Private sector solution: A dog team delivers antitoxin during Nome, Alaska’s 1925 diphtheria outbreak. Image: Bettmann/Getty

Fragile States Need Private Sector Allies

It was January of 1925, and Nome’s children were dying. Diphtheria had struck the Alaskan town, but the curative serum the local doctor needed was in Nenana, nearly 700 miles away.

Sub-zero temperatures meant that shipping the serum by air was not an option, so the governor turned to sled dog teams, which had delivered mail on that route. Over 5 and 1/2 days, 20 mush teams and their human drivers set up a relay and delivered the lifesaving medicine, a trek known as the “Great Race of Mercy”—now commemorated every year in an event called the Iditarod.

The moral: Get help when you need it, no matter how unorthodox.

We need to employ that strategy in global health development by integrating private sector organizations into our health system solutions more often. They operate where governments cannot and are a rich source of flexibility and innovation. When a country’s government is frozen by conflict, natural disasters, financial crisis, or another crippling event, its health care system is all too likely to follow. Health workers flee or fall victim themselves, and hospitals run out of medicine and go dark. Others must step in to fill the void.

The private sector, in all its forms, is the place to look.

In destabilizing conditions, deadly diseases flourish. In Venezuela, the rate of tuberculosis is the highest it has been in the country in the past 4 decades, with approximately 13,000 cases in 2017. Confirmed cases of malaria are up from 36,000 in 2009 to 414,000 in 2017. Reported cases of measles, almost nonexistent previously, reached 9,300 between 2017 and April 2019. When safety and security permit, humanitarian teams step in to provide lifesaving goods and services, but often even they don’t have access to regions in need. This is the case in the current Ebola epidemic, which is proving so difficult to quell amid conflicts in the Democratic Republic of Congo where government health workers and aid workers have been attacked and even killed.

Addressing issues in unstable and dangerous circumstances presents enormous challenges. And yet we must try. People living in fragile states comprise one-third of deaths from HIV/AIDS in low-income countries, one-third of those lacking access to clean water, and almost half of all child deaths.

This broader approach involves looking far beyond the public sector to fill gaps when government facilities are not functioning well. We can create more resilient health systems that respond to severe shocks by involving the people and organizations that remain on the ground even during some of the more volatile situations: private-sector doctors who are still seeing patients, drug sellers who are still selling medicines, and faith-based private organizations that are steadfast during a crisis in places no one else dare go.

Solutions need to be highly localized and adaptable. Private actors come in different shapes and sizes—for-profit, not-for-profit, faith-based, and entrepreneurial—but they are often solving similar problems as public organizations: getting products to people, leveraging technology, mobilizing financial resources, and providing specialized labor. They can be valuable allies, not just in easing immediate needs but also in constructing a better-performing, reliable health sector in which all systems function well.

In Somalia, rife with conflict and security risks, the UK’s Department for International Development has invested in local private providers to help reach challenging areas, making its activities more nimble and effective. One DFID program funded training private pharmacies, often present in rural and nomadic areas, to provide affordable basic medicines in Somaliland for illnesses like malaria, diarrhea and pneumonia—leading killers of women and children.

And in 2011, the Bill & Melinda Gates Foundation supported my organization, Management Sciences for Health, to help local drug sellers in Liberia procure quality-certified medicines and teach them to identify symptoms of prevalent disease so that patients can obtain quick referrals to health facilities when necessary. Programs like these—pioneered in Tanzania and now active in a half-dozen countries—help create reliable local operators, boosting health system resilience. When Ebola hit Liberia in 2014, the accredited medicine shops were among the few health providers that continued to operate. They can also provide access to mosquito nets, antibiotics, family planning products, early tuberculosis detection and referral, and more. In one study, availability of tracer antimicrobials in Tanzania increased by 26% and the proportion of drug sellers with unauthorized items decreased from 53% to 13%.

As urgent as today’s needs are, they will only intensify. By 2030, more than 40% of the world’s poorest people will live in a fragile state.

To equitably achieve global health goals—eradicating disease, achieving universal health coverage—we must leave no one behind. That means tapping every potential ally to help meet the needs of people who live in difficult circumstances, especially people with the least resources.


Marian W. Wentworth is President and CEO of Management Sciences for Health, a nonprofit global health organization.

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Private sector solution: A dog team delivers antitoxin during Nome, Alaska’s 1925 diphtheria outbreak. Image: Bettmann/Getty