Applying a Health Systems Assessment in a fragile setting.
The private sector needs to be part of efforts to achieve universal health coverage (UHC). Governments therefore need to engage with the private sector and identify common interests to foster new partnerships for universal health coverage (UHC). But before a government gets into partnerships with the private sector, regulatory processes – such as legislation, monitoring and compliance – need to be in place.
These are some of the key messages to come out of an event that took place on 21 May 2019 in Geneva on the side of the 72nd World Health Assembly. ‘Profiting from profit: aligning private sector interests with UHC goals’ was co-organised by UHC2030, the World Health Organization (WHO), the World Economic Forum and the Independent Accountability Panel for Every Woman, Every Child, Every Adolescent.
Moderated by Gerard Schmets of WHO, the main question to discuss was what role can and should the private sector play to reach UHC? The event also kicked off the process to develop a multi-stakeholder statement on private sector engagement for UHC.
Peter Salama, Executive Director UHC/Life Course at WHO opened the meeting by saying, “It is essential to reframe public and private sector engagement as a partnership for shared outcomes.”
Zafar Mirza, Minister of State for Health in Pakistan gave a key note speech arguing that capacity building is necessary to support the government’s stewardship role to engage ideally as a strategic purchaser of services and set the terms of engagement. This helps to leverage economies of scale to promote quality standards in service delivery. “Government shall never compromise its regulatory role! Market failure will occur if it is not well regulated, therefore ruining your goals to deliver better health for the people,” he said.
Representatives of the global health community then spoke about specific contexts and some delivered ‘asks’ to the private sector.
Ulana Suprun, Acting Minister of Health in Ukraine shared the experience of Ukraine, which had very little investment in health care or health infrastructure for 25 years. Potential investors had no incentive to invest in a country with a budgetary-run national health system and no regulation. Now much is changing. Ukraine has created a national health service and will be providing primary health care services free of charge to the population, having developed contracting-out services where every fifth facility delivering PHC services is private. The country has also established public private partnerships in e-health, health information systems, diagnostics, and infrastructure.
Emmanuel Odame Ankrah, representative from the Ministry of Health in Ghana said that the country needs to start a private sector conversation. The question is ‘How?’, especially considering the private sector is heterogenous in size and quality. “How can a country derive benefits from partnerships with the private sector?” he asked.
Kul Gautam, Co-Chair of the UN Secretary-General’s Independent Accountability Panel for Every Woman, Every Child, Every Adolescent argued that we need a good regulatory framework for the public and the private sector and for that we need the whole government on board, not just the Ministry of Health. He said the IAP issued recommendations for the private sector. It asks the pharmaceutical industry for essential drugs and commodities to be of good quality, affordable and accessible and that their research better aligns with public health interests. The private sector should respect the UN global compact that upholds human and labour rights. “The private sector claims to care about people, planet and profit, in that order and we ask the private sector to hold itself accountable for people and planet,” he said.
David Clarke, from the Department of Health Governance and Financing at WHO argued it is essential that we engage with the private sector on the road to UHC. He said that WHO asks the private sector to comply with the UHC rules of the game and react to country needs and demands; this means to work within agreed rules set out by governments. It also asks the private sector to comply with market rules in countries, and to stop engaging in anti-competitive behaviour like market skimming. WHO welcomes private sector contribution to innovation and new resources to help with UHC outcomes. “We ask that all commitments made by the private sector at the global level, should be implemented at country level. There is a need for greater transparency, shared information, metrics and accountability,” he said.
Damiano de Felice – Director of Strategy at the Access to Medicines Foundation (AMF) agreed that access to medicines is complex but pointed out that over the past ten years there has been progress with the pharmaceutical industry. AMF had four requests:
1) It asks companies to develop access plans as early as possible 2) It asks all companies to file for registration as early as possible to prevent the time-lag of registration
3) It asks companies to consider the ability of patients to pay for their medicines when setting the prices for pharmaceuticals.
4) It asks that more companies work with the medicines patent pool regarding voluntary licensing.
“Lastly, we ask UHC2030 to include more generics companies not just research-based pharmaceuticals” he said.
Priya Kanayson, Senior Advocacy Officer of the Non-Communicable Disease (NCD) Alliance said it is difficult to make asks to the heterogenous private sector. For NCDs and chronic illnesses, WHO ‘Best Buys’ in purchasing should be followed to avoid industry interference. “We have to ensure that global commitments by multinational companies are delivered at a country level,” she said.
Desta Lakew, Member of the Technical Working Group on the Private Sector in Health of Health Systems Global, reminded us that however complex health systems are, we need to remain mindful of UHC in policies and programmes. The diverse private sector should move beyond silos and competition and establish digital platforms to enable partnerships. “We ask for a shared value approach which means new partnerships that move beyond corporate social responsibility, and we ask for agreements to share knowledge and data to build health system capacity and protect patients,” she said.
Representatives of the private sector were given the opportunity to respond to those asks and provide for the private sector’s perspective.
Fumie Griego, Deputy Director General and Chief Operating Officer, International Federation of Pharmaceutical Manufacturers and Associations said that pharmaceutical companies agree about the importance of a framework for appropriate interaction and to build trust. The pharmaceutical industry is very well regulated and it appreciates regulation to ensure that patients get the quality drugs they need. “The private sector believes in collaboration, in addition to competition, with other sectors including with the generic pharmaceutical industry on, for example, antimicrobial resistance,” she said.
Erica Young, Chief of Staff, Group President’s Office, Fullerton Health, Singapore presented the company’s belief that a robust primary health care system is the linchpin to accessible good quality care for all. “Multistakeholder approaches are needed to achieve UHC,” she said.
