Claire Gapare
The World Health Organization (WHO) with the support of Impact for Health International organized a panel of 6 speakers to share the WHO strategy report on engaging the private health service delivery sector through the governance of mixed health systems at the Global Symposium on Health Systems Research. The Global Symposium on Health Systems Research (HSR) is organized every two years by Health Systems Global to bring together the full range of players involved in health systems and policy research and practice. From 8 to 12 November 2020, the HSR hosted their virtual Sixth Global Symposium on Health Systems Research with over 2,000 policymakers, practitioners and researchers from more than 100 countries. Here is a quick recap on our presentation - Seeing with both eyes - COVID-19 full relief. Engaging the Private Health Service Delivery Sector for UHC.
Vision of the Strategy
David Clarke
Global lead for the institutions and law theme at World Health Organization
The WHO strategy on the governance of mixed health systems defines a clear and compelling vision of a well-governed health system in which public and private actors collectively deliver on the realization of UHC. The mission of the strategy is to build consensus around the means and strategies of engaging the private sector in health care service delivery. This involves a focus on change management through six governance behaviours: build understanding, foster relations, enable stakeholders, align structures, nurture trust, and deliver strategy. In this blog, we will use COVID-19 to show examples that demonstrate the importance of governance of mixed health systems.
Click on a governance behaviour to learn more
Dr. Mark Hellowell - Director, Global Health Policy Unit, University of Edinburgh
Enabling stakeholders entails ensuring formal tools for implementation including incentives and sanctions.
Ms. Maraki Fikre - Private sector in health specialist
Build understanding is achieved through data collection and analysis to align priorities for action and build a shared understanding of the challenge and solution.
Fostering relations means building and sustaining partnerships and coalitions via regular communication and a sustainable
dialogue platform.
Dr. A. Venkat Raman - Professor, Faculty of Management Studies, University of Delhi
Aligning structures entails aligning policy, legal and institutional framework and organizational units with partnership agreements to engage with the private sector.
Ms. Robinah Kitungi - Executive Director, Uganda National Health Consumers Organization
To nurture trust is to understand the factors that promote or hinder accountability environments, and ground accountability agendas in diagnosis and dialogue.
Dr. Tryphine Zulu - Senior Manager at the Government Employees Medical Scheme in South Africa
To deliver strategy means to formulate policy direction by designing interventions that harness the private sector for universal health coverage.
Enable Stakeholders
Dr. Mark Hellowell
Director, Global Health Policy Unit, University of Edinburgh
The first governance behaviour was addressed by Dr. Mark Hellowell. Enabling stakeholders entails ensuring formal tools for implementation including incentives and sanctions. The objective of this is to create an institutional framework that recognizes the autonomy of public and private actors as well setting rules by defining what each health actor must do, how they must do it and, for who.
Analysis from eight African countries (Nigeria, Cote D’Ivoire,
Morocco, Ethiopia, Congo Brazzaville, Kenya, Uganda, Sudan)
An online survey of individual healthcare businesses and representative bodies in eight African countries and a comprehensive document analysis was conducted in July and August 2020. Findings from this analysis showed that service availability, staffing and the financial sustainability of private providers have all been seriously compromised by the pandemic. The key causes for this include government restrictions on health care delivery during the crisis, and reduced demand for services from the population. As a result, reductions in private sector capacity has limited the population’s access to and utilization of (a) COVID-19 related services; and (b) other essential services. The government responses to this vary but only countries with ‘inclusive’ governance regimes have been able to move beyond targeting symptoms to address ‘root causes’. This data shows that how whole health systems, public and private sectors are enabled makes a big difference to the nature and scale of such problems, their impact on core health system goals of access/ utilization - and the ‘toolkits’ available to address them.
Build Understanding & Foster Relations
Ms. Maraki Fikre
Private sector in health specialist
Ms. Maraki Fikre spoke on these two governance behaviours using the successful application example of Myanmar. Build understanding is achieved through data collection and analysis to align priorities for action and build a shared understanding of the challenge and solution. Fostering relations means building and sustaining partnerships and coalitions via regular communication and a sustainable dialogue platform.
