When Health Becomes a Business: Why We Must Stop Exploiting Public Health for Private Gain

Introduction
We pay for health care — through taxes, social contributions, insurance, or direct fees. That gives us the right to expect decent service: transparency, efficiency, integrity, and fair treatment. When health service providers or intermediaries abuse contracts or use public funds for their own benefit at the expense of patients, the system fails. It’s not just a policy issue, it's a moral issue: people’s lives, well‑being, dignity are on the line.

The recent SENASA / FARMACARD story in the Dominican Republic is a perfect example. FARMACARD is defending its contract with SENASA, saying everything’s legal and it has saved lots of money, but there are serious questions about whether “saving money” is coming at the cost of fairness, oversight, or proper care.

Let’s dig into what happened, why this kind of system abuse is dangerous, and how we fix it so health stays a right, not a profit center.

What’s going on: The SENASA / FARMACARD contract
Here’s what we know from the public reporting:

• FARMACARD handles contracts with SENASA (Dominican National Health Insurance) to distribute medicines. Dominican Today
• Between 2012‑2020, FARMACARD claims to have helped SENASA cut drug spending by nearly 40%. Dominican Today
• Under the new contract signed in February 2025, in only five months, they say they achieved RD$129 million in savings (about RD$25M per month) without affecting coverage. Dominican Today
• They also say they found irregularities: 68% of prescriptions in the contributory regime came from the public system — three times higher than average. They see that as possible fraud. Dominican Today
• To try to stop inefficiency or misuse, they introduced tighter controls: suspending unauthorized deliveries, using security tokens for medication purchases. Dominican Today
• They claim they restored transparency and ensured continuity of medicine distribution to millions. And that the contract model (capitated; meaning they assume financial risk) helps SENASA control costs, stabilize the budget. Dominican Today

Why this kind of system can (and often does) get abused

Having a contract, cutting costs, “improving efficiency” — sounds good on paper. But there are structural risks and places where private actors in health (or intermediaries) can exploit weaknesses. These are some of them:

1. Perverse incentives
   • When “savings” become more important than quality. You cut corners (cheaper drugs, longer waits, fewer services) and patients suffer.
   • When providers are rewarded for lowering cost rather than improving outcomes or fairness.
2. Lack of oversight / weak monitoring
   • Public contracts often involve complex terms, technical specifications, quality metrics. If oversight is lax, it’s easy for contractors to exploit loopholes.
   • Audits or controls may be infrequent, underpowered, or captured by vested interests.
3. Information asymmetry
   • The public, patients, often don’t see how contracts are written, how money moves, how costs are being “saved.”
   • Even governments may not always have all the data in clean, usable form.
4. Corruption and conflicts of interest
   • Private firms may have connections or influence that let them win contracts despite poor performance or higher risk.
   • Lack of transparency in bidding, in payments, or in the relationship between contractor and public official.
5. Risk shifting
   • As FARMACARD says, their contract is capitated — so they assume financial risk. But risk shifting can also mean shifting burden onto patients (e.g. by limiting drug options, denying coverage, stricter criteria) or delaying care.
6. Undermining public trust
   • When people believe health service is being misused or mismanaged, they lose trust. That can reduce compliance, increase public discontent, possibly lead people to avoid or delay needed care.

Using the SENASA case: What are the red flags

In the SENASA / FARMACARD example, here are things that warrant skepticism or further investigation:

• Is the “savings” really coming from better efficiency and quality, or from cutting essential services, or using lower‐quality medicines?
• The irregularity that 68% of prescriptions under contributory regime come from the “public system” — this might indicate abuse, but also could be due to misclassification or structural incentives. Does FARMACARD / SENASA have accurate data and transparent methodology?
• The “security tokens” for purchases — good in theory, but how are they audited? Who ensures they’re not bypassed or misused?
• Are all pharmacies in the network being treated equally? Are there conflicts of interest (e.g., private pharmacies favored, or certain suppliers)?
• Is there independent verification of the cost savings claimed? Are there third‑party audits or academic studies?

