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Private Sector Engagement for Universal Health Coverage.pdf

A session that was delivered as part of Egypt's Health Systems Flagship Course that was delivered in December 2030 by the World Bank.

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1
Session 7:
What can be the role of private sector service
delivery?
World Bank Health Systems Flagship Course:
Building Health Systems for the Future
December 3-7, 2023
Cairo
Alaa Hamed
2
3
Outline
Part I
• Alignment of Private Sector Engagement With the Goals of
Universal Health Coverage
Part II
• Understanding private provision in the health systems of low-
income and middle-income countries
Part III
• Managing the public–private mix to achieve universal
health coverage
4
Part I: Alignment of Private Sector
Engagement With the Goals of
Universal Health Coverage
5
What is the private sector
• The “private sector” refers to the totality of privately owned
institutions and individuals providing health care, including
private insurers.
• In LMICs, large, poorly documented, very heterogeneous; in
some largely serves better-off people; in others, many poor
rely on private provision.
• Operate for profit, many non-profit organizations also exist.
The Lancet, Universal Health Coverage: markets, profit, and the public good, 2016
6
The private sector’s role in health care is growing
Offers solutions to problems
• health fiscal space constraints
• increases in disease burden
(noncommunicable diseases)
• demographic shifts including
ageing
• population displacement
• political and economic instability
Offers access to
• greater service capacity
• more managerial expertise
• higher quality of services
• technology and innovation
• investment and funding

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Private Sector Engagement for Universal Health Coverage.pdf

  • 1. 1 Session 7: What can be the role of private sector service delivery? World Bank Health Systems Flagship Course: Building Health Systems for the Future December 3-7, 2023 Cairo Alaa Hamed
  • 2. 2
  • 3. 3 Outline Part I • Alignment of Private Sector Engagement With the Goals of Universal Health Coverage Part II • Understanding private provision in the health systems of low- income and middle-income countries Part III • Managing the public–private mix to achieve universal health coverage
  • 4. 4 Part I: Alignment of Private Sector Engagement With the Goals of Universal Health Coverage
  • 5. 5 What is the private sector • The “private sector” refers to the totality of privately owned institutions and individuals providing health care, including private insurers. • In LMICs, large, poorly documented, very heterogeneous; in some largely serves better-off people; in others, many poor rely on private provision. • Operate for profit, many non-profit organizations also exist. The Lancet, Universal Health Coverage: markets, profit, and the public good, 2016
  • 6. 6 The private sector’s role in health care is growing Offers solutions to problems • health fiscal space constraints • increases in disease burden (noncommunicable diseases) • demographic shifts including ageing • population displacement • political and economic instability Offers access to • greater service capacity • more managerial expertise • higher quality of services • technology and innovation • investment and funding
  • 7. 7 Private sector engagement involves risks For-Profit Providers, usually, not properly managed or regulated, could threaten UHC objectives of equity and quality • Abuse of market power (market skimming, monopolistic behavior, predatory pricing), • Unresolved conflicts of interest, regulatory capture Not-for-Profit Providers, many aligns well with UHC • How to harness the efforts of the not-for-profit private sector • Incomplete information about the not-for-profit providers, lack governance tools to help align the activities of these providers with national systems and priorities WHO. The private sector and universal health coverage, April 2019
  • 8. 8 A public policy vacuum exists regarding role of the private sector for UHC • The private sector could pursue own objectives, may or may not be closely aligned to UHC. • Lack an explicit government policy position on role of the private sector, nor plans to implement public policy on private sector. • No consensus among domestic stakeholders, including health systems users and civil society groups, about the role the private sector should play in health WHO. The private sector and universal health coverage, April 2019
  • 9. 9 The approach to managing, engaging the private sector as part of efforts to achieve UHC. • First, formulate domestic health goals, priorities; formulate public policies about role of private sector for UHC. • Second, • Align work of private sector with the goal of achieving UHC. • Choice and implementation of public-private UHC policies to be informed by understanding the different private sector actors that operate in a country. • Engage in multistakeholder dialogues to establish policy on the private sector and UHC. • Third, implement a mix of legal and financial regulatory tools to manage the private sector and steer efforts towards achieving UHC. WHO. The private sector and universal health coverage, April 2019
  • 10. 10 1. Incorporate UHC principles, including to leave no one behind, into our business 2. Deliver innovations that respond to the needs of all people including underserved populations, and make these safe, affordable, accessible and sustainable 3. Help strengthen the health workforce, responding to local context, priorities and needs 4. Contribute to efforts to raise the finance available for UHC 5. Champion and engage in multi-stakeholder policy dialogues that advance UHC
  • 11. 11 Part II: Understanding private provision in the health systems of low-income and middle-income countries
  • 12. 12 The Lancet, Universal Health Coverage: markets, profit, and the public good, 2016
  • 13. 13 The private sector can only be understood and effectively regulated by understanding the mixed health systems of which it forms part. • Identify and ensure appropriate roles for private providers and for health markets. • Better understand characteristics and key patterns of the private sector within the health system.
