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Private sector role in achieving universal health coverage

Most countries of the Eastern Mediterranean Region (EMR) have witnessed a rapid expansion of the private health sector over past decades. According to information available in some countries of the Region, an estimated 70% of the EMR population seeks health care from private providers and the percentage of health-care services from the private sector used by the poorest quintile ranges between 11% and 81%. It is increasingly recognized that the private sector has an important role to play in contributing to countries’ health system goals, notably in the achievement of universal health coverage (UHC), which ensures that everyone who needs health services is able to get them, without undue financial hardship. Yet many challenges remain. The range of services provided by the private sector is variable, standards are questionable, regulation is poor and there is insufficient information about the financial burden to the users of these services. Enforcement of service delivery quality standards in the private sector is among the biggest challenges faced by governments and ministries of health in the Region. Ways are needed to partner effectively with the private sector, by strengthening public–private partnerships (PPPs) for health-care provision, so that its contribution can be better harnessed.

At the World Health Assembly in May 2012 and the Regional Committee for the Eastern Mediterranean meeting in October 2012 Member States agreed on the need to engage with the private health sector as part of efforts towards UHC, and a preliminary analysis of the private health sector in the Region was presented at the 60th session of the Regional Committee in October 2013. To draw on international and regional experience of involving the private health sector in EMR countries a Regional Consultation on engaging the private health sector for accelerating progress towards UHC took place in Cairo, Egypt, in June 2014. The aims of the workshop were to: raise awareness among policy-makers and key stakeholders on the role and contribution of the private health sector in progressing towards UHC; share experiences and results of analytical studies in selected countries of the Region on regulation of the private sector and its role in health service provision; and develop a roadmap for private sector involvement in moving towards UHC in the EMR countries.

The consultation involved representatives from ministries of health, academia and the private sector from 14 countries of the Region along with selected health system focal points from WHO country offices in collaboration with the International Development Research Centre, a Canadian government agency that works with developing countries. The workshop was facilitated by WHO staff from the Regional Office as well as international experts in PPPs.

Challenges in developing the private sector role in service provision

A rapid assessment of the private health sector in 12 countries has shown that one-quarter of total health expenditure goes to the private health sector in group 1 countries (high income), half in group 2 countries (middle income) and as much as three-quarters of total health expenditure in group 3 (low income/conflict zones); most of this expenditure is direct out-of-pocket payments. Yet private health insurance has limited scope in all three groups of countries. EMR has a diversity of private sector service provision; in some countries health-care services are mostly provided by the public sector, while in other countries the private sector has a much larger role. Service utilization also varies across different income groups within countries. The key priority areas to consider with regard to involvement of the private sector in service provision are: the regulatory capacity of ministries of health; partnerships with the private health sector; reducing out-of-pocket payments incurred in the private sector; and improving quality.

The discussions raised several issues. It was highlighted that the public perception in the Region is that the private sector provides better quality health-care services, despite a lack of evidence for this. The issue of quality of care needed to be addressed and linked not only to the system of governance in general but also to the public’s perception of services. Even within the same income bands there is great variability among countries in the development and status of the private health sector; for example, in some countries the private health sector has sufficient political power to influence regulation. Furthermore, in some countries public sector physicians also work in the private sector and this could be a barrier to developing an appropriate regulatory framework. It was noted that public sector officials may fail to understand the potential contribution of the private health sector, and at the same time private sector providers may not be aware of their role in UHC. Often complex clinical cases are managed by the public health sector and the less complex ones by the private health sector. Countries needs to plan for the future role of the private health sector to ensure UHC and private health providers need to be engaged in these discussions. There is also a need to better understand how the private health sector can benefit from the public health sector.

Countries’ experiences and success stories

Universal health coverage

The first technical session considered how to leverage the private health sector to accelerate UHC. Experience from Thailand—which achieved UHC after 2001—shows how the private sector (albeit providing only 6% of total health facilities) plays an important role in filling government gaps in UHC implementation. In Lebanon efforts are being made to expand the primary health-care network with a prepaid benefit pack of services, tariff unification, links between key providers and payers through an e-health system and the strengthening of public hospitals.

Regulatory assessment

The second technical session looked at the challenges for governments in regulating the private sector particularly in low- and middle-income countries. Regulation in the health sector is a contextually evolving process, not a one-time radical shift, and is not an alternative to better governance. Presentations were also given on experiences of private sector regulatory assessment from Egypt and Yemen, and on regulation of the pharmaceutical sector and medical products. It was noted that regulatory agencies spend more time in enforcement of the private than the public health sector and a paradigm shift is required so that the focus of regulation is on outputs like quality, efficiency and accessibility. Unified Regional regulations should be developed for medical devices and pharmaceuticals as they have for vaccines.

Assessment tools

The third technical session looked at methodologies available to assess the private health sector. Participants were shown a presentation of the new web-based private sector assessment (PSA) tool which helps to centralize data and inform strategic recommendations. Experiences of rapid assessment of the role and contribution of the private sector in health care delivery were shared from four countries of the Region: Lebanon, Jordan, Saudi Arabia and Pakistan. It was pointed out that regulation of the private sector should be seen as facilitating rather than controlling, with the private sector as equal partners. Participants agreed that health information systems that pool information would protect confidentiality and be less threatening to the private sector.

Public–private partnerships

The fourth technical session looked at PPPs and included experiences of medical syndicates from Lebanon, Egypt and Pakistan. The presentations showed how different contracting arrangements in health care have led to the development of different PPP arrangements. It was noted that implementing UHC can increase the burden of care delivery by the private sector. Experience from India shows that despite the vast network of health facilities, systemic deficiencies have steadily eroded the ability of the public health system to meet the burgeoning demand for health services effectively. Many provincial governments across India are exploring PPPs to address the challenge of equitable access to affordable health-care services for the poor.

Participants at the Regional Consultation on engaging the private health sector for accelerating progress towards universal health coverage, June 2014

The way forward

The meeting reviewed the Regional framework of action for engaging the private sector which includes seven commitments: building platforms for dialogue; policy and stewardship; mapping private sectors; regulation and governance; purchasing and financing private sector services; leveraging quality and access; and patient information, engagement and satisfaction. Participants agreed on a set of recommendations organized around these seven areas of work (Box 1) and identified those for priority action within their own country.

The meeting emphasized the essential role WHO plays to advocate and guide countries in engaging with the private sector and the importance of linking PPPs with UHC to keep in mind the reason for engaging the private health sector. The challenge is how to leverage the private sector to ensure health coverage for vulnerable groups of the population.