Shaping future health markets: Reflections from Bellagio


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“Engaging with health markets is going to be critical for governments in the future, especially given the recent UN resolution,” notes Sara Bennett, referring to a UN resolution urging countries to work towards affordable Universal Health Coverage (UHC).

Many country governments will need to purchase services from both public and private providers to achieve UHC. At the same time governments need to guard against arrangements that enable powerful stakeholders to consolidate their position in a health system that provides ineffective services at an unnecessarily high cost.

Policy-makers, entrepreneurs, academics and funders convened in Bellagio, Italy, in December 2012 to explore this tension. The result was the Bellagio Statement on the Future of Health Markets (

To broaden the conversation, participants in the Bellagio meeting are holding a roundtable webinar. The webinar will be chaired by Dr Sara Bennett from Johns Hopkins School of Public Health, who convened the session in Bellagio.

Discussants include: Kelechi Ohiri, Senior Special Adviser to the Honourable Minister of State for Health in Nigeria; Kwasi Boahene, Director Advocacy & Program Development at the Health Insurance Fund; and Sikder Zakir, Founder of the Telemedicine Reference Center Ltd. (TRCL); Guy Stallworthy, Senior Program Officer at the Bill & Melinda Gates Foundation; & Dr Allan Pamba, Director Public Engagement & Access Initiatives at GSK.

An initial presentation will help set the scene, outlining the background to the meeting as well as highlighting key points from the resultant statement. Following the introduction, the discussants will offer their reactions to and commentary on the Bellagio Statement. The webinar will then shift to a ‘fishbowl’ format, where the speakers and other participants at the meeting will have an open discussion on some of the main topics from Bellagio. The webinar will wrap up with a question and answer session for all.

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Shaping future health markets: Reflections from Bellagio

