Waiting for Godot: Evidence, The Private Sector, and UHC
Stefan Nachuk, Lead for the Private Sector Health Initiative at UCSF Global Health Group and member of the HSG Private Sector in Health Thematic Working Group, provides his reflections on the recently published Lancet Series on the role of the private sector in achieving Universal Health Coverage.
Some years ago while at the Rockefeller Foundation I commissioned a set of papers on the private sector in health, in an effort to shed light on what was, and appears still to be, highly contested space. One of the most interesting papers addressed attitudes towards private providers by a range of global and national stakeholders, and found that many people have strong feelings about private providers, positive or negative, which appear to be somewhat immutable. However, the current Lancet series on the private sector confirms something we suspected eight years ago — a common working definition of “the private sector” does not yet exist, and evidence regarding the impact of private providers on health systems is fragmented, sometimes contradictory, and definitely incomplete.
After engaging stakeholders and producing papers for a year at Rockefeller, and listening to people reflect on the topic, it finally occurred to me that I was using the wrong paradigm. Instead of public policy, I should have been thinking about this topic as one that frames a political or religious debate — evidence alone is not the only, or even primary, basis upon which individuals arrive at their conclusions. Having said that, many people are creating facts on the ground in countries across the world. Three broader challenges and opportunities are worth noting.
Follow the money: public-private integration through provider payment and contracting channels is being tested or employed already in many countries
A recent World Bank study of 24 countries moving towards Universal Health Coverage (UHC) found that half of the countries already use public or pooled funds to pay private providers, at least to some extent. This does not tell us how equitable or efficient this approach has been, only that it is being employed in wide variety of contexts.
A number of countries have expanded publically financed risk pools in recent years (Ghana, Thailand, China) as a means to expand coverage and improve financial protection, but also to integrate private providers into the system through, at times, publically purchasing services from them. One major challenge to integrating private providers into national health systems is that state officials are not accountable for private providers’ performance. By changing financing arrangements, there is potential to change broader accountability arrangements within the state and between the state and private sectors, as state officials will become accountable for how money is spent. This will be one theme of an upcoming Joint Learning Network meeting in Malaysia in July 2016.
Service quality in low performing systems is a consistent challenge, and creating islands of excellence within the private sector may have limitations
For example, a well known standardized patient study in India comparing the quality of both public and private provision found that neither were close to providing minimally acceptable quality of care in most interactions with mystery clients.
Efforts to improve access and quality in low-performing systems like Afghanistan or Cambodia have focused on using donor funds to contract out a significant proportion of health services to private actors. While this may be a logical short-term solution, questions remain regarding to what extent this approach will promote improved overall health system performance over time, or what additional reforms might be necessary. Montagu and Goodman cite Health Equity Funds in Cambodia as a reasonable short-term solution to addressing population level health needs, and creating a foundation upon which the government can rebuild its system. However, as this ODI report on the political economy of health equity funds in Cambodia points out, this approach has achieved short-term gains, but is both heavily dependent on external funding, and does not appear to have, yet, influenced the broader underlying incentives driving the financing and provision of health within the country.
Political commitment is necessary, but windows of opportunity may be just as important
McPake and Hanson cite Indonesia as a place where high level commitment to UHC could make a difference, if sound technical strategies exist, and where private providers are included in the new JKN universal coverage scheme. However, out of the approximately $100 per capita spent on health, only about one quarter of that is spent by JKN at present, with half spent out of pocket, and another quarter spent directly on public providers. In addition, the scheme will be implemented through the more than 400 district governments (of varying capacity). Commitment matters, but pooling and administrative arrangements will likely have to significantly improve before the private sector can be fully leveraged and the scheme can reach its potential.
Another approach is to exploit windows of opportunity that can change the conversation. The RSBY scheme in India purchases services from both public and private providers, in a country where the government has traditionally been reluctant to engage with the private sector. Perhaps most interestingly, this scheme started under the Ministry of Labor because the Ministry of Health and Family Welfare was not open to developing an approach that employed a payer-provider split and included private providers (though private providers constitute as much as 80% of overall provision). RSBY has been far from perfect but, along with the (arguably better designed) state-level scheme Aarogyasri Trust, appears to have changed the nature of the policy debate in India regarding potential solutions to expanding and improving health coverage.
Thus, the call for more evidence, while welcome, may underplay the fact that actors within countries are experimenting in real time to improve health systems performance and leverage the private sector to achieve national health objectives. Postponing critical policy decision until the best evidence is available may be like Waiting for Godot. Within these papers, and the broader literature, some themes and potential ways forward begin to emerge.
