Until now, research on the private health sector has been seen to be of modest relevance to global health strategies. Our Private Sector in Health Thematic Working Group symposia have focused on demonstrating the significance of the private sector as an important source of health care, mapping the complex reality of pluralistic health systems and presenting the results of relatively modest interventions. This needs to change as governments are becoming increasingly interested in the contribution that non-state actors can make towards their Universal Health Coverage (UHC) strategies. This was the major conclusion of a brainstorming session – entitled ‘Engaging with the private sector for UHC: what we have learned’ – that the Private Sector in Health Thematic Working Group organized at the Fifth Global Symposium on Health Systems Research.
A changing health ecosystem
In many countries, the development of pluralistic health systems was a response to the absence of a clear policy framework. This resulted in highly fragmented systems, which provide services of varying quality. Many governments have recognized the importance of the private sector and they are making major policy changes. For example, a number of countries are introducing national health insurance schemes that reimburse private actors. Many are also establishing a variety of public-private partnerships. Others have been managing a transition to a market economy, which has substantially altered the institutional arrangements within which the health system is embedded. These policy initiatives are changing the health ecosystem and its influence on the private sector. If they are not based on a good understanding of the structure of local health markets, they can produce undesirable outcomes. For instance, health insurance can lead to increases in the cost of medical care and problems with quality, if effective arrangements for regulation and strategic purchasing are not in place. The speed of change and the need to build appropriate institutions quickly is creating new challenges for governments, health service providers and other stakeholders. Researchers can make a big contribution towards addressing these challenges by identifying problems that emerge early and providing evidence about what works well.
The emergence of new private health providers
We also discussed the influence of new technologies, including low cost diagnostics and information and communication technology, in enabling new types of organization to emerge as providers of health-related services. These have the capacity to disrupt the health sector by offering new approaches for making evidence-based medical care available to all. But, the outcome, in terms of equity of access to services and the degree to which these services are safe, appropriate and affordable, will be strongly influenced by institutional arrangements in the health sector. This is another important research priority: to identify approaches for accelerating the emergence of technological innovations and for integrating these innovations into new kinds of partnership for health service delivery and to identify emergent problems that governments will need to address through strengthening regulation.
What approach should governments take?
Our discussions identified a number of factors that governments need to take into account as they build their capacity to be effective stewards of a pluralistic health systems.
They need to:
- ensure that governments and health insurance schemes have the capacity to function as effective purchasers of services;
- take into account local realities and the complex markets that exist in both rural areas and rapidly changing urban localities;
- make sure that the experiences of users of health services are taken into account in overseeing health system development;
- establish an effective regulatory regime appropriate to the changing realities and avoid capture by powerful interest groups.
We discussed the limited capacity of government to control a very complex health system and its need to form partnerships with other stakeholders to discourage potentially damaging behavior and reward contributions to achievement of UHC. The establishment of new kinds of partnership for “smart regulation” has great potential for improving health system performance, but there are no blueprints for achieving this.
We also touched on the increasing role of transnational companies in national health systems. These include producers and distributors of drugs and diagnostic devices, health service organisations and IT platforms. Governments need to increase their capacity to regulate their behavior and build effective partnerships with them. They will also need to participate in global efforts to agree to norms of behavior for these organisations.
Areas for further research
We concluded that the agenda for policy-engaged research on the private sector needs to respond to these new realities by supporting experimentation and learning about effective strategies for improving the performance of the private sector in contributing to UHC at scale.
Important topics for research include studies of the political economy of the health sector, studies of local and national health markets and the structure of incentives that providers face and support for governments in building effective regulatory arrangements.
We ended with a discussion of how early actions can help avoid the emergence of increasingly complex and fragmented systems with a complicated political economy that make effective stewardship very difficult. One suggestion was that we learn lessons from countries that have been successful in building effective health services involving public and private sectors. Another was a need to provide support to governments in understanding local health markets and designing interventions for improving their performance in meeting needs.
There is clearly a pressing and exciting agenda for engaged research that will involve people with a wide range of experiences and skills. HSR 2018 marked a turning point in research on the private sector in health. Now the major work begins.