Applying a Health Systems Assessment in a fragile setting.
“Hello and welcome to Erehwon news. Today’s top headlines. Collusion in the health system sparks outrage. Following a report between the rampant collusion between Erehwon’s private health insurers and private hospitals, five thousand people have taken to the streets in the capital,” presents Erehwon’s top newsreader in a short video clip.
So began a session on private sector accountability at the fifth Global Symposium on Health System Research in Liverpool on Monday 8 October. But this was not real news! It was part of a country simulation exercise organised by UHC2030 and the WHO Health Systems Governance team to explore accountability problems of the private health insurance market in the fictitious country of Erehwon. The keen-eyed among you will notice this is Nowhere spelt backwards.
Why did we do this exercise? Currently, definitions and theoretical frameworks surrounding private sector engagement for UHC are inadequate and we need to reach a common understanding among all stakeholders including governments, civil society, academia and the private sector itself. So what do all these different groups think?
To set the scene, David Clarke, WHO, presented a draft framework for private sector accountability developed for the session.
Following the newsreaders’ clip about corruption in the health system and rising health care costs for patients, Shana Dörr, UHC2030, presented the country context of Erehwon and posed the question: “From your viewpoint as government, researcher, civil society or private sector, is there an accountability problem in Erehwon and what would you do about it?” Over 40 participants then took part in the Erehwon country simulation exercise.
Participants were asked to assume the mindset and arguments of their respective groups to argue their case and facilitator Dr Josep Figueras, Director of the European Observatory on Health Systems and Policies, asked each group to present and answer questions.
Private sector response to Erehwon’s situation
The private sector group, under the lead of Dr Mostafa Hunter, Governance and Private Sector Expert, identified problems within their own accountability structures towards shareholders and consumers. The group feared the Government overregulating their sector and that rising premiums might undermine their own market base, leading to a reduction in profits.
However, the private sector was also interested in accessing the 90% market share. They were very interested in being part of the public private dialogue with the Government to shape policies. They wanted to ask the Government to reshape the health financing system so that the private sector can contribute in a complementary and supplementary way. Their suggestions were that Government should expand the insurance and provision market so insurances can have a bigger market share while aligning it with UHC objectives.
The Government should pay for poor people to access private services, and therefore receive high quality health care. Private providers and private insurances will allow internal accountability mechanisms and ensure that there will be no cross-directorship. “People should have the choice to use our services!” they said.
Civil society response to Erehwon’s situation
The civil society group, facilitated by Dr Githinji Gitahi, CEO of AMREF and co-chair of UHC2030, stressed the importance of focusing on people not consumers. As 90% of the population of Erehwon is currently not insured, the civil society of Erehwon focused their attention on this 90%. Civil society is against the commercialization of health which opposes the fundamental right to health and equity. The Government needs to insure these 90% by creating a national insurance pool which could be complemented by the private sector.
They call upon the Government to regulate the private sector and to establish an audit committee. Furthermore, the Government should fight information asymmetry, so that people can make a choice. “Government should increase their expenditure for health to 5% of GDP!” they said, and they will continue to protest in the streets until this is done.
Academia response to Erehwon’s situation
The researchers, led by Dr Elizabeth Mason, Independent Accountability Panel, were worried about the private sector and all their resources only catering to 10% of the population. Research in Erehwon should therefore include a landscape analysis, including the regulatory and legal mechanisms and market-base. Furthermore, they want to look at the real costs of every service, the provider payment mechanisms and the actually quality of care in both public and private sectors. For all these research areas, research from other countries can inform the discussion in Erehwon. “Research informs solutions!” they said.
Government response to Erehwon’s situation
Akaki Zoidze, MP and Chairman of the Healthcare and Social Issues Committee of Georgia, reported on behalf of the government group. Erehwon’s Government recognizes that the regulation vacuum has led to vertical integration and collusion in the health system. The perceived higher quality in the private system is leading to uninsured patients seeking care and thus high out-of-pocket expenditures. Another aspect is the weak self-regulation and ethics of the medical profession and the health insurance.
The Government needs to regulate not only the private sector but also provider-payment mechanisms, and prices and quality standards for both public and private sectors. Furthermore, the Government should address issues regarding information asymmetry and transparency. Erehwon’s Government commits to establishing a public health insurance system and will establish a multi-stakeholder commission for political dialogue.
Concluding remarks included that although the private sector does already make commitments to health, they come mostly from corporate social responsibility strategies rather than the main daily business of the private sector. There is a need to promote another concept of governance that goes beyond accountability to shareholders and profits, towards the social logic of benefiting society and the environment, thereby aligning the incentives of the private and public sector. When it comes to private sector accountability, it is important to hold it accountable to what quality of care they actually deliver as the spectrum of players is vast.
WHO was specifically called on to provide guidance on what works in terms of policy, governance and regulatory arrangements for steering the private sector towards UHC and to actively support countries with this challenging issue. Lastly, it was stressed that there is a lack of trust between the different stakeholders and that CSOs can play a strong role to bring everybody together, including the private sector which also needs to be at the table.
Private sector constituency in UHC2030 – new!
UHC2030 has recently established a private sector constituency within the partnership and will continue to work on private sector accountability, involving all stakeholders including the private sector.
The Independent Accountability Panel (IAP) on “Private Sector: Who is Accountable for Women’s, Children’s and Adolescents’ Health?” said, “The UHC2030 partnership should drive political leadership at the highest level to address private sector transparency and accountability.” It is important to give the private sector a platform to organise themselves around the social logic of UHC and to build trust between all actors.
The news video and the country situation of Erehwon can be found here.