GHF2008 – PS07 – Can Mixed Health Systems Be Equitable?

Session Outline

Parallel session PS07, Monday, May 26 2008, 16:00-17:30, Room 3
Chair(s): Oliver Mudyarabikwa, Health Services Management, School of Health and Bioscience, University of East London, UK, Maureen Mackintosh, Professor of Economics, Department of Economics, The Open University, Milton Keynes, Sussex, UK 
Economic Dynamics and Health Systems: Analysing Public-Private Relationships
Maureen Mackintosh, Professor of Economics, Department of Economics, The Open University, Milton Keynes, UK 
The Rockefeller Foundation: Leveraging the Private Sector to Improve Health Systems
Stefan Nachuk, Associate Director, Rockefeller Foundation, USA 
Private Sector and the Health Policy Process in Pakistan: An Egalitarian Construct for a Mixed Health System
Sania Nishtar, Founder and President, Heartfile, Pakistan
Public-Private Partnerships in Zimbabwe
Oliver Mudyarabikwa, Health Services Management, School of Health and Bioscience, University of East London, UK 

Session Documents

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Session Report

Submitted by: Victoria Ferris (ICVolunteers)

Analysis should be more dynamic and move away from a static 'public-private mix' framework to one informed by economic analysis of market structure, incentives, interactions and, importantly, sufficient evidence gathered from various countries' experience. Literature on how the private and the public sectors in health services mutually influence each other through market dynamics and forces over time is still very much limited. How can a variety of sources be best used and matched to achieve the desired Geneva Health Forum 2008 goal of "global access to health"?

The Commercialisation of Health Care projectled by the UN Research Institute for Social Development, supported by the UK's Department for International Development and the Economic and Social Research Council, researched Public Private Partnership (PPP) interaction that moves away from the all too common framework of analysis: private sector expansion, market liberalisations and privatising of state assets. Economic dynamics in health markets and how it evolves over time is important to consider for improved "analytical bite".

Where they work, even where they work badly, public/social insurance health systems are core redistributive institutions. Commercialisation of the public sector can undermine its redistributive and public health capabilities. Market segmentation via investment can embed inequality. Evidence from Africa clearly shows how income commercialisation in conditions of generalised poverty is very damaging. Prof. Mackintosh's example of low income fee-based commercialisation in Tanzania shows how fee-based systems can lead to falling access to care, resulting in a shift to the use of drug shops and self-treatment. Furthermore, one tends to see reputable private providers squeezed out of the middle and lower end of the market. The Tanzanian study also showed that all facilities that offer better care, in all sectors, relied on government subsidy which, she continues, is badly used in terms of health system capacity and equity. Her Tanzanian research leads her to believe that market dynamics are worsening inequity there and there is a need for more provision at point of use.

Both Professor Mackintosh and Dr. Oliver Mudyarabikwa pointed out the widespread use, strength and reach of NGOs, missions and, faith based organisations (FBO) in African countries, specifically Tanzania and Zimbabwe. The government in Zimbabwe retains the leading role in health care provision; followed by missions and FBOs who care for 70% of Zimbabwe's rural population, which is in turn 80% of the total population. The use of traditional healers is still very significant.

For-profit practices are highly concentrated in urban areas which comprise only 20% of the Zimbabwean population. Often these for-profit practices are wasteful and inefficient, focusing on curative rather than preventive services, there is price collusion, industry entry barriers are created and experienced public sector workers are 'poached' to do administrative work or other tasks for which they are well over-qualified.

The not-for-profit sector does not provide trained doctors; worryingly 75% of doctors are in the private sector. The missions have a very successful outreach, but need more resources. Assumptions are not always supported by evidence, thus more evidence and research is needed in the PPP debate. Even in free markets, interventions to drive up standards and equity are necessary.

Dr. Sania Nishtar stated that health system reform in Pakistan is urgently needed as the unregulated private sector grows, while the state health system suffers inadequate funding. Any improvement is marred by systematic weaknesses in governance and complete institutional instability. Pakistan, with a population of 160 million, only spends 0.6% of its GDP on health! Because of frequent political instability, turning a solid reform agenda into a plan of action is not viable.

Dr. Nishtar founded the NGO Heartfile in 1999, which focuses on catalysing change, but reminded the audience that it takes at least 10-15 years of only incremental change to make reform last. As key avenues to effect change she mentioned the problems caused by the current political climate, lack of transparency and the mis-targeting of both resources and talent. But she believes that administered well, civil society, NGOs and the private sector can act as a positive catalyst for change towards universal health.

Heartfile's proposed policies construct an egalitarian vision of a broad-based stakeholder group whereby the private sector is brought into the national mainstream to deliver health as a public good. Using the specific example of Pakistan she extended the debate on equitable health systems in general, so that the panel and audience could discuss a turn around of primary health care delivery.

The Rockerfeller Foundation aims to deliver health equity, good health at low cost and an economic transition to health. However, they aim to do this mainly through the private sector, quoting the current reality that the private health sector is quite large in many developing countries. There is an ideal of working for the world, as it should be, and there is also pragmatic approach that deals with the way the world really is. And it is through this latter approach that the Rockerfeller Foundation bases its health spending rationale.

However, Rockerfeller's Associate Director, Stefan Nachuk also feels more exploration is pertinent, especially in determining the effectiveness of risk polling/health insurances, provider purchasing models and innovative service models. The floor then questioned whether concentrating heavily on the private sector is effective in improving the health of the world's poor.

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