may accelerate contraceptive uptake and reduce unmet need in Nigeria. While some strategies for increasing the cost-efficiency of the CBD emerged, future research on this delivery model should focus on key concerns about the modality’s sustainability.

Impact Assessment of Leadership Effectiveness in Public Sector Delivery Process

Impact Assessment of Leadership Effectiveness in Public Sector Delivery Process

An evaluation of South Africa\u2019s public\u2013private partnership for the localisation of vaccine research, manufacture and distribution

BackgroundPublic–private partnerships (PPPs), widely used as a means of leveraging the skills, expertise and resources of the private sector to mutual advantage, were similarly adopted by South Africa to support public sector delivery. This study has evaluated one such partnership, namely the Biovac Institute, which was established in 2003 to cover vaccine research and development, manufacturing, and supply. The initiative was highly unusual given that it attempted to combine all three aspects in a single PPP.MethodsThe research has followed a concurrent mixed methods approach. In the quantitative study, data for prices and product volumes were extracted from secondary data sources and used to calculate the economic cost and value-for-money of the PPP. Simultaneously, a qualitative study was undertaken in which a number of key stakeholders were interviewed using a semi-structured questionnaire on their perceptions of the PPP’s value.ResultsThe institute earns a premium on the procurement cost of a broad range of vaccines required by the South African National Department of Health for its immunisation programme, the net value of which was US$85.7 million over the period 2010 to 2014. These funds were used to finance the institute’s operations, including vaccine research, distribution and quality control. Capital expenditure to support the establishment of facilities for laboratory testing, packaging and labelling, filling, formulation and, finally, active pharmaceutical ingredient manufacture, approximately US$40 million in total, had to be secured through loans and grants. According to the respondents in the qualitative survey, the principal benefit of the PPP has been the uninterrupted supply of vaccines and the ability to respond quickly to vaccine shortages. The main disadvantages appear to have been a slow and ineffectual establishment of a vaccine manufacturing centre and, initially, a limited ability to negotiate highly competitive vaccine prices.ConclusionsOverall, it is concluded that a positive value-for-money has been achieved and the institute has been of significant public benefit. Relationships of this nature can be used to achieve public health goals, but need to be realistic about timeframes, costs and the limitations of relational governance in ensuring that complex programmatic outcomes are achieved. It is recommended that a more incremental approach, with clearer contractual goals, penalties and incentives, is adopted in attempting initiatives aimed at the localisation of manufacturing technology by leveraging public procurement.

The management of medical records in the context of service delivery in the public sector in KwaZulu-Natal, South Africa: the case of Ngwelezana hospital

In South Africa, under the public sector reforms, issues of public service delivery are anchored to by Batho Pele principles that were introduced in 1997 to entrench public service delivery in order to underscore transparency and accountability. Among other issues, the Batho Pele principles espouse efficient and effective public health sector delivery services which, in context, can be propelled by a reliable and trustworthy medical records regime. Several studies conducted at national level and particularly at provincial level (Limpopo, Gauteng, Eastern Cape and Western Cape) point to the fact that good and efficient records management is critical in realising accountable and transparent health service delivery. There has been the recognition of this synergy between medical records management and service delivery, yet there are few empirical studies which examine the role of records management in KwaZulu-Natal province; more particularly, with specific reference to the Ngwelezana Public Hospital. This study, therefore, presents empirical results of an investigation into the implementation of good records management services and the extent to which this contributes to corresponding citizen satisfaction of good health delivery at the community level. The ultimate goal of the study is to understand the scale and dimension of good medical records management in determining issues of accountability in health care for citizens at local or community level in the quest for optimal health service delivery and governance. Overall, the evidence shows that poor records management could undermine the service delivery, particularly transparency and accountability in health delivery. The study endorses, based on best practice, recommendations that underscore good records management governance, recordkeeping system, records management technology and infrastructure, records archival processes, and records management human resource capabilities

Diarrhea no more: does zinc help the poor? Evidence on the effectiveness of programmatic efforts to reach poorest in delivering zinc and ORS at scale in UP and Gujarat, India.

