More than one route to reach universal health coverage
THIS week, health ministers from around the world gather in Geneva for the annual meeting of the World Health Organization (WHO). While they will no doubt take some time to enjoy the beautiful scenery, their working agenda will cover some of the world's biggest health challenges, including planning for the next pandemic ebola and influenza outbreaks.
Decisions will also be made on topics that are less alarming but equally important for health. Chief among these is how to encourage developing countries to move towards universal health coverage (UHC), in which everyone in a country can access basic health services without facing financial hardship.
WHO director-general Margaret Chan has described UHC as "the single most powerful concept that public health has to offer". Given that 150 million people each year suffer financial catastrophe due to paying for health care, this is no exaggeration.
Countries from India to Uganda now have UHC at the top of their domestic agenda, thanks partly to advocacy led by WHO. But progress is being complicated by a needless debate about the role of the private sector in health care provision in developing countries.
The humanitarian non-governmental organisation (NGO) Oxfam, which holds the ear of many development officials, summed it up in a series of papers attacking private sector involvement in health care, describing it as "unregulated, unaccountable, and out of control".
According to this view, which is shared by many western aid agencies, UHC can only be achieved by a massive expansion of government-owned hospitals and clinics in developing countries.
The idea that involving the private sector is antithetical to UHC is bizarre. The private sector (which includes non-profit providers) forms the backbone of health care in a range of Organisation for Economic Co-operation and Development (OECD) countries including Japan, South Korea and Germany. In fact, over two-thirds of all OECD countries rely mostly on private outpatient care and some of the best performing countries also deliver the majority of inpatient care through private hospitals. All of these countries have achieved both universal coverage and high levels of patient satisfaction.
The private sector also provides up to 80 per cent of health care in many developing countries. Proponents of public sector care are therefore effectively asking governments to massively expand government health provision in order to duplicate existing hospitals, doctors, laboratories, clinics, blood banks, maternity homes and pharmacies. This is not only an unrealistic proposition, it is also pointless. There is no evidence that government control is the only way to achieve UHC. Quite the opposite: The evidence suggests that there are many ways to get to UHC, and advising countries otherwise will drive them into needless, and enormous, spending to replicate resources that already exist.
Harnessing the private sector to achieve UHC need not be traumatic. National or social health insurance schemes should be agnostic about whom they purchase services from: private or public, so long as quality, fairness and cost standards are met.
AN APPROACH THAT WORKS
This approach works well in many developing countries. Certain districts in Thailand have achieved UHC by allowing all residents to use private hospitals, and then reimbursing those facilities. In the Philippines, growing numbers of pregnant women use private midwives, reimbursed by the national social health insurance fund, PhilHealth.
Expanding health insurance coverage to poor people, allowing them to freely access private providers, is well underway in Ghana, Thailand, South Korea, Malaysia and many other countries. A host of other countries are advancing towards this approach, including Kenya, Indonesia, India and Uganda.
The idea that "tawdry" notions such as profit and business have no room in health care is perhaps understandable among those who have made a career in public health, and whose motivations are altruistic rather than financial.
Even a cursory examination of most health systems, however, reveals that very few countries can meet this high moral standard. Pharmacies in the UK, France, and in most other countries are private, profit driven, and most effective when they are well-run businesses. Dental services in most countries are private, as are outpatient clinics. Good care is still delivered. High-quality medicines can still be found at Boots, Watsons and Walgreens.
As a growing number of developing countries stand ready to redouble their financial and political commitments to making health care more accessible to their citizens, we do them no favours by giving them ideologically-driven advice. Cuba has the best health system in the world according to many, and Brits are impressively vocal about their love of the National Health Service (NHS). But the Dutch, Germans and Japanese, while less vocal, are - surveys tell us - no less satisfied with their private-delivery-based health systems.
WHO and the supportive aid ministries in the developed world should provide the best objective advice and evidence to developing countries on this topic. UHC is the goal - let's not be side-tracked by pointless debates about getting "my way" or "your way". However we arrive at our goal, a great many people will benefit.