Country example: Myanmar
Building Understanding
At the start of the year 2020, the Ministry of Health and Sports (MOHS) appointed the Myanmar Academy of Medical Science (MAMS), a senior group of retired healthcare practitioners to serve as a bridge between the public and private sector. MAMS partnered with the World Bank/Global Financing Facility (GFF) team, to guide and provide technical assistance and develop a sustainable strategy and action plan for private health sector engagement. Together, they started a landscape assessment of private health sector actors. When the pandemic struck in March 2020, the existing national public-private dialogue (PPD) platform was refocused for the COVID-19 response. Prior to initiating the country’s COVID-19 PPD, the GFF team shared different country experiences on private-public partnership models addressing COVID-19. Using this evidence and based on their collective understanding of the government’s needs and private sector’s resources and capabilities, the PPD partners agreed to focus on three partnership areas – COVID-19 clinical treatment, testing, and procurement of supplies. Meeting minutes were documented and circulated among all members to ensure transparency and accountability. All actors agreed to share data to better inform decisions.
Foster Relations
During the COVID-19 PPD, the PPD stakeholders were intentional about improving their working relationships by agreeing to meet every week. They enthusiastically participated in all the planning meetings and even scheduled additional ones. For three weeks the PPD partners were involved in a series of intense meetings, “side” conversations, Viber group chats, and phone conversations. The informal interactions helped build trust and establish new working relationships based on a better understanding of each other. Also, MAMS and GFF played a mediator role as the honest broker, helping to resolve any conflicts that arose.
Align Structures
Dr. A. Venkat Raman
Professor, Faculty of Management Studies, University of Delhi
Dr. A. Venkat Raman presented on this governance behaviour showcasing how India was able to align different structures in the pandemic response. Aligning structures entails aligning policy, legal and institutional framework and organizational units with partnership agreements to engage with the private sector. It also means ensuring that communication channels are established, relevant stakeholder groups are mobilized, regulatory and governance arrangements are put in place to work more efficiently to gain optimum benefits from partnerships.
Country example: India
Most provinces in India do not have formal structures or institutionalised mechanisms to dialogue and engage with the private health sector. When COVID-19 struck, governments across the country struggled to establish necessary systems and structures to communicate and engage with the private sector, which is evident even today. Expertise or strategies to influence collaboration with the private sector was limited to a few schemes. However, over time governments managed to align some structures for collective action. While leveraging the private sector in response to the COVID-19 situation, the government may explore aligning structures in eight broad areas. These are (i) Planning and Coordination; (ii) Screening and Diagnosis; (iii) Hospital Treatment (COVID-19 and Non-Covid Cases); (iv) Ensuring Supplies; (v) Mobilising Human Resources; (vi) Leveraging Information and Communication Technologies; (vii) Creating Social Safety and Community Mobilization, and (viii) Mobilising Funds and Private Sector Resources.
During Planning, the government was able to coordinate with both the public and the private sectors to map all health sector infrastructure and resources such as ventilators, ICU beds, etc. High powered task force dedicated to private sector collaboration was created. Nearly half of the labs impaneled for COVID-19 testing in India are from the private sector. Private sector resources were repurposed e.g. the ministry of textiles for PPE, to support government efforts. The government also extended short-term credits, rapid research grants, facilitating rapid licensing and technical capacity building to the private sector. Dedicated COVI-19 facilities were categorized into 3 levels depending on the severity of the cases. Health facilities of other ministries, public and private sector companies helped augment capacity expansion. Additional human resources were augmented through temporary contracting, reemployment of retired, and deployment of post-graduate students. Temporary accreditation of a number of private hospitals helped to increase bed capacity. In some provinces, telehealth resources were deployed to screen potential COVID-19 cases. The government also encouraged over 90,000 civil organizations to apply for grants in the form of aid (food, shelter) to provide relief to affected populations. An exclusive COVID-19 fund was created. Development partners offered support for vaccine development. Today there are three candidate vaccines in India.
Nurture Trust
Ms. Robinah Kitungi
Executive Director, Uganda National Health Consumers Organization
This governance behaviour was addressed by Ms. Robinah Kitungi using Uganda as an example. To nurture trust is to understand the factors that promote or hinder accountability environments, and ground accountability agendas in diagnosis and dialogue.
