7 April 2020

By David Clarke, WHO HQ; Dr. Mark Hellowell, Director, Global Health Policy Unit University of Edinburgh; Barbara O'Hanlon member of the WHO Expert Advisory Group on the Governance of the Private Sector; & Cynthia Eldridge, Impact for Health.

All hands on deck: mobilising the private sector for the COVID-19 response

Key government priorities include:

  1. Preventing, and responding to and mitigating the impact of COVID-19
    • Establishing essential public health measures to minimize the spread of the epidemic including information and communication, surveillance, contact identification and tracing
    • Facilitating the most effective treatment for people with COVID-19;
    • Managing stocks of essential materials, test kits, ventilators and oxygen; and
    • Ensuring that all health care workers have access to tools to do their jobs, including having access to appropriate PPE for their role.
    • Protecting the most vulnerable people in each of their communities from the effects of COVID-19.
       
  2. Preserving the functional capacity of their healthcare systems to support ongoing health care provision for all other conditions; What can countries do to address these priorities immediately?
     

By necessity, it is time for all hands on deck. Governments must adopt a whole of government, whole of society approach to the COVID-19 response, mobilising all available resources to keep health systems functioning.  To do so, governments must have a policy framework for private health sector engagement (PSE). Effective PSE in the current crisis means having the capacity to:

  1. Quickly understand what is going on in the private health sector in their country;
  2. Select a fit-for-purpose, fit-for-context strategy to engage the private health sector as part of their response;
  3. Identify and use the appropriate set of instruments for engagement; and
  4. Involve a broad range of private providers of health‑related products and services , whether they are NGOs, faith-based organisations, individual private practitioners or for-profit businesses, in the national response.

Drawing on private sector resources and capacity is critical because in almost all countries, and especially in low- and middle- income countries (LMICs), in which the private health sector provides a significant proportion of essential health services and products to the population. Research shows that the private sector is the dominant source of treatment for children with fever or cough in a sample of 70 LMICs. (1) New research commissioned by WHO in 2019 showed that the private sector provides nearly 40 per cent of health care across the majority of WHO regions and provides 62 per cent of health care in the EMRO region. (2)

In the current global context, the pandemic is simply overwhelming public health systems, and turning to the private sector for additional capacity has become an important part of the campaign to save lives. (3)

What are the main policy challenges countries are grappling with?

While the COVID-19 response should be coordinated with actors in the private sector and civil society, LMICs are struggling with six main policy challenges in enabling the domestic private health sector to support the national response to COVID-19:

  1. Countries are unsure of how best to include the private sector in planning for the national response effort;
  2. Resource-based planning cannot take place as critical data on private sector resources and capacity are not held by the government;
  3. The private health sector lacks certain inputs needed for it to play a role as an effective partner for the government in the response;
  4. Emergency legislation, compounded by weak systems and regulation, can limit the private sector’s role;
  5. Countries are unsure of whether, or how best to, reimburse the private sector for health services provided during the outbreak; and
  6. Private healthcare businesses are exposed to significant financial losses at this time, but governments lack clear criteria for providing support.

Governments are already working with the private sector on COVID-19. What are they doing? What do we see on the ground?  

Some countries have already built private sector capacity into their COVID-19 responses. For example, England, France, Germany, the Lombardy region in Italy and South Africa, have used private health sector engagement to increase testing capacity and add extra hospital beds, ventilators and health workers to their response capacity. Many of these countries have secured a cost price for this additional capacity, such that the private sector is unable to make excess profits for providing these facilities, equipment and services. Countries such as Australia and Spain have taken a different approach, providing authorities with the power to requisition private sector facilities, equipment and staff as needed.

The German response to COVID-19 is particularly instructive.  The German health system has been able to draw significantly on private-sector laboratories and policlinic capacity, which has allowed it to analyse far more samples than any other country.  And, across the country, testing for the coronavirus is free at the point of use for patients whether they are covered by statutory or private health insurance.

While taking different approaches to private sector involvement in their response, all these countries have one thing in common. They have long practised PSE as a matter of routine management of their health systems. They understand their private health sectors – its strengths and limitations - and have developed the tools and know-how to effectively engage with it, enabled by well-established regulatory frameworks and strong direct or indirect financing.

Illustrative examples are at the bottom of this blog. More are under development to help guide countries efforts.

The situation is far more challenging in low and middle-income countries.

Anecdotally, it seems that many private health providers in LMICs are looking for ways to contribute to the response. However, they are not always well-positioned to work effectively with the government. LMIC governments are engaging private actors outside of the health system (such a telecommunication and mattress companies), but engagement with the private health sector remains patchy.

