How to transform health markets to improve health care for all

On Wednesday, October 17, Results for Development hosted a discussion of _[Transforming Health Markets in Asia and Africa: Improving Quality and Access for the Poor](, a new book edited by David Peters of the [Johns Hopkins Bloomberg School of Public Health]( (JHSPH), Gerry Bloom of the [Institute of Development Studies]( (IDS), Barun Kanjilal, and Henry Lucas. The book documents the problems associated with unregulated health markets and presents innovative approaches that have emerged to address them.

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The [DC Health Systems Board]( discussion was moderated by Cristian Baeza, a former director of [Health, Nutrition, and Population]( at the World Bank who recently re-joined [McKinsey & Company](, and the panel featured Dr. Peters, Dr. Bloom, and Gina Lagomarsino, Managing Director at [Results for Development](

Left: New book _Transforming Health Markets in Asia and Africa_.

The book suggests that the global debate on how to address the shortage of health service provision needs to transition into how to address issues around the quality, efficiency, and cost of the health market system. Discussion focused on the role of informal providers in delivering health services and opportunities for academics, governments, NGOs, social entrepreneurs and businesses to deliver effective services for the poor.

Lagomarsino said the book turned the study of health systems on its head, moving a discussion between people in positions of power (government and academia) to a reality-based look at the vibrant and sometimes chaotic health markets where most people get health care in low- and middle-income countries.

“Health markets are very transactional,” said Lagomarsino, “consumers and patients make decisions about what they’re going to ask for from providers and what they’re going to expect to get, and providers make decisions about what kind of care they provide.”

**The reality of health markets**

Tele-porting from IDS in Britain onto a big television screen behind Dr. Peters and Lagomarsino, Dr. Bloom set the scene for a discussion of health market challenges, opportunities, and interventions.

“Health markets developed very quickly,” said Dr. Bloom, “with a lack of mechanisms to identify and reward quality.” Dr. Bloom also pointed to blurred boundaries between the public and private sectors, with informal payments, dual practices, and perverse incentives making these large, complex health markets difficult to navigate.

**A framework to study health markets**

Following Dr. Bloom, David Peters of JHSPH pointed to several key factors that relate to the strong dependence of local communities on informal providers in health markets, including the **need for more data** about health markets, and:

* New opportunities for improving access to health knowledge and influencing providers and the public emerging with the **growth of information communication technology**,
* Health systems segmented by factors such as purchasing power, understanding of health and disease, and culture and social factors, but affecting people of all socioeconomic factors
* The need for institutions to **assure provider competence and quality**
* Solving the problem of information asymmetry, a situation in which providers and patients enter a health transaction with different levels of understanding and knowledge about health care.

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Above: Panelists (from left to right); Gina Lagomarsino, Gerald Bloom, Cristian Baeza.

**Diving deep into the informal provision of care in health markets**

Next, Gina Lagomarsino described recent [CHMI-commissioned studies]( of health markets in Bangladesh, India, and Nigeria.

“In some ways, these studies confirmed what’s known, for example that informal providers [represent] the first line of care for the poor, since they are convenient and well known [to the community],” said Lagomarsino, “and that they engage in some harmful practices such as inappropriate injections.”

Yet there were unexpected findings, too. Providers often run well established, successful businesses responding to local demand. In addition, the studies revealed that informal health providers are characterized by:

* Having **deep roots in communities**: Informal providers are trusted and respected members of communities with long-running practices—often “social elites” who view theirs as a “noble profession”
* Relatively **well-educated**: They are often relatively well-educated, attending secondary school or beyond
* Most have some **formal training**, commercially offered courses or community health worker training, or they have apprenticed
* Informal providers are **eager for more training and formalization**

More findings from these studies, and their implications for policy and practical interventions, will be explored at the upcoming [Second Global Symposium on Health Systems Research](, in Beijing, at a session the morning of Friday, November 2.

**Uncovering innovation and market-based solutions**

“If you visit informal providers, they are amazingly innovative,” said Gerry Bloom, pointing out that the onus was now on institutions to respond to markets in order to assure quality in health markets.

He presented innovation as part of a multi-stage process to address health market challenges:

* Analyse the local health market system,
* Understand and support innovators,
* Design interventions based on an understanding of the likely responses of different actors, and
* Use a learning approach to build new kinds of partnership and respond to unintended outcomes.

As an example, he said in China “[barefoot doctors” have to pass an annual licensing exam](, and are now signing contracts with the government around primary healthcare delivery.

Gina pointed to the effort by [CHMI to profile innovations in health markets]( and suggested that health markets could present a solution to the commonly raised issue of human resource shortages.

Admonishing the group that one “should never ask me to be a moderator,” Baeza interjected several apt observations from his vantage point as a former CEO of Chile’s national health insurance program.

“Yes, markets have tremendous problems,” said Dr. Baeza, “but as compared to what—public monopolies?”

Speakers agreed that learning more about the dynamics of health markets can help identify creative solutions to better utilize all providers to deliver quality, affordable, and accessible care, especially for the poorest and most vulnerable.