3 principles for improving mixed health systems

[Editor’s note: This is the first post in a series of blogs sharing experiences from R4D’s work on mixed health systems. The authors of this series hope to encourage debate and the sharing of ideas on the topic of mixed health systems and public-private sector engagement for universal health coverage (UHC). This blog, in particular, explores some of the principles policymakers can consider to help them better steward mixed health systems. Subsequent blogs in the series will include insights from R4D’s work in supporting private sector networks to better integrate in government-stewarded mixed health systems. The series will also highlight the state of evidence around mixed health systems and what it means for the field.]

Over the years, we’ve worked with country governments, social entrepreneurs, and private provider networks on how to better integrate private health care providers within government plans to achieve universal health coverage (UHC). The reality in many low- and middle-income countries is that health systems are mixed, such that the public and private sectors operate side-by-side to provide health care services and products.

But governments often make, at best, only modest efforts to coordinate and optimize the use of both the public and private sectors in pursuit of public health goals. We believe that if governments could better steward and engage the private sector, it will help to ensure that everyone, regardless of income level or background, can have access to high-quality and affordable health care when they need it.

In conversations we’ve had with government practitioners, they are keen to accelerate progress toward UHC by developing well-functioning mixed health systems, and they seek support to better play their stewardship role. They note that they want to ensure patients are receiving quality services whenever and wherever they seek care. Often, these government practitioners are looking for improving engagement with the private sector because:

• The local private sector may operate in remote or rural areas, where government currently does not — and, by engaging private providers, they may be able to move closer to their UHC goal.
• Patients are voting with their feet and using private sector services because they perceive private sector providers to be higher quality, more accessible, or responsive to their needs. However, governments are not successfully regulating those services and their quality is unknown.

But how can countries more successfully engage and leverage the private sector?

While there is no single answer to evolving well-functioning mixed health systems, based on our work, we have found that there are some principles policymakers in countries can bear in mind as they aim to more effectively steward mixed health systems:

1. Public-private engagement for UHC needs to be driven by local demand.

Public-private engagement needs to be demanded and led by local stakeholders with the ability and the authority to do so (as opposed to being led by donor agencies or multilaterals). Leaders with credibility and political will are key to pushing the work forward. Additionally, it should be recognized that there must be a well-defined rationale for the engagement to inspire buy-in and interest from both the public and private sector.

In Tanzania, for example, the government has shown strong interest in working with private not-for-profit providers organized under the Christian Social Services Commission (CSSC). The CSSC organizes approximately 900 facilities from local dispensaries to specialist teaching hospitals. With leadership from Tanzania’s national-level government, they routinely contract with the CSSC facilities to provide services. Given that CSSC reportedly provides forty percent of health services in the country, Tanzania’s government sees this engagement as key to achieving its public health goals.Similarly, in India, current reforms toward UHC through Ayushman Bharat (a national health protection scheme) — comes from the highest level, which includes a plan for secondary services to be strategically purchased from both public and private sectors. Though India still has a long way to go in terms of figuring out how to operationalize public-private sector engagement, this high-level support is an important step.

2. Countries have also reported greater success when they co-design engagements working with a range of stakeholders, including government, communities, and the private sector.

As part of Brazil’s SUS Sistema Unico de Saude national, state, and municipal health councils have stewardship responsibilities to plan, purchase, and finance services. The councils are responsible for health funds and have multisectoral participation to give input into how the councils manage both public and private sector providers.

In another example from Benin, the government has supported workshops and platforms for the public and private sector to come together as a multi-stakeholder group, begin initial communications about the constraints of engagement, and develop specific step-by-step roadmaps for improving the engagement.

3. Countries also see value and need in conducting rapid analyses to understand the specific constraints to public-private engagement and adapting global knowledge and lessons learned to their country context.

This helps to provide the evidence needed for decision-making and developing practical, step-by-step roadmaps.

For instance, in Malaysia, where half of primary health care services are being provided in the private health sector, the government decided to draw on global tools and best practices to begin initial communications with the private sector. Then, it conducted rapid analyses to identify private providers, understand their capacity, and determine how to better integrate them in government-stewarded PHC delivery.

These are just a few lessons from some of the countries we have worked with that have asked for support in engaging with the private health sector. We have found that there is no single answer but rather principles that can help countries navigate this complex environment.

Are there principles or approaches that you have used and found valuable? We’re interested in hearing from you in the comments below.

Photo © Allan Gichigi