We also see pockets of bad practice.  In some LMICs, laboratories are charging prohibitively high testing fees, private hospitals turning away patients where Covid-19 is suspected, and some private facilities are refusing to treat patients whose insurance status is uncertain.

However, the reasons for PSE for the COVID-19 response in LMICs are just as compelling as for high-income countries – perhaps even more so. These countries are, after all, highly dependent on private sector provision across many essential service areas. Thus, the private health sector owns and manages precious resources that can, potentially, make a major contribution to the capacity needed for the response: facilities, health professionals, medical equipment and essential supplies.

The COVID-19 response in these countries cannot, however, simply replicate what has occurred this far. New, fit-for-context approaches, are urgently needed. Many of the public health and hospital-based interventions deployed by high-income countries aren't relevant to at least some LMICs. Glassman and colleagues (Glassman, Chalkidou, and Sullivan, 2020) argue that in LMICs, priorities for the response include:

  1. Protecting the health workforce: prioritising testing and PPE.
  2. Targeted tests: Provide testing in key public hospitals and community settings where patients are likely to show up to determine their COVID-19 status.
  3. Getting better information using real-world national and subnational data to inform modelling forecasts for evidenced-based policy.
  4. Develop triage protocols for ventilation.

What can we do about this?

WHO calls on national governments everywhere to adopt a whole-of-government and whole-of-society approach in responding to the COVID-19 pandemic. Reducing the further spread of COVID-19 and mitigating its impact should be a top priority for Heads of State and Governments. The response should be coordinated with actors in the private sector and civil society. WHO is working with its member state to find solutions to fix these problems and help countries optimise their response to the pandemic. It has already released an action plan for Ministries of Health to begin to engage private sector capacity (i.e. space, staff, stuff and systems) in response to COVID-19. This is organised around six pillars.

  1. Plan: Get organised to work together;
  2. Space: Secure private sector assets to increase surge capacity;
  3. Staff: Mobilise and manage public and private health staff allocation according to need;
  4. Stuff: Ensure all health facilities and staff have the supplies they need to respond to the crisis;
  5. Systems: Establish systems to integrate the public and private sector response effort; and
  6. Supply-Side Financing: Secure financing mechanisms to ensure access.

WHO is evolving this action plan and developing tools to implement it, including tools about mapping the private sector, how to run planning processes and public-private dialogues and coordination processes and advice on the use of regulatory and health financing tools.

Our advice is that governments should take steps to fully integrate private health sector capacity into the national response and ensure that the activities of the public and private health sector actors are well aligned.  A wide variety of private health sector actors may exist in LMIC health systems – including informal, unregulated service providers, private pharmacists, petty drug sellers, and community health workers. All such providers should be notifying cases, abiding with clinical protocols for testing, isolation and treatment, and ensuring financial and other barriers to care utilisation are eliminated. The lack of engagement with these actors represents a potential threat to the efficacy of the response effort, just as effective PSE can make a major contribution to it.

As Glassman and colleagues point out, a one size fits all approach to the COVID 19 response simply won't work. That's why we think the solution is to provide practical, hands-on, tailored guidance for how to work together during the COVID-19 crisis effectively.

We plan work in three phases:

Phase 1, over the next 3 months, providing Emergency Response in real time

A ‘push’, real-time function to disseminate existing resources through WHO platforms to existing networks. Focused on empowering countries.

Phase 2, next 6 months, providing On demand peer-to-peer support

A ‘pull’ function that responds to prioritized problems. Expert practitioner panels, curated evidence for peer-to-peer problem solving. Focused on empowering member state leaders from public and private sectors to problem solve.

Phase 3, 12-18 months. Virtual coaching support for effective private sector governance 

A ‘push and pull’ function that documents and disseminates practical, “hands-on” support to member states to strengthen private sector governance in mixed health systems.

In the short term, such support will significantly enhance the COVID-19 response. In the near term, it will help establish a strong foundation for stronger health system governance in the post-COVID world. n the long term, private sector engagement can contribute to Universal Health Coverage and the health-related Sustainable Development Goals as member states work to replenish, recover and reform.

Contact us if you need our support. Please share your lessons with us about your private sector engagement efforts - good and bad. Critical lessons learned will be shared with all member states.

References

[1] Grepin, K. 2016. Private Sector an Important But Not Dominant Provider Of Key Health Services in Low- And Middle-Income Countries. Health Affairs 35, no.7. 1214-1221

[2] Dominic Montagu, and Nirali Chakraborty, Standard survey data: insights into private sector utilization, a technical report for WHO

[3] Elston, J. W. T., Cartwright, C., Ndumbi, P., & Wright, J. (2017). The health impact of the 2014–15 Ebola outbreak. Public Health, 143, 60–70.