BackgroundIndia has the greatest burden of diarrhea in children under 5 years globally. The Diarrhea Alleviation through zinc and oral rehydration salts (ORS) Therapy program (2010–2014) sought to improve access to and utilization of zinc and ORS among children 2–59 months in Gujarat and Uttar Pradesh (UP), India, through public and private sector delivery channels. In this analysis, we present findings on program’s effect in reducing child–health inequities.MethodsData from cross–sectional baseline and endline surveys were used to assess disparities in key outcomes across six dimensions: socioeconomic strata, gender, caregiver education, ethnicity and geography.ResultsCareseeking outside the home for children under 5 years with diarrhea did not increase significantly in UP or Gujarat across socioeconomic strata. Declines in private sector careseeking were observed in both sites along with concurrent increases in public sector careseeking. Zinc, ORS, zinc+ORS use did not increase significantly in UP across socioeconomic strata. In Gujarat, increases in zinc use (20% overall; 33% in the Quintile 5 (Q5) strata) and zinc+ORS (18% overall; 30% in the Q5 strata) were disproportionately observed in the high income strata, among members of the most advantaged caste, and among children whose mothers had ≥1 year of schooling. ORS use increased significantly across all socioeconomic strata for children in Gujarat with diarrhea (23% overall; 33% in Q5 strata) and those with dehydration + diarrhea (33% overall; 38% in Q5 strata). The magnitude of increase in ORS receipt from the public sector was nearly twice that observed in the private sector. In Gujarat, while out of pocket spending for diarrhea was significantly higher for male children, overall costs to users declined by a mean of US$ 2; largely due to significant reductions in wages lost (–US$ 0.79; P < 0.003), and transportation costs (–US$ 0.44; P < 0.00).ConclusionsWhile significant improvements in diarrhea treatment were achieved in Gujarat, new strategies are needed in UP, particularly in the private sector. If national–level reductions in diarrheal disease burden are to be realized, improved understanding is needed of how to optimally increase coverage of zinc and ORS and decrease contraindicated treatments amongst the most disadvantaged across geographic areas and axes of gender, ethnicity, education and socioeconomic status.

Contracting out parks and roads maintenance in England

Purpose – Different models have been adopted in England over time to organise public service delivery. The purpose of this paper is to explore contracting-out, a prevalent model of public service delivery in England, in relation to parks and roads maintenance delivery by examining private contractors’ performance according to local authority stakeholders. Design/methodology/approach – Since the Conservative Government was in power during the 1980s, local authorities have been an arena for experimentation of contracting-out to private and other sectors. This paper provides a review of the academic and grey literature, and findings are presented from a large-scale online questionnaire survey (n=103) which was distributed to the relevant public realm managers in English local authorities. Findings – The paper shows that contracting-out of parks and roads maintenance happens across the country in different ways. By and large, local authorities are satisfied with the performance of contractors, particularly as a response to economic constraints. Responsibilities, particularly for parks, are increasingly shared with non-governmental organisations, including community groups, although this is not reflected in budget distribution. Research limitations/implications – Despite the efforts, the response rate was relatively low (32 per cent), potentially due to the e-mail communication and online nature of the questionnaire. Originality/value – The research provides empirical evidence about how contracting-out is currently delivering public services and how it has changed in recent years. The findings suggest that responsibilities (and to a lesser extent, budgets) are increasingly shared in England between different combinations of public, private, third and community sector stakeholders. This marks a shift away from in-house public sector delivery of parks and roads services.

The influence of political factors in policymakers' perceptions on the implementation of Web 2.0 technologies for citizen participation and knowledge sharing in public sector delivery

Public administration is being pressured for innovation, driving service delivery towards a more personalized, outcome-driven, participative, efficient and collaborative model. In this regard, Web 2.0 technologies are potential powerful tools for supporting public engagement, intended to improve public services and to establish relationships between government and citizens based on information sharing and dialogue. This paper seeks to analyse the influence that political variables could have in the perception of policymakers regarding the use of Web 2.0 technologies for user participation, for knowledge sharing, and for technological innovation in public service delivery. Findings indicate that policymakers are prone to using Web 2.0 tech- nologies to improve internal productivity of local governments and the engagement of citizens in the process of public services' delivery, but with the aim of making suggestions through consultations. In addition, political factors such as ideology, political competition or political stability could influence the perception of policymakers regarding the use of Web 2.0 technologies for citizen participation and knowledge sharing in public sector delivery.

Measuring Service Delivery in Relation to Recruitment Policies

Public sector delivery of goods and services has been considered to be weak if not poor in developing countries. In an effort to meet the World Bank Millennium Development Goals aimed at eradicating poverty by the year 2015, many countries (developed and developing) have embarked on several reforms to improve, strengthen and provide quality, efficient and effective services. This paper centres on public service delivery based on a recruitment policies perspective in both the Nigerian and South African contexts. It aims to examine the quality of services provided, the relationship between public service delivery and the capability of the human resources providing the services. The research design is based on secondary data. The findings suggest that though well-intentioned, the current recruitment processes, which are based on socio-political factors or considerations (sentiments), contribute to poor service delivery. Recommendations include modifications to encourage more emphasis on merit-based recruitment processes that will ensure the right candidate for the right job and, thus, lead to effective and efficient service delivery.