Ted Talks on the private sector and UHC
For the next section of the meeting, we invited speakers to present their ideas using a Ted Talks style. Here is an extract from each of these talks:
Jan-Willem Sheijgrond, Phillips
“I have a conflict of interest. I was first diagnosed with a conflict of interest by WHO two years ago, and it turns out to be chronic. Since me coming out that I have a conflict of interest, I have been stigmatized, I have been ignored and I have been discriminated against. But I am now at a stage that I can manage my conflict of interest and I should be ok, but I have to warn you: it is communicable. By the end of the evening, you will all have a conflict of interest and those in denial just did not yet have their Anonymous Alcoholics moment to admit that they are indeed conflicted. And it is ok to be conflicted!”
It starts that we have common interests: Philips wants to serve people, we believe in UHC, so we are fully aligned with this. As we dig down, we might find a conflict of interest deep down and it is important that we understand it and then we can disclose it and then you can start managing it. The promise of UHC means that there is technology, innovation and disruption and the private sector is really important to actually solve that.”
“When we start to distinguish if we should invest in immunization for women and children or shall we invest in ultrasound for neonatal care, I will always tell you to invest in ultrasounds, because I sell ultrasounds and I don't do vaccinations. That is my conflict of interest, understand it- don't ask me to choose between vaccines and ultrasound because I always choose ultrasound, I don't know anything else. And when it comes to ultrasound, I want you to buy my ultrasound, I don't want you to buy one from the other 15 providers, I want you to buy mine. So make sure that when you talk about ultrasound with me, make sure that you also talk to the other providers – understand the conflict and then manage it.”
Akaki Zoidze, Member of Parliament in Georgia
“Georgia has a population of 3.7 million. It’s a small country, which had a state run and centralized health system during the Soviet times and then reformed towards over-reliance on privatization and deregulation. This was the idea about how to fight the corruption and it worked (…) The door was wide open and now we have 95% for-profit private providers, 100% pharmaceutical firms and 15 % private insurance, most of them vertically aligned. It is not people-planet-profit but profit-profit-profit.”
“The health care market is broken in many ways in multiple places, you have cream skimming of private insurances, you have patients receiving services not according to their needs, (…) a race of hospital beds and hospitals because health care became too profitable. We pursued the goal of UHC and tripled the health budget. So you have private providers, the public payer pursuing UHC goals and regulation that does not exist. Those who not believe in health market interventions, I invite those economists to Georgia. This all resulted in a higher proportion of MRI scanners per population than in Japan, twice as many hospital beds as required, we have double the emergency services required as they are not regulated and there is no selected contracting. Everybody is free to provide services and the doctors decide, and as they are dependent on the pharmaceutical companies, they prescribe medicines, so that 40% of our total health expenditure is now on drugs.
It is very difficult to reverse these issues once these problems are in place. Now we are thinking about aligning incentives because the root of the problem is asymmetry; asymmetry of information of public and private and asymmetry of power between public and private (…) it is about balancing the incentives to ensure that providing quality care is more profitable”.
Cynthia Eldridge, Impact for Health
“I want to propose to you, perhaps somewhat surprisingly, that “profiting from profit” and “aligning private sector interests with UHC” isn’t all about the private sector. In many ways, it is about the public sector. It’s about the government’s role, about stewardship, about guidance vis-à-vis private sector delivery of care.
Holistic maps of the health system, which include the private sector, can reveal new opportunities to accelerate progress in service delivery.
It is about the public sector: 1) Changing its vision from a mono to pluralistic health system; 2) strategically deciding what the private sector’s role in this mixed health system will be, and; 3) building state capacity to creatively and effectively use policy, financing, systems and processes to harness and leverage the private health sector’s capacity to support rapid, measurable and sustainable progress towards publicly-financed UHC."
Discussion and closing remarks
A discussion followed where participants suggested that before a government gets into partnerships with the private sector, regulatory framework and processes need to be in place. This environment however is costly to create, but there are substantial benefits. For example, 70% of patients in Ukraine are satisfied because competition now exists and patients have the freedom to choose their own physician. Finally, a key point is that countries need support from the United Nations or other agencies to engage with the private sector.
Agnes Soucat, Director for Health Systems Governance and Financing at the WHO remarked that there is a need to separate private sector for UHC into service delivery and financing components. Public sector financing is necessary to achieve UHC, while for service delivery, harnessing the private sector is essential to achieve UHC. WHO is developing a framework for private sector engagement for UHC.
Githinji Gitahi, CEO AMREF Health Africa and UHC2030 Co-chair made the closing remarks. He summarized the need for collaboration, improved regulatory capacity, data and sharing of information between the public and private sectors, and a stronger evidence base (rather than pilots) to determine the cost effectiveness of interventions. “Private versus pubic is an unhelpful discussion. There is one health system with different players and different roles that need a publicly -led responsive regulatory and legal framework that governs towards equitable access to health with financial protection.” This is why partners of the UHC movement are calling political leaders, as part of their set of key asks, to regulate and legislate – create a strong, enabling regulatory and legal environment responsive to peoples’ needs.
UHC2030 multi-stakeholder statement on private sector engagement for UHC
This event was also the occasion for UHC2030 to kickstart a process of developing a multi-stakeholder statement on Private Sector Engagement for UHC. UHC2030 will gather inputs from its various partners, including the private sector constituency, to develop a joint vision on how the private sector can contribute to UHC. The statement will be presented alongside the High Level Meeting on Universal Health Coverage on 23 September 2019 and provide a joint vision for better multi-stakeholder partnerships for UHC.