Glassman, A, Chalkidou, K, and Sullivan, R. Does One Size Fit All? Realistic Alternatives for COVID-19 Response in Low-Income Countries, Accessed 2 April, 2020. 

O’Hanlon, B, Hellowell, M, Eldridge, C, Clarke, D. An action plan to engage the private sector in response to covid-19, Consultation draft of Interim Guidance, 30 March 2020, WHO Geneva.

O’Hanlon, B, Hellowell, M. Enabling the private sector in the national response to COVID-19: six current policy challenges, May 2020

Our special thanks to Klaus-Dirk Henke of the Technical University of Berlin and Stefanie Ettelt London School of Hygiene and Tropical Medicine, for early access to and permission to use information from their soon-to-be-published study on the German COVID 19 response.

Also thanks to Agnes Soucat, Edward Kelley and Gerard Schmets, all of WHO HQ for their helpful comments.

 

Illustrative examples of private sector engagement for the COVID-19 response

England

What did they do?
The NHS has taken over management of all private inpatient facilities treat COVID-19 patients and other urgent operations and treatments. In addition, local agreements cover: (1) inpatient respiratory care to COVID-19 patients; (2) urgent elective care services during the surge; (3). diagnostic capacity to maintain urgent priority elective and cancer pathways; (4) inpatient non-elective care to help free up bed capacity; and (5) making staff available for redeployment in other settings

How did they do it?
Contracts are structured as follows: Payment is made by central government directly, based on actual costs per patient (zero profit), with an open book calculation assessed by an independent auditor.

What have they achieved?
An additional 8,000 hospital beds, 1,200 more ventilators, 10,000 nurses, 700 doctors and over 8,000 other clinical staff have been included in the response effort.

Italy (Lombardy)

What did they do?
Private providers in Lombardy have been engaged in the regional response since the initial surge in demand. Dialogue was rapidly established between the private hospital association and regional health authorities, focusing on: (1) provision of inpatient respiratory care capacity; (2) urgent elective care services during the surge; and (3) inpatient non-elective care to patients to free up beds. The private sector agreed to reduce the number of admissions in non-urgent elective and outpatient care; later, these activities were suspended altogether to provide space and personnel for the emergency.

How did they do it?
Contracts between regional authorities and accredited private hospitals, on a retrospective per case basis. Payments will be set to provide no above-cost remuneration.

What have they achieved?
An additional 407 intensive care beds and 4,570 inpatient beds available to support the response effort. The entire regional system has been re-organised by creating reference hospitals (hubs), both public and private, where activity for non-COVID-19 patients in need of urgent care has been concentrated.

France

What did they do?
Various examples of inter-sectoral collaboration have emerged, including: 1) private hospitals agreeing to cancel all non-urgent activities to free up beds (including 100,000 interventions per week); 2) redeployment of beds to tackle COVID-19 demand; 3) seamless transfer of patients between public and private sector facilities; and 4) the provision of lists of private sector employees that are to be made available for deployment by the public sector as part of the response.

How did they do it?
Existing strategic purchasing arrangements have been leveraged to quickly ramp up purchasing of Covid-19 and other urgent treatments by the private sector.

What have they achieved?
Some 800 for-profit health facilities, and 704 non-profit health facilities have been engaged in the COVID-19 response. Private hospitals are now embedded in the response – e.g. Ramsay Sante is treating some 10% of COVID-19 ICU patients in Paris.

Germany

What did they do?
In Germany, private sector diagnostic capacity is substantial - able to analyse 58,000 tests per day - and this capacity has been leveraged for the COVID-19 response. There are 54 laboratories offering SARS-CoV-2 PCR tests, of which 22 are private. Despite the importance of private labs to this effort, testing for SARS-CoV-2 is free at the point of use under all insurance schemes (statutory and private health insurance).

How did they do it?
Existing reimbursement systems for diagnostic services have been deployed to quickly ramp up purchasing of additional tests.

What have they achieved?
According to the Association of Accredited Laboratories (ALM), privately owned labs and policlinics analysed over 260,000 SARS-CoV-2 PCR samples in just one week in March.

South Africa

What did they do?
Life Healthcare is treating 10 COVID-19 patients, all privately insured. However, it is also currently negotiating a per case tariff with the government to care for uninsured COVID-19 cases, and receive reimbursement. Procedures are likely to be similar for the other two large corporate hospital chains, Netcare and Mediclinic

How did they do it?
New reimbursement systems are being negotiated to ramp up purchasing of Covid-19 and other urgent treatments by the private hospital sector.

What have they achieved?
Privately insured patients are receiving care. Non-insured patients will be able to access free privately delivered care, subject to the ongoing public/private dialogue.

Photo: @MaikoValentino

Categories: Move together, Private sector

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