Accountability responses to the spread of health markets
Uranchimeg Tsevelvaanchig, Priya Balasubramaniam and Meenakshi Gautham, all members of the coordinating committee for the Private Sector In Health TWG
We recently attended the Accountability for Health Equity Workshop, 18-21 July 2017, organized by the Institute of Development Studies. In this blog, we share our reflections from this workshop focusing on accountability responses to the spread of health markets, which was one of the themes of this event. National and transnational challenges and responses to the spread of health markets were discussed based on country experiences of Mongolia, China, India, and Brazil.
As characteristics of mixed health systems vary a lot in different contexts, so do the strategies that countries apply to make private health care more equitable and affordable. This is especially true of countries like China, Mongolia and Brazil where the public sector still plays a dominant role, but with increasing participation of the private sector through managed collaborations that still represent several challenges. In India on the other hand, where the private sector has grown exponentially over the last two decades, current challenges call for a different set of solutions. The following country examples presented during the workshop are a starting point for further discussions and explorations of an effective engagement of private health care providers for equitable care.
Government contracting for private care
The government of Mongolia has been contracting for-profit private hospitals as part of the Social Health Insurance Scheme (SHI) - which covers the entire population - since 2005. Dr. Uranchimeg Tsevelvaanchig (University of Queensland, Australia) presented her research, which shows that SHI subsidy in Mongolia has not guaranteed financial protection for patients in the private sector. This is due to patients paying much higher direct out-of-pocket payments in private hospitals than in public hospitals.The vulnerable and financially disadvantaged patients that make up half of the patients who use private hospitals bear the brunt of this financial burden despite insurance coverage.
In contrast, Brazil’s national health care system (known as the SUS) has been contracting with non-for-profit organizations (OSS) for primary health care. A presentation by Dr. Vera Schattan Coelho (Cebrap, Brazil) showed how the Public Private Partnerships with OSS within a universal health system made a significant impact on increasing the access to primary care in poorer areas, and improving quality of care and hospital efficiency. The transparent planning and monitoring, flexibility in human resource management, presence of a wide range of external accountability mechanisms in the SUS played an important role for these achievements. Despite these achievements, as she emphasized, inequalities in health indicators still persist, and require to be addressed in the future.
Need for greater stewardship of private health markets
The mixed health market system in India presents both unique opportunities and challenges for health care access and delivery in India. Chronic underfunding of the public sector and lack of an effective regulatory framework for the heterogeneous private sector has widened inequities in access, affordability and quality of healthcare services in India. Dr. Priya Balasubramaniam (Public Health Foundation of India) emphasized that the neglect of publicly delivered urban primary care in India had given rise to innovative models of care delivery initiated by non-profit foundations as well as for-profit private sector who are trying to focus on providing standardized affordable primary care of good quality. These include franchisee models where municipal primary health clinics have been contracted out to NGO’s and private primary health ‘clinic chains’ catering to the urban middle classes and the ‘working poor’ on a fee-for-service basis. However, these models remain fragmented and cannot compensate in scale and outreach to achieve population wide coverage without public sector investment, regulation and capacity building. The complex dynamics of mixed health markets pose regulatory challenges and governments need to modify and strengthen institutional arrangements to address various partnerships. Strong accountability questions emerge on: When should we regulate and whom do we regulate for in pluralistic health markets?
Dr. Abhay Shukla (SATHI, India) outlined his concerns about the lack of ethics in the formal private health sector in India and described the work that he and his group are doing to increase accountability in the sector. Dr. Shukla is a firm believer in citizen power, and his vision of ‘social regulation’ combines legal regulation with participatory citizen monitoring and self-regulation of the medical profession.
Shifting the focus from formal to informal private providers in India Dr. Meenakshi Gautham (LSHTM, UK/India) raised larger issues of accountability around the inappropriate use of antibiotics in the context of increasing antibiotic resistance. The majority of private providers are unqualified and unregistered, providing allopathic treatments including antibiotics. She described the pharmaceutical industry’s aggressive antibiotic marketing and promoting strategies, the regulatory system’s inadequacies and patients’ limited purchasing capacity as some of the key drivers in this market where informal providers may only represent the tip of the ‘accountability iceberg’.
The role of civil society
Dr. Lijie Fang (CASS Institute of Sociology, China) highlighted that community based social organizations have been playing an increasing role in China in promoting community health, and in managing chronic conditions in the ageing population. Community based organisations enabled and empowered end-users in better managing health conditions as well as to participate in better provision of health services. Examples of community based social organizations included a patient club to promote self-management of health, and a community led health promotion organisation for chronic disease and disability prevention.
Enhanced civil society legitimacy and accountability can be the basis for new models of health sector governance. Global experience suggests that civil society can hold—national governments, private firms, and transnational corporations—to higher standards of performance and health system accountability. Regulatory mechanisms for the health sector across countries were not led by any one actor, but rather brought together a variety of actors and institutions across sectors.