By Shehla Zaidi, Associate Professor of Health Policy & Systems, Aga Khan University, Pakistan and consults as senior health specialist on policy advisory work, Mott Macdonald, UK
When health systems threaten to be overwhelmed by a pandemic, can the crisis catalyse new partnerships across the public-and private sectors, as well as across national-provincial governments for the public good? And can devolved powers provide an agile and impactful response while navigating complex power sharing arrangements?
In decentralised Pakistan, health stewardship is a joint function of national and provincial governments, whereas service delivery relies on mixed health systems. In Sindh, a province of 40 million population, has the highest share of COVID19 cases – 201,080 out of 451,494 cases reported nationally. It’s response, based on public-private partnerships, provides reflections on how private engagement was rapidly escalated and how existing policy windows can be used for longer-term planning for pandemics and Universal Health Coverage (UHC).
Navigating stewardship across federal-provincial authority lines
In the wake of Pakistan’s radical political devolution in 2011, strategic health planning between federal and provincial government has been disjointed at best, and often confrontational . A coherent private sector engagement has been one of many fatalities. The COVID-19 pandemic catalysed advisory relationships with the private sector through both the federal and Sindh task forces for a joint operation response, providing aligned and clear messaging. Digitalised data-sharing of cases and hospital capacity across private and public providers guided federal-provincial procurement. National supply chains were boosted by federal facilitation of domestic private industry. Private expertise was mobilised by federal and Sindh taskforces for quality care protocols.
But beyond a new window of joined-up federal-provincial actions, downstream private engagement also happened in one province. In Sindh, laboratory regulatory licencing was fast-tracked allowing private laboratories to take on 50% of testing requirements. Proactive government negotiations in Sindh secured enough treatment in local private hospitals to meet surge capacity. Private hospitals partnered with provincial government for critical care training of public sector hospitals. Digital partnerships with the private sector in Sindh established virtual triaging platforms, call and referral centres enabling swift hospital cross-referrals, whereas telemedicine consultations from private practitioners supported government quarantine centers. A provincial COVID relief fund in Sind, jointly managed by government and private philanthropies, pooled private-public funding and procured medical supplies.
Drivers for unlocking public-private partnerships
Several factors made these partnerships possible. Common private sector representation in both national and Sindh task forces helped provide consistent messaging. A robust private health market in Sindh, ongoing strategic purchasing initiatives, and presence of government champions resulted in Sindh’s proactive engagement of the private sector. Mutual benefits were seen – the government gained positive imaging, free expertise and critically needed supplementary services/supply chains, whereas for the private sector, the collaborations provided communication pathways out of a crisis, policy recognition, and winning business with other payers.
Unfulfilled stewardship agendas
Experience from the immediate fire-fighting response to COVID-19 also provides important deliberations on what worked less well and what needs strengthening for longer-term public-private solutions for pandemic preparedness and UHC 2030. Strategic purchasing of private inpatient services for the poor was attempted by Sindh at favourable market rates, but private hospitals preferred to tap into ample patient demand at full price, becoming superior negotiators. Reliance on private healthcare for critical surge capacity made the national-provincial governments hesitant to enforce price controls. Existing regulatory support could not counter uneven quality of local supplies and protect essential service delivery. And whereas national-provincial engagement platforms were strengthened, district-based led harnessing of frontline private sector for a continued response has been over-looked.
Transitioning COVID governance towards global health security platforms
So, what’s different about the Pakistan experience? Two important take-aways:
- The Pakistan experience shows that governments are driven to steward new private partnerships when health systems threaten to be overwhelmed – dependency, need for legitimacy, and credible relationships provide a window of opportunity. A pluralistic private sector, on the other hand, more carefully chooses its terms of engagement. The relationships are not always transactional, limited to purchasing arrangements, but comprise wide-ranging formal agreements for co-production.
- Devolved settings can provide an agile and impactful response when there is swift data sharing for national-provincial coordination, common trusted actors across national-provincial power platforms, and well-informed local government champions for mobilizing an inclusive response.
This blog post draws on a World Bank funded Pakistan policy analysis study on Public Private Collaborations for COVID19 Response in Pakistan: Zaidi S, Orr D, Huszar A, Fairfax J, Palmer L. Public Private Collaborations for COVID19 Response: Experience and Lessons from Pakistan, Research Report, Mott Macdonald London, commissioned by the World Bank Washington DC. September 2020.
Image: © Aga Khan University, used with permission