The 8th iHEA World Congress Symposium: The Private Sector in Health

Health markets took center stage on Saturday at the 2nd Pre-Congress Symposium on the Private Sector in Health. Kicking off the 8th iHEA World Health Economics Congress, the Symposium showcased the latest evidence on private provision of health care around the world and explored the role of the sector within a broader health system. Sessions covered a wide range of topics, but here are a couple of takeaways:

**Moving beyond the public-private debate.** Private versus public provision of health care has long been a contentious issue characterized by a deep divide between those that believe that health care is a public good that should be provided by the state and others who promote the private sector as the virtuous space in which care is delivered efficiently and with better quality. The debate, however, is much less clear cut. In his opening keynote address, Tim Evans, Dean of the School of Public Health at BRAC, framed what would become the key theme of the day: how do we overcome the “public-private” schism that often overshadows health systems dialogue and instead, focus on the market as a whole? Health systems are characterized by a dynamic mix of actors, many of which cross the public-private divide (for example, public sector practitioners that have private practices). Rather than continue to shape the debate in terms of public versus private, the global health community would be much better served by studying the market in its entirety and the incentives that shape the interactions between different market actors.

**Shifting research from describing the private sector to effective management.** There is significant evidence supporting the dominant role of the private sector in health care delivery in much of the developing world. Building this evidence base has been and continues to be a key step in obtaining the necessary political will to foster greater private sector engagement. Descriptive studies, however, are limited in their impact and need to eventually evolve into actionable research providing an effective road map for better private sector management and integration. Proper engagement of the private sector will require commitment to long-term action. Barbara O'Hanlon (O'Hanlon Health Consulting, SHOPS Project) [presented findings from a study showing that simple assessments are not sufficient to ensure substantive change]( Rather, the study endorses a process called Assessment to Action (A2A), which involves Private Sector Assessment (PSA) followed by an organized Public-Private Dialogue (PPD). Whereas a traditional PSA includes only the technical research team, A2A also encourages participation from an advisory group and in-country stakeholders, both of which have balanced representation from the public and private sectors.

**Closing the gaps in knowledge of comparative health outcomes and service quality.** There continues to be a lack of evidence regarding service quality and health outcomes of different market actors, especially within the broad spectrum of private providers. Dominic Montagu of the Global Health Group at UCSF [presented findings from a systematic review of literature]( looking at the difference in health outcomes between the public and private sector. The review, which included 21 studies from 8 countries, determined that while limited data from lower-middle income countries shows that the private sector leads to better health outcomes, there is no comparative outcome data on public versus private health care provision in low-income countries, and data from middle-income countries is of questionable quality. Looking at the informal sector, whose quality is often debated, Barun Kanjilal of the Institute of Health Management Research-Jaipur, [presented a study of rural medical practitioners (RMPs)]( in India’s Sundarban Islands. The study found that although the provider’s knowledge of medicine appeared to be surprisingly high, upon further investigation, it was found to be primarily superficial (e.g., approximate 80% of the surveyed providers prescribed amoxicillin to patients with a common cold). Several reasons may have accounted for this disconnect, including the providers’ inability to translate knowledge to practice and the existence of strong incentives to divert from medical protocol. This highlights the importance of including practical applications in provider training and pairing educational interventions with incentives to maintain care quality.

**From a segmented to a pluralistic health systems model.** Delivering the closing keynote address, Julio Frenk, Dean of the Faculty at the Harvard School of Public Health, [discussed the pitfalls of a typical health systems model]( in which the Ministry of Health is the primary institution responsible for the financing and delivery of health care services to poor populations. Recognizing that the poor frequently rely on the private sector for care and pay out of pocket for services, it is necessary to reframe the role of the Health Ministries in the overall health system. The images below, presented by Frenk at the close of the symposium, outline the difference between a segmented (left) and a pluralistic (right) health systems model. In the latter, the government plays the primary role in stewarding the health system and ensuring universal access to health services through financing mechanisms such as risk pooling and contracting, while health service delivery is performed by a wide variety of providers.

<img src=" frenk image combined.png" WIDTH="562" HEIGHT="240" BORDER="300"ALIGN=LEFT>

Although a myriad challenges remain - including potential push back from public sector practitioners faced with privatization, as [demonstrated in this example from Indonesia]( - this model leverages the comparative strength of all institutions within the health system and has real potential to ensure equitable access to health care for all populations.

Click [here]( to view all presentations from the Private Sector Symposium.