  • 14. 14 Metrics for understanding private sectors in mixed health systems • The private share in total health expenditure (Demand) • The private share in primary and secondary care episodes (Supply) • The extent of reliance of the public sector on private fee payment (Commercialization)
  • 15. 15 Five types of private sector in mixed systems • A dominant private sector (India and Nigeria), high private spending, high share of supply, high public fees • A non-commercialized public sector and complementary private sector (Sri Lanka and Thailand), moderate to low private spending, moderate share of supply, very low or no public fees • A private sector at the top of a stratified system (Argentina and South Africa), high private spending (insurance), substantial supply, low public fees • A highly commercialized public sector (China), high spending, small share of supply, high public fees • A stratified private sector shaped by low incomes and public sector characteristics (Tanzania, Ghana, Malawi, and Nepal), high but declining spending, substantial share of supply, varying reliance on public fees
  • 16. 16 Key Features of Private Sector in Mixed Health Systems • When private sector dominates, the poor struggle to access fee-for- service care, generally of low quality • An insurance-funded private sector at the top of a stratified system reinforces inequality, might display cost escalation • A dominant, highly commercialized public sector constrains private provision while excluding the poor • A reasonably competent, highly accessible public sector can generate a complementary, reasonable-quality private sector, can reduce both exclusion and reliance by the poor on low-quality private providers
  • 17. 17 Performance of the private healthcare sector: Quality • Service quality is better in the private sector than in the public sector. • By contrast, technical quality seems to be inferior to public sector, although public sector services could also be of a low standard. • Where a strong public sector and a complementary and better-regulated private sector are present, quality of private practitioners was close to that of public practitioners.
  • 18. 18 Performance of the private healthcare sector: Equity • Most private services are funded directly out-of-pocket, the wealthy more likely use private providers. • Gaps in public provision results in the poor people using private providers; usually of low quality, delivered by unqualified providers, however accessible. • The convenience, accessibility and affordability of small private providers compared with public alternatives make them attractive to patients. • Lack of effective regulation exposes the poor to inadequately qualified practitioners providing low-quality care.
  • 19. 19 Performance of the private healthcare sector: Efficiency • Private treatment results in high service costs, use of potentially unnecessary and expensive procedures, potential inefficiency. • No clear benchmarks of quality, largely at mercy of private prescribing. • Delays in diagnosis due to lack of linkage between sectors, further contributing to higher prices for users. • Absence of referral linkage between sectors and within sectors, repeated diagnostic investigations, information not passed between providers, high costs and low efficiency.
  • 20. 20 Implications for universal health coverage • Requires health systems that maximize health outcomes, equitably and progressively distributes good quality, financially and geographically accessible services delivered efficiently, low levels of out-of-pocket expenditure. • Need to understand factors influencing the overall performance of a health system, how these factors interact. • Changing the performance of the private sector will need interventions that target the sector as a whole, not individual providers.