  1. 1. #healthmktShaping the future of health markets: Reflections from Bellagio An initiative of the Private Sector in Health Symposium
  2. 2. Symposium: Sydney – 6 July 2013• Since 2009 a group of researchers and policy analysts working on health markets in low and middle-income countries have organised a pre-congress symposium at the biennial conferences of the International Health Economics Association• The aim has been to encourage and disseminate high quality research on the performance of these markets and on practical strategies for improving access to safe and effective services by the poor• The Future Health Systems Consortium is responsible for organising the 2013 symposium with financial support from the Gates and Rockefeller Foundations and SHOPS
  3. 3. This webinar series provides opportunities to set the scene before the Sydney meeting and to ensure that those who may not be attending the Symposium have the opportunity toparticipate in debates about strategies for improving the performance of health markets in meeting the needs of the poor.
  4. 4. Webinar series• Facilitated by the Future Health Systems Consortium• Organised by a number of institutes• Publicised widely to involve a wide audience• The next webinar will be held in April
  5. 5. Organisation of webinar• Introduction to the Bellagio Statement on Shaping Future Health Markets (Sara Bennett)• Commentary from: – Dr Allan Pamba, Director of Public Engagement & Access Initiatives, GSK – Kwasi Boahene, Director Advocacy & Program Development, Health Insurance Fund – Kelechi Ohiri, Senior Special Adviser to the Honourable Minister of State for Health, Government of Nigeria – Guy Stallworthy, Senior Program Officer, Bill & Melinda Gates Foundation• Fishbowl discussion• Question and answer session
  6. 6. What future for healthmarkets? Dr. Sara Bennett CEO Future Health Systems
  7. 7. Why health markets?• Health markets are pervasive – Health related goods and services – Sub-national, national and global – Public and private sector actors• Understanding how markets work will enable us to intervene in them better, particularly to protect the poor.
  8. 8. Health markets - The past 20 years• Have learnt much: heterogeneity of private providers, “informal” markets, contracting for services, social marketing• But much still to learn: scaling up effective market interventions, improving quality of services, especially for poor• Increased importance of health markets: due to economic growth, new technologies e.g. ICTs, economic liberalization
  9. 9. Health markets – The next 20 years? Supplier-side • Consolidation to stronger players • Vertical integration Consumer-side Governance-side • New technologies • Push for UHC • Consumer • Public finance for education private providers? • Non-communicable • Oversight diseases Evolving market dynamics
  10. 10. ProcessLandscaping Identification Preparation Bellagio Researchanalysis of key topics of meeting uptake• Document • Regulation of background (December activities review health markets papers 2012) • Bellagio• Interviews with • Networking • Scoping papers • Consultation statement range of providers and literature with diverse • Webinar stakeholders • Learning in reviews stakeholders • Journal special health markets issue • Meeting with HANSHEP
  11. 11. The Bellagio Statement
  12. 12. Strengthen data• Lack of data on health markets continues to plague decision making• Identify key data that health market actors should provide – Require data provision as part of participation in government financing schemes• Pilot a market data platform – that draws together different types of data from diverse sources (eg. DHS, NHA, market research)
  13. 13. Experiment with regulatory approaches• Effective regulation requires bundles of regulatory approaches• Dynamic regulatory approaches are required to respond to dynamic market situations• “Learn and do” – Regulatory experimentation – Real time, rigorous, assessment of effects – Adaptation of strategy – Lessons learned?
  14. 14. Strengthen government stewardshipcapacity• Governments frequently lack appropriate capacities to manage health markets• Develop individual skills and organizational capacity for: Leadership Technical Collaborative Analytical skills – capacity – capacity – skills – to balance to develop to work with to anticipate powerful market civil society, future interests information private developments systems, providers, in health contract out business markets
  15. 15. Sustain investments• Donor funding has supported private sector experimentation e.g. social franchising• Such initiatives – often small scale, but some provide critical services to poor• How will these be sustained going forward?• While initiative seek to develop sustainable models, government financing is key to enabling access for the poor• Needs to be proactive engagement with government on future sustainability
  16. 16. Link market and health worker policies• Connections between health workers and health markets insufficiently acknowledged: –Moonlighting –Migration• Future for community health workers, if governments do not funding their salaries?
  17. 17. Learn about and manage networks• Business models are evolving – greater networking and integration of previously disorganized private providers?• Networks can help to correct failures typical of health markets:- – Informational asymmetries – Facilitate distribution of subsidies• But, networks can also create monopolies and exert political influence
