This year’s iHEA World Congress on Health Economics was the 9th meeting of International Health Economics Association – this time in Sydney, Australia. The topics of focus spanned a wide and disparate set of topics, ranging from macro-level discussions on the role of health technology assessments in policymaking decisions, to the micro such as the impact of out-of-pocket expenditure on access to MNCH services in Bangladesh. Given that this was my first iHEA conference, I was curious to see what themes would emerge and their relevance to practical policy decisions around health market activity.
In the midst of such technical discussions, there was considerable attention given to the role of nonstate actors in the world of health economics. And I was encouraged by the diversity of the group of participants – as Tom pointed out in his reflections on the iHEA Private Sector in Health Symposium, there were many governmental Ministries of Health represented, in addition to a sprinkling of health practitioners and policy researchers. Topics ranged from the role of informal providers in health markets to how microinsurance can support government-sponsored universal coverage – always getting at the push/pull between public and private, but actively identifying opportunities for private health market activity to support national health priorities.
One of the topics of focus was the role of informal providers as countries strive for universal health coverage (UHC). Chaired by Birger Forsberg of the Karolinska Institutet, the session was kicked off by a presentation from Gerry Bloom of Future Health Systems to share research findings from Meenakshi Gautham’s Crenio Group. The research, commissioned by CHMI, focused on Rural Medical Practitioners in two states in India – Utarrakhand and Andhra Pradesh (AP). The research highlighted that rural medical providers are often the first source of healthcare, and while they demonstrate some issues in quality of care delivered, they also are strong potential vehicles for extending essential healthcare services to low-income households in India.
The study mapped providers and collected data on their education and practice characteristics through interviews. The results were surprising - RMPs are seen as highly respected members of their communities, with fairly high knowledge levels (70%) when compared to WHO guidelines. However, patient observations revealed that only 40% of RMP practices were correct for fever, and over 70% of all observed patients in AP received an injection. They also have strong relationships with the formal sector, with strong referrals rates to private sector doctors and hospitals. The message was clear – informal providers play an important role in healthcare delivery, so how do we harness them to support the delivery of key health interventions in a way that’s high quality, affordable, and accessible?
Other presenters focused on the possibility of working through informal providers to deliver key health interventions – namely remote diagnostic tests (RDTs) for malaria in Nigeria. Jenny Liu, of UCSF’s Global Health Group, shared her research on the potential for diagnostic tests to change patient behaviors. Through their research they found that both providers and patients believed that a wide range of symptoms were attributable to malaria – including bad dreams and exhaustion. This is result in massive overtreatment of ACTs, which in turn in resulting in drug resistance. A private medical vendor in peri-urban Ibadan shared with the researchers that “twenty patients a day have malaria”.
The pilot study surveyed 465 patients of private pharmacies and drug sellers in Oyo state to determine whether a negative result after using the RDT would result in patients not taking the drugs. The results showed that only 4% of adults purchasing malaria drugs were RDT+, with a high overall adherence rate at 72.8% - in other words, taking the drugs if positive, or not taking the drugs if negative. It showed interesting findings in terms of the use of RDTs to steer patient behavior, but also demonstrated the importance of working through informal providers to reach low-income households with malaria management in Nigeria.
The Results for Development Institute also had the opportunity to share its research in partnership with the Microinsurance Innovation Facility at the ILO on the evolving role for insurance partners on the path toward universal coverage. The research was designed to look at the role that health microinsurance and other private actors can play in achieving UHC – in particular, in expanding coverage to informal workers.
The researchers developed a conceptual framework that outlines the relationship between microinsurance – defined as smaller scale schemes that are mostly private in nature - and UHC, and documented 8 country case studies that either had active HMI schemes in parallel to government reform, or that used microinsurance as a building block for government reform.
The country examples demonstrate that both government-led schemes and microinsurance schemes share common objectives and complementary approaches. Even more, microinsurance can contribute to government efforts to serve people in the informal economy, and leaving them out of government strategies may result in duplicative or competing models.
This highlights just a few of the topics covered at the conference – other presentations touched on the economics of informal care and barriers to utilization and delivery of health services. Many speakers advocated for taking a close look at the admittedly complex interplay between public and private actors and the dynamics of local markets. The good news is that it sparked significant discussion and debate and pointed to many areas for further research, particularly around how to develop practical responses to the findings – to be continued at the next iHEA conference.