  • 21. 21 Key Messages 1. The private sector in health is strongly influenced by, and also influences, the public sector 2. A reasonably competent, highly accessible public sector can generate a complementary, reasonable-quality private sector 3. The crucial policy question about the private sector is not its performance in isolation, or relative to the public sector, but the extent to which it supports or detracts from progress towards universal health coverage. 4. Deriving population benefit from the private health-care sector will require interventions that target the sector as a whole, rather than individual providers alone.
  • 22. 22 Part III: Managing the public– private mix to achieve universal health coverage
  • 23. 23 Four Approaches for engaging with private providers to address market failures: • Prohibition of private practice; • Constraint of its operation through regulation; • Encouragement and subsidy of private sector delivery for specific services; • Purchase of services from the private sector Approaches for Private Sector Engagement
  • 24. 24 Approaches for Private Sector Engagement - Prohibit • A formal ban on some or all forms of private practice, requires social support, sufficient regulatory and enforcement capacity, or both. Difficult in low income countries. • Bans on practice by unlicensed providers, never eliminated, practice undercover • Successful bans are rare in LMICs; documented in strongly controlled socialist economies, reversed as economies open.
  • 25. 25 Approaches for Private Sector Engagement - Constraint Statutory constraints in health care • Controls on quality of facilities, human resources, medicines, equipment, through licensing facilities, registering health workers, products. • Counter monopoly power of providers Self-regulation by professional organization • Assess performance, provide public information about provider quality • Accreditation Consumer-based regulation • Consumers sue providers for adverse experiences and outcomes
  • 26. 26 Approaches for Private Sector Engagement - Encourage Positive incentives to increase access or improve quality • Training to private providers, encourage use of standard treatment guidelines • Social marketing of commodities, create demand for products of high public health value • Social franchising, for more complex services, link private providers in a network under a common brand • Targeted tax incentives to encourage investments or reduce end-user prices, offering subsidies to potential clients
  • 27. 27 Approaches for Private Sector Engagement - Purchase • Contract for narrowly defined services • Leverage private funds for initial infrastructure investments to expand capacity faster than government funds alone allow. • Fill a specialized need through private expertise, allow more rapid expansion of service provision. • Contract for primary-care provision in a defined geographical area, common in fragile and post-conflict states • Indirectly purchase services by providing vouchers to users
  • 28. 28 Four stylized private provider types on the basis of the three dimensions • Objectives (for-profit or non-profit), • Size of organization • Quality (proxied by qualified or unqualified front-line staffing) • Low quality, underqualified sector • Not-for-profit providers • Formally registered small- to-medium private practices • Emerging corporate commercial hospital sector
  • 29. 29 Key Characteristics • Low-quality, underqualified providers. A publicly financed health service can crowd out the low quality element of the private sector • Non-profit providers. Some subsidized to increase access to providers of reasonable quality, some enrich their owners at public expense • Formally registered, small-to-medium private practices. Strategic purchasing offers potential for governments to exert influence over both what is provided, under what contractual terms. • Corporate, commercial providers. Unrealistic to achieve UHC, divert resources from more accessible, cost-effective primary care.
  • 30. 30 Role of Government • Stewardship to ensure public resources serve public interest. Public stewardship matters, not ownership of provider organizations. • Regulation to ensure availability of a core health system, publicly subsidized, reasonably effective, accessible to most population, has a crucial role in management of rest of the system. • Effective Strategic Purchasing to ensure efficiency, adequate quality, fair distribution of services whether through public or private providers.
  • 31. 31 • Provision of a package of publicly financed, universally accessible, basic or essential health services. • Provision of additional services, beyond basic, less cost-effective to offer additional accessibility, additional amenity, could be through supplementary or complementary insurance Role of Private Sector
  • 32. 32 Key Messages • Aim of government policies is to encourage a public– private mix that ensures widespread availability of good quality, affordable care, health system meets the needs of the population as a whole. • Governments’ role is to ensure public resources used for the public’s benefit.
  • 34. 34
  • 35. 35