By Alyssa Govindan
“Governments have everything to gain when they prioritize human health. I am hopeful for global progress because universal health coverage is included in the SDGs” – Dr. Agnes Binagwaho, Rwanda’s Minister of Health.
What is UHC?
Countries around the world have developed many different models for delivering healthcare. Some are fully public, some are mostly private, and others are an intricate mix of both. The truth is that no perfect model exists, and no country is starting from scratch. Every country must attempt to augment its existing health system to accommodate all of its residents, justly and effectively.
Because of the inevitably complex nature of national health systems, many people who live in poverty-stricken areas face two problems:
- barriers to accessing the medical services they need, resulting in poor health outcomes; and/or
- catastrophic financial burden caused by paying for the medical services that do exist.
It is in this context that the debate around Universal Health Coverage (UHC) is gaining traction. As governments seek to further enshrine health as a human right, the UHC framework requires that they consider the ability for all citizens – rich, poor, rural and urban – to access quality health services, where they need it and without suffering financial hardship.
A fully integrated and functioning public health system is essential to ensure care is accessible, affordable and of high-quality. Without all three elements, the system is failing to honor the universal rights of its citizens to adequate healthcare.
A Nationwide UHC Model: Mutuelle de Santé in Rwanda
Rwanda is one country that demonstrates what UHC can look like and why it is valuable. The unique circumstances of post-genocide Rwanda allowed the government to develop a community-based insurance scheme in 1999 which has grown to cover 90% of its 12 million people. The system utilizes a poverty map to categorize members into three groups based on economic status. The poorest members pay no premiums while the rest pay different levels of premiums and copayments. The more participants that pay premiums into the system, the more poor and vulnerable individuals the system can cover at subsidized cost. Rwanda’s health system has also trained 45,000 volunteer community health workers in an attempt to extend basic healthcare to villagers in more remote areas.
The financial ease this model has brought to many Rwandans has increased health outcomes dramatically. The infant mortality rate in Rwanda dropped by nearly 75% and life expectancy increased by 18 years from 2000 to 2015. Out of pocket health expenses dropped from 28% to 12% of total health costs thanks to the Mutuelle de Santé scheme.
While Rwanda’s insurance scheme is a successful example of a state-led UHC program, the country’s distinctive history and recent resettlement is not something that many other countries in the region have experienced. The private sector in Rwanda also plays a limited role in providing services. For instance, only 1% of families with insurance have private coverage and only 4% of women obtain contraception from private providers.
Complexities and hurdles of private sector involvement
“That almost every country has a mixed healthcare system, combining private and public providers, is accepted; but what that system should look like and what the balance should be often remains unclear.”- UN Sustainable Development
Governments have a tendency to view the private sector as a single group and with a general mistrust. In many cases, private providers are perceived as circumventing regulations, consumed by profit and disinterested in serving the poor. However, while the private sector may have different motivations, platforms that build trust, can reap significant dividends in accelerating UHC. The government’s obligation to provide certain services at an affordable price can be complemented by leveraging the expertise of the private sector and optimizing business models to bring in more patients and reduce overall system costs. In this way, the profit motivation of private provider could become a powerful force for good.
A discussion convened by GSK and Save the Children at a UN political forum mentioned that private providers can be beneficial if supervised by the national government, which has a responsibility to provide a base package of publicly funded care. More such platforms are needed.
Integrating the private sector into UHC: India
One country working to integrate the private sector in its quest for UHC is India. Despite the acceptance of UHC at the policy level in India, almost three-quarters of healthcare spending is borne by households. Public spending on health in India has comprised a historically low percentage of the country’s GDP and most of the financing has focused on supply including improving infrastructure and human resources.
India’s new National Health Policy 2017 wrestles with how to view the private sector as a strategic partner in providing healthcare. With a focus on emerging diseases and preventive healthcare, the new policy aims to engage the private sector to fill gaps in achieving national goals. The governmentill turn to the private sector specifically for:
- Strategic purchasing
- Capacity building
- Skill development programs
- Generating awareness
- Developing networks for mental health services
- Disaster management
The hope is that boosting overall healthcare spending and embracing public-private partnerships (PPPs), will open up a space for the private sector to provide services at subsidized rates.
Nevertheless, many concerns are yet to be resolved including fundamental issues such as: how to incentivize private providers to offer quality and affordable care to those in rural areas and how to ensure the poor are not left without any source of affordable care either public or private.
How should the private sector help?
The UN has said that: “The exact role that the private sector can play is still unclear and how it can go beyond health projects to championing government-led UHC”.
The private sector can contribute to UHC in three primary ways:
- Private providers working closely with public providers to expand the reach of health services, close gaps in quality care and lower costs. Some ways of doing so include:
- Upgrading infrastructure of hospitals and clinics.
- Investing in secondary and tertiary care provisions particularly in countries where public funding may be lacking.
- Prioritizing access in the introduction of new services and products, particularly in peri-urban areas.
- Businesses committing valuable resources and expertise to public partners to advance UHC policies. Examples include:
- Ensuring effective and efficient spending and that regulatory rules are followed with the aim of improving patient outcomes.
- Supporting innovations in healthcare that benefit the poor and vulnerable populations including technology such as smart phone based services, tiered pricing, pro-poor products, and beyond.
- Training of health workers which entails clear guidelines for private providers and a certification, data collection, sharing and monitoring framework.
- Investing in health care for employees and having clear workplace health and safety policies. By doing so, they are contributing to the broader system, ultimately driving down costs and reducing risk by ensuring their workers are utilizing higher-quality health services. This is particularly true for small- and medium-sized businesses entering into nascent insurance markets.
At the end of the day…
According to a recent Lancet article, the crucial policy question about the private sector is not its performance in isolation, or relative to the public sector, but the extent to which it supports or detracts from progress towards universal health coverage.
In the context of recognizing health as a human right, UHC is the holy grail. How it is achieved, and exactly what role each stakeholder plays may not be entirely clear yet, but countries as different and diverse as Rwanda and India are trying. It is not necessary for the private sector to hold the same motivations as the government to be supportive of achieving UHC. Companies and private providers bring a unique set of skills and resources that can complement the public sector to improve access and outcomes particularly for poor and rural families.
As governments continue to embrace UHC, they will need to invite the private sector to join key conversations to build trust and ensure innovations and initiatives are supporting long-term goals. To be clear, this is not just a developing world problem. Political buy-in and complementary private sector action to ensure access to health without financial burden is equally necessary in the United States as in India. An integrated, multisectoral approach will ensure that adequate resources and knowledge are leveraged for the common good everywhere.