  18. 18. Promote learning in health markets• Better coordination and more consolidated research on health markets needed• Priorities? Effects of New Mobile and information regulatory informational on consumer approaches technologies behavior• Real time learning – need for alternative evaluation approaches
  19. 19. Next steps
  20. 20. Next steps• HANSHEP – knowledge priorities group• Collaborate with developing countries to pilot data collection systems for health markets• Create a challenge fund to support experimentation and learning on health markets• Broaden the debate, in particular including more market actors
  21. 21. Dr Allan Pamba
  22. 22. A shifting global landscape Global economic downturn Market opportunities Donor Developed funding markets Role of African (and other private emerging) sector markets Need to create a vision for future health markets andcreate an enabling environment to support this transition
  23. 23. Challenges and opportunities Challenges Opportunities • Cultural shift towards • Reductions in public private sector sector funding • Alignment on • Rising middle class in approach Africa • Bridging between existing solutions and new markets • Technology and innovations Need strong leadership
  24. 24. Next steps Sharper Catalyse Get health framing of change Supporting higher on the issues through emergent government that need targeted innovation agenda addressing support
  25. 25. Dr Kwasi Boahene
  26. 26. Context• Health care is a public good and it is the primary responsibility of governments to ensure that proper care is provided to their citizens.• But, sub-Saharan African (SSA) countries have a chronic lack of resources for health care.• Thus, supporting and involving the private sector in the delivery of health care to achieve universal health coverage (UHC) is complimentary.• The weak States and the large informal sector that characterize SSA means that rights and laws are not consistently enforced.
  27. 27. Contributions of the BellagioStatement• Must understand market dimensions, where supply and demand apply and citizens make choices.• Addressing failures in health markets can help minimize financial risks and improve the capacity to deliver quality.• Availability of data and effective analysis will improve the functioning of health markets.• A transnational, cross-sectoral community of practice can be reinforced by initiatives that support capacity building, policy making, research and the development of business models at local-level.
  28. 28. Conclusions• Government and donor countries should recognize the need to stimulate trust and investment, and avoid crowding out.• The private sector is important in the delivery of health care.• Access to capital and technical assistance is vital to improving quality of care.• Promotion of public-private partnerships (PPPs) in health care development is key.• The group in Bellagio overestimates the importance of „development partners‟ in the development of healthcare markets.• Discussions on the healthcare package for UHC should be central to initiatives and policies for developing health markets
  29. 29. Dr Kelechi Ohiri
  30. 30. Outline• Overview of the health sector• Addressing market constraints• Perspectives and moving forward
  31. 31. Nigeria is a federation with 6 zones spanning 36 states and a diversepopulation of over 160 Million people … Region/state map of Nigeria Sokoto Population in mn (3.6) Katsina ▪ Constitutional structure (5.7) Jigawa is a Federal system Zamfara 4.3 (3.2) Kano Yobe Borno with 36 states, 774 Kebbi (2.3) 9.3 (3.08) (4.1) LGAs and 9,565 wards Kaduna Bauchi Gombe ▪ The Federal 6.0 (4.6) (2.3) Constitution divides Niger (3.9) Adamawa responsibility for FCT Plateau (3.1) healthcare across the Kwara Abuja (3.1) (2.3) (1.4) Nassarawa three tiers of Oyo (5.5) (1.8) Taraba government Ekiti Kogi (2.3) Osun (2.3) (3.2) Benue ▪ (3.4) (4.2) Ogun (3.7) Ondo (3.4) Enugu The 1999 Constitution Edo Lagos (3.22) Anam- (3.2) Ebonyi placed „Health‟ on the (9.0) bra Cross (4.1) (2.1) river concurrent list with no North west (35.8) Delta Imo Abia (3.9) (2.8) North east (18.9) explicit delineation of (4.0) (2.8) Akwa North central (18.8) responsibilities Bayelsa (1.7) Rivers (5.1) lbom (3.9) South east (21) amongst tiers of govt South South (16.4) South west (27.5)SOURCE: Nigeria Population Census 2006
  32. 32. There is a call to action to address health systems and structuralchallenges, unlock the market potential of the private health sector ▪ High maternal, newborn and Expected vs actual level of engagementSuboptimal child mortality rates with private sectorhealth ▪ Inequalities in health outcomesoutcomes and utilization ▪ Poor quality of health care services in public and private facilities ▪ ~23,000 health facilitiesMixedhealth ▪ Private sector accounts for 50% of healthcare service provision. Business environment in Nigeria vs SSAsystem average It is fragmented; variable quality 938 644Insufficient ▪ Health insurance coverage is 457 317protection minimal. Most payment remains 31 44 79 96from out of pocketfinancial ▪ National health insurance Time to enforce Time to Time to start prepare and a business Cost of start up (%risk scheme currently covers mainly contract pay taxes (days) of income the formal sector (days) (hours per yr) per capita)