Country example: Uganda
In an effort to build trust and promote accountability the Ugandan government developed a Public Private Partnership for Health(PPPH) Policy that provides a platform for engagement across all levels of the health sector. Through all the national and district structures the private sector participates in policy development and ensuring accountability for the delivery of health services. The Uganda Healthcare Federation (UHF) has a direct working relationship with the government as a member of the National Health Policy Advisory Committee and is the Chair of the PPPH Committee. The private sector via UHF is a member of the National COVID-19 Response Taskforce – is participating in the COVID-19 Case Management and Risk Communication pillars. It is also represented on the National Response Fund Group and Chair of the Health Committee on that platform. The government and private sector are also working with the Global Financing Facility to adopt the health worker training to the private sector to build capacity of lower-level providers such as drug-shops, dental and maternity units, among others. So far 400+ health professionals have been trained in COVID-19 case management. There are still challenges and a need to increase transparency and sharing of resources between the public and private sector. For Uganda, the best way to engage is to continue to build on the trust that has been demonstrated by the government.
Although the Ugandan government has demonstrated good faith in terms of inclusiveness, there are challenges with transparency. Government sharing resources remains a challenge. For instance, there has not been financial resources from the private sector to address the shortage of supplies such as personal protective equipment (PPEs), reagents and contact tracing capacity, space for isolation.
Deliver Strategy
Dr. Tryphine Zulu
Senior Manager at the Government Employees Medical Scheme in South Africa
Finally, Dr. Tryphine Zulu spoke on this governance behavior using South Africa to showcase its successful application. To deliver strategy means to formulate policy direction by designing interventions that harness the private sector for universal health coverage. The objective is to have an agreed sense of direction and articulation of roles and responsibilities.
Country example: South Africa
For South Africa to deliver on this strategy in relation to COVID19, there needed to be an agreed sense of direction, articulation of roles & responsibilities, and openness to change for a mixed health system that includes the private sector. In South Africa, there was an existing framework of public-private engagement through the National Economic Development and Labour Council (NEDLAC). NEDLAC is a statutory body which is governed and mandated by The National Economic Development and Labour Council Act, Act 35 of 1994. It comprises representatives from the government, organised labour, business and community representatives. In addition, the president convened the Presidential Health Summit compact earlier on in 2018. Its aim is to strengthen the South African Health system towards an integrated and unified health system by bringing together all health sector stakeholders coordinated by the office of the presidency. This level of attention given to the health sector with its traditionally dual service delivery approach demonstrated the government’s acknowledgment of the challenges of a mixed health system and willingness to bring about integration. Therefore, by the time the pandemic struck, these behaviours of public-private engagement and working together had been established and were tested and found solid as shown by the effective COVID-19 response mounted by the country as a whole. The country rallied together on solidarity principles with business and private individuals coming together with the government to provide funding and expertise in response to the pandemic. One entity, Business4SA, emerged as a force for change and action bringing together expertise from the private sector working together with the Ministry of Health to: -
Scale-up testing across both the public and private sectors
Securing medical equipment such as PPE and Oxygen Concentrators and quality assurance thereof
Coordinating the funding instruments.
Developing a common database providing visibility of resources across public and private healthcare sectors.
COVID-19 modeling and analytics to inform progress on the progress.
The pandemic happened at a time when the purchasing of services by the government such as hospital beds from the private sector had not been refined and not fully fledged. In this regard, the Government Employees Medical Scheme (GEMS) assisted the Ministry of Health by providing information on tariffs. GEMS is a health Insurance Fund set up by the government to provide health insurance cover for State employees.
To complement these objectives, there was the promulgation of enabling legislation and clear policies for effective oversight. The regulations were centered on enabling access to care such as Prescribed Minimum Benefits for COVID-19 to protect privately insured citizens, regulations against price gouging, and easing of regulations to allow negotiation between purchasers of health services and providers such as pathology labs by the Competition Regulator.
Conclusion
This panel demonstrated that in order to move away from two parallel universes and achieve a single health system there is a need for far more regular, structured, and closer collaboration. The WHO strategy on mixed health systems will guide and support member states in the strengthening of governance behaviours to assure private and public actors work together to drive UHC in ways that promote equity, access, quality and, financial protection for the population and collectively deliver on the realization of UHC.