Measuring Service Delivery in Relation to Recruitment Policies

Public sector delivery of goods and services has been considered to be weak if not poor in developing countries. In an effort to meet the World Bank Millennium Development Goals aimed at eradicating poverty by the year 2015, many countries (developed and developing) have embarked on several reforms to improve, strengthen and provide quality, efficient and effective services. This paper centres on public service delivery based on a recruitment policies perspective in both the Nigerian and South African contexts. It aims to examine the quality of services provided, the relationship between public service delivery and the capability of the human resources providing the services. The research design is based on secondary data. The findings suggest that though well-intentioned, the current recruitment processes, which are based on socio-political factors or considerations (sentiments), contribute to poor service delivery. Recommendations include modifications to encourage more emphasis on merit-based recruitment processes that will ensure the right candidate for the right job and, thus, lead to effective and efficient service delivery.

Comparative performance of public and private sector delivery of BCG vaccination: Evidence from Sub-Saharan Africa

BackgroundThe private sector is an important source of health care in the developing world. However, there is limited evidence on how private providers compare to public providers, particularly for preventive services such as immunizations. We used data from Sub-Saharan Africa (SSA) to assess public–private differences in Bacillus Calmette–Guérin (BCG) vaccine delivery. Methods and findingsWe used demographic and health surveys from 102,629 children aged 0–59 months from 29 countries across SSA to measure differences in BCG status for children born at private versus public health facilities (BCG is recommended at birth). We used a probit model to estimate public–private differences in BCG delivery, while controlling for key confounders. Next, we estimated how differences in BCG status evolved over time for children born at private versus public facilities. Finally, we estimated heterogeneity in public–private differences based on wealth and rural–urban residency. We found that children born at a private facility were 7.1 percentage points less likely to receive BCG vaccine in the same month as birth than children born at a public facility (95% CI 6.3–8.0; p<0.001). Most of this difference was driven by for-profit private providers (as opposed to NGOs) where the BCG provision rate was 10.0 percentage points less than public providers (95% CI 9.0–11.2; p<0.001) compared to only 2.4 percentage points for NGOs (95% CI 1.0–3. 8; p<0.01). Moreover, children born at private for-profit facilities remained less likely to be vaccinated up to 59 months after birth. Finally, public–private differences were more pronounced for poorer children and children in rural areas. ConclusionsThe for-profit private sector performed substantially worse than the public sector in providing BCG vaccine to newborns, resulting in a longer duration of vulnerability to tuberculosis. This disparity was greater for poorer children and children in rural areas.

The Valuation of Public Projects: Risks, Cost of Financing and Cost of Capital Current

It is often said that the private sector is in a good position to manage project costs and meet deadlines, but not, generally, to fund or finance projects. The underlying argument runs as follows: because the interest rate on government borrowings (the government’s financing cost) is lower than what is available to the private sector, the cost of goods or services will necessarily be lower if it is funded by government. However, there is confusion between the cost of financing and the cost of capital (or discount rate) that stems from an analytical error in assessing the true cost of public funds. This is a subtle but important error that is widespread in both the public and private sectors as well as in academia.This analytical illusion is due to the fact that a significant portion of the government’s cost of capital is unaccounted for or not recognized. This portion is the implicit option granted by taxpayers to their government to require additional funds in order to meet the commitments made to the lenders when a project does not meet the expected level of profitability. Discounting at an essentially risk-free rate is often justified by “the virtually unlimited taxing power of the Crown” – the project appears risk-free to lenders, but is obviously not risk-free for taxpaying citizens.The authors identify the implications for the evaluation of public investments and relevant public policies such as direct subsidies to businesses, government endorsements of corporate borrowings, the comparison of public sector versus private sector delivery of public projects and holding a portfolio of risky investments dedicated to the future repayment of the debt. It goes without saying that other evaluations of government policies and interventions could be similarly challenged.

The effect of healthcare delivery privatisation on avoidable mortality: longitudinal cross-regional results from Italy, 1993–2003

BackgroundDuring the 1990s, Italy privatised a significant portion of its healthcare delivery. The authors compared the effectiveness of private and public sector healthcare delivery in reducing avoidable mortality (deaths that...