  33. 33. The health sector is currently laden with market failures on the supply and demand side with policy and regulatory constraints ▪ The private health sector is fragmented, dominated by small clinics and Supply side hospitals, that are largely sole proprietorships ▪ Minimal scaleable platforms across the healthcare value chain ▪ Poor quality of care in facilities, inadequate health workforce and frequent stock outs of essential commodities ▪ Most private health institutions are unable to qualify for regular bank Demand side loans / investments, due to little financial / business management and planning capacity among the majority of private health sector organisations ▪ High cost of capital / hurdle rates for loans to the health sector Public sector ▪ Inadequate organisation among private providers engagement ▪ Minimal formal engagement with the public sector ▪ Limited organised advocacy platforms for communicating with policy makers ▪ Current regulations do not actively foster private health sector Regulation and development. institutions ▪ Common challenges faced include, but are not limited to the following: 1) lack of enforced and enforceable quality standards; 2) constraining regulations; 3) Bureaucratic bottlenecksSOURCE: Interviews, consultations with the private health sector
  34. 34. However, there are opportunities to unlock the market potential of thehealth sector by addressing critical constraints and shaping the market1 ▪ Review of fiscal and monetary policies that affect the health sector; Fiscal policy including import duty and tariffs of medical equipment, drugs & consumables; tax regimes and other duties2 ▪ Development of quality of care standards and accreditation system Regulatory ▪ Review/clarify on regulations to provide consistent interpretation environment ▪ Strengthening the regulatory framework of NHIS3 ▪ Innovative financing for health investments such as a healthcare Access to intervention / investment fund; healthcare bond; capital ▪ Capability building for business and management skills in the sector4 ▪ Revise Healthcare PPP Policy Model ▪ To develop private sector led model PPP transactions that could yield investment demonstrable and visible impacts in the health sector projects5 Engaging ▪ Activate the Nigeria Private Sector Health Alliance to mobilize business broader private leaders towards a multisectoral approach to improving health outcomes sector
  35. 35. Bellagio meeting proved to be timely and relevant and the output of the meeting should be taken forwardPerspectives Steps for moving this forward ▪ Most of the issues were familiar and very ▪ Research agenda toIssues relevant to the country contextresonated generate evidence on ▪ Need for clarifying and framing the issue health markets ▪ Health markets are complex adaptiveWhen not systems, evolving with pressures on ▪ Country „labs‟ for testing regulatory innovationswhat if? governments (Internally – responsiveness; and contextual factors externally – universal coverage). ▪ Governments can either engage now, within the window of opportunity, or play catch up ▪ Community of practice for sharing experiences ▪ Lack of routine data remains a key and learningsInformation challenge and must be addressedis key ▪ Type of data needed from both private and ▪ Link all these initiatives public sector should enhance stewardship to results using function of government accountability frameworks such as ▪ Regulatory innovation/evolution scorecardsInnovation ▪ New business models e.g. networks, low cost models of care ▪ New labor market dynamics
  36. 36. Guy Stallworthy
  37. 37. It is quite possible to believe that... On the one hand… And also…• Healthcare delivery can be • People have a right to decent usefully understood as a health and healthcare services mixed (public and private) • The state is ultimately system that has some responsible for the health of its features of markets: citizens – Transactions • Collective, public or mandatory funding is the most effective, – Interaction of supply and efficient and equitable way to demand finance healthcare (financing ≠ – Customers exercising provision) choices • Market outcomes are usually far – Incentives from ideal; markets are to be• Some things are best done managed by non-state actors • People are not only motivated by profit maximization • Privatization is not an appropriate goal
  38. 38. It is quite possible to believe that... The private health sector is terrible: The private health sector is terrific: it is a large part of the problem. If it: it is a large part of the solution. If it:• Is self-interested and driven mainly by • Is particularly customer-friendly profits, not public good • Is ubiquitous• Is the source of much misuse of • Can do things to unprecedented antibiotics and drug resistance scale• Often exploits ill-informed patients • Is inherently results-based• Routinely misdiagnoses patients and • Tends to be innovative and dynamic provides inappropriate or even dangerous care • Tends to be efficient• Often plunges the poor into financial • Is often opposed for ideological crisis reasons rather than for public health efficiency and effectiveness• Is often promoted for ideological reasons rather than for public health efficiency and effectiveness The opposite of a fact is a falsehood, but the opposite of one profound truth may very well be another profound truth. - Niels Bohr
  39. 39. Submit questionsHow to submit• Via the „Questions‟ box in the GoToWebinar Control Panel• Via Twitter using the hashtag #healthmktBe sure to include your name,organization and locationwith your question!
  40. 40. ‘Fish bowl’
  41. 41. Questions?How to submit• Via the „Questions‟ box in the GoToWebinar Control Panel• Via Twitter using the hashtag #healthmktBe sure to include your name,organization and locationwith your question!