World Health Summit 2013

Universal Health Coverage: The Role of the Private Sector

Symposium, 22 October

Welcome Address Dirk Schattschneider I Director General for Planning & Communication I German Federal Ministry for Economic Cooperation and Development

DISCLAIMER: This document is not a consensus statement, and should not be viewed as necessarily expressing the individual or collective views of the panellists or organisations associated with this symposium.

RAPPORTEUR NOTES Definitions

The panel began by discussing different definitions of the key terms Universal Health Coverage (UHC) and the private sector. It was debated whether Universal Health Coverage (UHC) should refer not only to providing access to services for all, but also to ensuring that those services are of high quality and operate in combination with some form of financial protection that will protect patients from falling into poverty due to out of pocket payments. However, it was suggested that UHC can only be a means to an end, the end being improved health status, which is dependent on many other factors including the social determinants of health. The value of the term non-state actors was also discussed as potentially offering a more inclusive term for referring to (and recognising the diversity of) the private sector, which was suggested as encompassing a wide range of providers from the larger for-profit, non-profit and faith-based institutions to pharmacists, village doctors and traditional healers at the local level. It was debated that while health may still be viewed as a public good and indeed, a basic human right this does not mean that it is the exclusive responsibility of governments to deliver health services. An example provided by Khama Rogo of a pregnant woman seeking treatment in Kampala was used to illustrate the reality of many people in moving frequently between all kinds of public and private health providers, and the associated challenges patients can face when these services are poorly integrated with each other. It was suggested that in the eyes of the patient, the cost, quality and accessibility of care are more important than if the provider is public or private. A number of panel members agreed that governments alone cannot achieve the health outcomes required for their populations, and that the role of non-state actors is still largely overlooked due to poor awareness of their potential contribution and a lack of capacity within governments to engage effectively with the private market. The notion that achieving UHC is itself dependent on the nonstate sector being acknowledged and harnessed as an equal partner in providing healthcare was also debated, in light of some of the comparative advantage NSAs may have in generating resources, undertaking R&D, piloting new innovative approaches and (primarily) their potentially deeper penetration into the harder-to-reach communities.

Regulation and Financial Protection mechanisms

The positioning of health as a basic human right rather than a marketable good was debated, leading to discussion around the potential importance of regulation in preventing a profit-driven market distorting the ability of all citizens especially the poor to afford and access quality services. Panel members debated the role of legal, regulatory, financial and ethical frameworks in creating an enabling environment that would allow NSAs to make an effective, appropriate and integrated contribution to quality health care for all. Panel members discussed the apparent lack of government regulation of non-state actors in developing countries, and a perceived trend towards medicalising the idea of health as being based around the consumption of drugs rather than attention to an individuals broader wellbeing.

DISCLAIMER: This document is not a consensus statement, and should not be viewed as necessarily expressing the individual or collective views of the panellists or organisations associated with this symposium.

The issue of regulatory enforcement was also discussed, and it was noted by some that while UHC can be enshrined in a constitution, the reality can sometimes be very different for patients who must pay bribes and informal payments at the point of service. The panel members debated the previous experiences of governments in introducing regulatory frameworks, and the potential value of inviting NSAs to the table as a government partner in order to co-produce regulatory frameworks relevant to the particular health priorities of that country. The capacity building needs of both parties in this context were also debated, as was the need to more effectively incentivise NSAs to comply and report against these frameworks and assist governments in being able to effectively enforce and evolve regulatory frameworks as appropriate. Mechanisms to provide financial protection to patients (e.g. health insurance schemes or patient subsidies) were debated from the perspective of helping to prevent patients from falling (deeper) into poverty as a result of out-of-pocket costs when seeking healthcare services. It was acknowledged that national health insurance schemes are now becoming more common, with the African Union recently mandating that every African country must introduce some form of social health insurance scheme. The appropriate balance and respective contributions of both public and private actors in such schemes was debated, and many panellists expressed support for the idea that governments must take the lead in developing and overseeing these schemes, but that NSAs should also play a role to enhance sustainability and efficiency. The challenge of making these financial protection schemes both equitable and pro-poor was discussed, with some panellists suggesting that these schemes should promote healthy wellbeing as well as medical treatment, and include transparent risk-sharing arrangements between the public and private partners to cover the diversity of patient needs. One panellist also highlighted the importance of increasing access to finance for private investment in helping the private sector participate in these schemes, referring to the apparently high interest rates in many African countries that are potentially preventing many NSAs from providing business models that serve the poor as well as the rich.

Issues for further discussion

The panel discussion and ensuing Q&A with the audience demonstrated that there are still diverse opinions around the idea of health, and what is within and outside this sector. It was suggested by some that the diversity of health care services now required in the 21st century is such that it demands an equally diverse group of actors (i.e. public and private) to deliver them. The panel also debated the potential value to be found in balancing the current perceived trend towards combatting specific diseases (e.g. malaria) with recognition and investment in the more basic needs associated with shelter, clean drinking water and nutritious food, which may have a far greater impact in improving the health of impoverished communities. As one panellist suggested, this approach would be more effective in focusing on the life of the individual and not just the survival of a patient. The symposium concluded with a discussion around how to develop greater sophistication in health systems in order to respond to changing patterns in the burden of diseases, e.g. with the rapid increase of non-communicable diseases now affecting the poor as well as the rich. One suggestion put forward by a panellist was to invest in creating a more informed and educated patient population able to identify, select and evaluate healthcare services appropriate to them.

DISCLAIMER: This document is not a consensus statement, and should not be viewed as necessarily expressing the individual or collective views of the panellists or organisations associated with this symposium.