Applying a Health Systems Assessment in a fragile setting.
A recent event hosted by UHC2030 and the Health Systems Governance team from the World Health Organization during the 71st World Health Assembly in Geneva explored how various partners might engage the private sector in their efforts to achieve universal health coverage (UHC).
The event, which took place on 22 May at the International Committee of the Red Cross, Geneva, brought together a range of government, private sector, academia and civil society actors to discuss how countries can engage the private sector productively; and how countries can engage the private sector in a way that does not put UHC in peril.
The key messages to emerge from the meeting were:
- The private sector is a heterogeneous group; it is not just pharmaceutical companies or private care providers.
- In order to reach UHC by 2030, we need to engage with the private sector and the private sector needs to commit to UHC.
- We must work with the private sector because the private sector is part of any health system and it would be inefficient for the public service to try to produce these products.
- It is important to engage the private sector and ensure that the population can access these goods and services at an affordable price.
- Risk mitigation and regulation is key when governments engage with the private sector.
Speaking about achieving universal health coverage, Dr Githinji Gitahi, Global CEO and Director General of AMREF and Co-chair of UHC2030 said, “We must work with the private sector because the private sector is part of any health system and has a role to play in every building block. The question is how.” He reaffirmed the importance of governments to first define their ‘shopping list’, define a strategy, then invite the private sector. In the end, “The community must always win in any engagement with the private sector”.
Dr Anbar Pillay, Deputy Director General Health Regulation and Compliance, Ministry of Health of South Africa, said that by not engaging with the private sector, “You would effectively reduce the options that are available for patients to be able to access goods and services and consequently […] the type of health services patients could access.” However, the private sector is for profit and their objectives are different; first the objective for profit has to be aligned with the objective of maximizing the health of patients. In governmental contracting mechanisms, mitigating strategies need to be included. To expect the private sector to delivers services at the lowest possible cost, simply because you ask for it, is naïve. “People need to bear in mind that this is a possible risk and mitigate it,” he said.
Aurélie du Châtelet, Advocacy Advisor-Health and Nutrition, Action Against Hunger said that it is important how we work with the private sector: “Countries have everything to lose, as well as their populations, if there are no previously defined rules on how we engage. We need safeguards to ensure it is a one-time commitment with a precise objective.” The problem with engaging the private sector, it is that some governments put all responsibilities onto another actor, thinking that the private sector is taking care of the population. It is important to remember that the health is within the state’s domain, and it is the prerogative of the state. The private sector has a complementary role, to go further and maybe faster, but it must not replace the state. She further argued for CSOs to engage saying, “An important role for CSOs is working with the private sector to ensure they adopt a constructive approach.”
Bakhuti Shengelia, Executive Director for Global Policy and Healthcare Systems, Novartis Oncology responded by saying that the private sector is based on research and development; the role of innovation and disrupting the system is part of their DNA. Without the private sector, it will be harder to close the gaps preventing us from achieving UHC. He invited all partners to leave the leave ideology behind: “We should not think of winners and losers, we should think of partners who work collectively toward the common goals”.
Dr Mercy Mwangangi, Health Financing Expert at the Ministry of Health, Kenya described how the private sector has been productively perilous in Kenya. This requires, “Consistently asking if it is bringing equity, financial protection and quality” she said.
Jade Khalife, Researcher-Coordinator at Joint Health Systems Research project, Lebanon presented Lebanon’s experience with public-private partnerships for aligning incentives, effective stewardship and participation. He highlighted, “Participatory governance and transparency in dealing with private sector, involving them throughout the process” are key lessons.
Dr Carmen Barroso, Co-Chair, United Nations Secretary General’s Independent Accountability Panel for Every Woman Every Child, highlighted the importance of sustainable partnerships models, with mechanisms for accountability. She said, “Without accountability, the engagement of the private sector can be quite perilous. With accountability, we can turn peril into productivity.”
Background on work of UHC2030 and WHO
The delivery of health-related goods and services in almost all health systems is mixed, undertaken by both public and private organizations. Rapid developments in the health sector are key drivers for governments to leverage the massive role played by the private sector. Changes in the burden of disease and disease patterns, aging populations, rapid technology innovations, political instability and restrictions of the public fiscal space all contribute to this pressure. To better deal with these pressures, the engagement of the private sector is frequently proposed as a solution for enhancing the responsiveness and effectiveness of health systems.
The governance arrangements and policy tools deployed to steer the private sector differ greatly from those used to steer public-only health delivery. Many countries struggle to get to grips with these challenges. Existing conceptual frameworks for examining health policy options for engaging the private sector are not fit for purpose and there is a lack of guidance about implementing regulatory and fiscal tools to steer the private sector towards UHC.
It follows there is a pressing need for far more research, guidance and dialogue about these issues if countries are to reach UHC by 2030. This is where new work from UHC2030 and WHO is trying to make a difference.
UHC2030 is supporting efforts to bring the private sector into constructive partnership with governments, health system users and civil society in service of UHC through its new private sector constituency. The aim of this constituency is help solve some of the intractable problems associated with private sector engagement.
It will provide a place for the private sector to come together with other stakeholders to grapple with the political, technical and controversial aspects of the private sector in health and create a space for information exchange and dialogue about the contribution of the private sector to UHC. Dr Naoko Yamamoto, ADG for UHC and Health Systems, WHO, announced the launch of the private sector constituency during the WHA side event.
UHC2030 is calling on private sector health providers to join this constituency for more information contact Shana Dörr firstname.lastname@example.org.
At the same time WHO’s health systems governance team is working with countries to strengthen their governance capacity for private sector engagement (PSE). This work involves developing and adopting national strategies and tools, strengthening legal and regulatory environments for facilitating PSE, managing risk and ensuring transparency and accountability.
This work is squarely focused on helping governments’ implement UHC by 2030 and aims to help navigate governments through the complexity of PSE using a new framework and approach that focuses on creating public value through private means, adaptable to different country contexts, scenarios and multiple stakeholder perspectives.
The backbone of the new approach is step-by-step decision-making model supported by a background analysis toolkit. The toolkit includes both assessment and analysis tools, which will assist governments to understand the private sector status quo and decide on actions required to align the private sector with governments health priorities.
Comments or questions? Contact David Clarke from the health systems governance team email@example.com