Why we need health care to stay transparent and non‐exploitative

Because folks’ lives depend on it. Health care is more than a price tag. Ethical, moral, economic reasons:

• When people don’t get needed medicines or care, morbidity and mortality rise.
• Inequities get worse: poorer or underserved populations suffer more when profit or cost cutting becomes priority.
• Health is public good: sickness spreads, socioeconomic consequences ripple. A compromised system means risk for all.
• Trust in institutions depends on accountability. Once lost, hard to restore.

How we fix this — concrete reforms

I’m not saying the perfect system exists, but here are hard‑headed, real fixes to ensure that when public health is managed or contracted out, it’s fair, transparent, efficient, accountable.

1. Full transparency of contracts
   • Make all contracts, bidding documents, performance metrics, KPIs, oversight reports public.
   • Publish data on how savings are calculated, what the baseline is, what quality thresholds exist, and whether they’re met.
2. Independent, external audits
   • Not just internal reports. Independent audits (by national audit offices, academic institutions, civil society) done regularly.
   • Verifiable findings must be published.
3. Clear performance metrics tied to health outcomes, not just cost
   • Metrics should include patient access, quality of medicines, timeliness, adverse events, satisfaction.
   • Contracts should include penalties for failing to meet quality, not just cost overruns.
4. Strong monitoring and enforcement mechanisms
   • Real regulatory institutions with teeth to investigate, sanction abuses.
   • Whistleblower protection.
5. Citizen / patient participation and oversight
   • Patients, civil society should have access to information, ability to lodge complaints, see data.
   • Maybe citizen advisory boards, ombudsman offices focused on health.
6. Digital systems / tech for tracking
   • Prescription systems, medication tracking, supply chain monitoring to prevent fraud, diversion, waste.
   • Public dashboards showing usage, spending, coverage.
7. Separation of profit and essential health rights
   • Private actors may play important roles, but public interest must always have priority. If something is essential medicine, essential care, it can’t be compromised for profit.
8. Legal / regulatory framework tightening
   • Laws that punish misuse of public funds, that enforce conflict of interest rules.
   • Strong penalties for fraud, misuse, negligence.
9. Culture shift: accountability as core value
   • Training, institutional norms that treat transparency not as a checkbox, but as fundamental.
   • Leaders and managers in public health must be held personally accountable.

What citizens can/should demand

Here’s what we — ordinary people — need to demand so these reforms actually happen:

• Public, accessible reporting on how our health funds are spent.
• Access to data: how many people got medicine, waiting times, drug quality, etc.
• Prosecution or at least public sanction when corruption or misuse happens. No more sweeping things under the rug.
• Civil society and media empowered to investigate and expose issues.
• Political will: lawmakers and executives must act, not just give speeches.

Potential objections and responses

Some will argue:

• “We need private efficiency to reduce cost.” — Yes, private management can bring efficiencies. But those gains must not sacrifice quality or access. And efficiency must be verified.
• “Too much regulation slows things down.” — Maybe. But the cost of weak regulation is much higher: harm to patients, loss of trust, wasted money. Good regulation can be smart regulation.
• “Transparancy costs money.” — True. But in the long run, transparency saves much more by reducing waste and corruption.

Conclusion

Health care is a human right, not a profit stream. When public health services are exploited — when contractors or private entities treat public contracts like opportunities to maximize gain with minimal accountability — we all lose. The sick, the vulnerable suffer first, but eventually society pays the cost: weaker institutions, more distrust, poorer health outcomes, more inequality.

The SENASA / FARMACARD case should serve as a warning and a wake‑up call: savings are not enough. Legal compliance claims are not enough. We must see proof: quality, fairness, outcomes.

Let’s demand transparency. Let’s demand accountability. Let’s demand health care service providers and contractors be servants of the public good — not private profit.