Reinventing health systems in fragile states: the role of the private sector
By Barbara Profeta of the Health Systems in fragile and conflict-affected states (FCAS) TWG and Priya Balasubramaniam of the Private Sector in Health (PSIH) TWG.
By 2030, approximately 80% of the world’s poorest will live in situations characterised by fragility and conflict. To achieve Universal Health Coverage (UHC) the international community must recognise the role of promising local private sector initiatives and capitalise on their efficiencies. This blog is a brief recount of a series of discussions and events on the role of the private sector in fragile states held by the PSIH and FCAS TWGs in 2018 and 2019.
Context matters
The concepts of ‘fragility in states’ and ‘engagement with the private sector’ in delivering public goods has increasingly gained traction – though at different times and through separate siloes of literature and research in health systems capacity building. However, these two streams of independent research have only recently started to realise that, together, they pave the way in re-imagining how country health systems could be better understood, (re)structured and supported in times of social, political and economic transition.
Much of this thinking has been initiated by health system actors and practitioners from the “global south”, who are operating in fragile country contexts and in countries with mixed health systems. In these settings, the failures of the formal public health system and/or governance structures have called for creative and resilient alternatives. Many interventions have come from a diversity of non-state actors both profit and non-profit. These include non-traditional health providers like technology innovators, social entrepreneurs, informal providers and private equity social impact funds.
The debate about the role of the private sector in contributing to health systems has taken a promising direction in going beyond big pharma, tertiary hospital chains, and medical devices. However, many questions emerge around the forging of new kinds of partnerships between the state and the private sector, accountability and transparency issues, the politics of corruption, regulation of data and the long-term sustainability of such unconventional partnerships. Research in this direction is still emerging, yet essential to inform policy, design and delivery of these evolving health systems.
The private sector’s unique features
The PSIH and FCAS TWGs organised a number of recent debates in Africa and Asia, including at important events including the Sankalp Forum, the Africa Health Business Summit, Asia-Africa Innovations for UHC Conclaves and the Africa Health Agenda Summit (AHAIC 2019). These highlighted some unique features that make the private sector better equipped to operate in complex environments with unreliable institutions and governance, including:
- risk-taking reflexes
- ability to deal with uncertainty and informality
- adaptability to demand-side health service needs
- flexibility to tweak or adapt interventions, services and technologies to suit geographic, demographic and population needs.
Increasing numbers of providers in fragile and low resource settings engage in improving health services access, quality and affordability without the “profiteering logic” usually associated with private sector engagement and incentive.
AHAIC 2019 concluded, for example, that local entrepreneurs and businesses are particularly successful in tailoring services. Trust, proximity, and empathy are a few qualities attributed to local private providers that outweigh the associated costs when people are choosing healthcare. In many cases, the local private sector is a pioneering platform for the use of mobile technology-based interventions in fragile states, where solutions need to be highly localised and adaptable.
Learning from newer heath system dynamics
The HSG webinar on ‘Delivering UHC in Frontier Economies: The role of indigenous businesses in strengthening health systems’ organised in September by the PSIH and FCAS TWGs attempted to further the debate. Panellists stressed that, despite the ambitions of the SDG agenda for increased stakeholder collaboration and the growing acceptance that health systems need to be patient-centred, global scrutiny in health remains biased towards the for-profit sector and unorthodox approaches and actors in health sector capacity building.
The experience gathered from the events listed above, and testimonies provided by webinar panellists, suggests that FCAS are emblematic of health system environments that allow “unusual” health sector actors to provide interventions to vulnerable communities in the absence of a strong and credible government. Despite ‘fragility’ being a temporary state debates increasingly acknowledge that newer heath system dynamics generated by the private sector in conflicted times time tend not to disappear during reconstruction phases nor beyond.
The research and practitioner community must begin viewing FCAS as a starting point for reinventing more inclusive, patient-based, unique health systems that include and embed the creative enterprise that private sector brings. Health system debates should not only consider the diversity of private sector actors but actively involve them in consultations and policy platforms by creating a more balanced approach to private capacity in delivering public goods. In FCAS particularly, utilisation of private care is far bigger than what formal health systems assessments are ready to admit and these actors are often de facto the preferred healthcare option for many “last mile” patients around the world, so why ignore it in health systems policy?
What can we do next?
There is renewed interest in better understanding the role of non-state actors in the design of present and future health systems and agreement on the need for the public and private sectors to reconcile their mutual prejudices and work on mutual trust. However, key questions emerge such as how these partnerships should evolve, participation of the private sector in policy debates, and how it can contribute to health equity. This drives home the larger point that much more research and evidence is needed in this vital thematic area of health systems research.
In February 2020, the PSIH TWG will bring together private sector practitioners, academia and policy makers for an Un-conference on Unlocking Private Enterprise for Public Good -Building Future Health in Beirut, Lebanon. This meeting will be used to further the PSIH TWG’s agenda of better understanding, documenting and better regulating different aspects of the private sector in health systems – and to build partnerships between researchers, governments and private actors for engaged research and priority setting for UHC.
In a call for ‘narrative justice’, many of the indigenous health businesses and non-state providers operating in frontier economies have requested that a different story about health systems in FCAS be told. This new discourse should begin from gathering the right data from the right sources – giving more credit and voice to concrete facilities, professionals, outlets, promoters of local initiatives that not only struggle on a daily basis but also achieve little steps in the direction of UHC with their own unorthodox (at times), but efficient means of getting there. In the research community, colleagues have come forward suggesting the elaboration of a taxonomy of the private sector to try and capture the diversity of actors falling into this broad group, as well as their added value within the different aspects of a health system. Reconciliation always begins from mutual understanding.
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Image credit: Caitlin Mazzilli
