Without the private sector, we won’t reach universal health coverage
This year’s UHC day allows us to rethink the traditional public sector-lead approach in healthcare
It is 2020, and half of the world population does not have access to the healthcare they need[1]. The conventional approach to improve access to care has been public sector lead [2], governments in low- and middle-income countries delivering services with their own budget and the support of international donors. Private provision of public goods is still much debated. But to accelerate the path to universal health coverage (UHC) it is time to recognize the existing role of the private sector in Africa and find ways to harness its strength vis-à-vis the public sector.
Fortunately, COVID-19 has presented us with an opportunity to rethink our strategy. Like with any outbreak and pandemic, weaknesses of health systems become clearly visible and countries worldwide need to take the strain of public health workers. In March 2020, the World Health Organization’s Private Health Sector Engagement for COVID-19 Initiative (WHO-PCI) called for a “renewed focus on governance within mixed health systems where private health providers can participate as equal players in the national response to COVID-19[3].
Private providers in sub-Saharan Africa reflect a diverse and segmented sector. Inconsistency in quality raises legitimate concerns. But the global health community often opposes ‘in principle’ the role of for-profit health providers[4]. By neglecting the sector, it misses opportunities to serve the most vulnerable population, scale inclusive insurance schemes, utilize the potential of mobile health and encourage much-needed financial sustainability in the health sector.
Private health providers already co-exist but are often perceived by the global health community as serving the rich[5]. The opposite is true in Africa. The private health sector — from midwives to pharmacies to hospitals — can fill the gap where public services are strained. They already provide half of Africa’s health products and services [2]. For instance, in Nigeria, with a population of over 200 million, less than 20% of the 24,000 primary health facilities are functional[6] meaning there is a big gap to fill when it comes to basic health services — particularly in rural and remote areas.
This begs the question, if private healthcare providers already co-exist and the vast majority of the region’s urban and rural poor relies on the private sector[4] — then why not do more to engage them?
Leveraging the private sector can mean better access to quality care. In Tanzania, for example, allowing members to access care through private providers has boosted enrollment rates for its health insurance scheme iCHF[7]. When facilities within a scheme receive reimbursements based on the number of registered patients at their facility, they start competing with each other. It can encourage public providers to invest in the two areas private providers often surpass them: timeliness and patients’ experience of hospitality[8].
The continued growth in digital health solutions will thrive by enabling tech companies to collaborate with the public sector. With innovations like mobile health platform M-TIBA patients can pre-pay for health and access care at nearby facilities, both public and private. M-TIBA gathers valuable data on healthcare provision and enables better alignment and referrals between facilities. Moreover, patients do not get lost while navigating the health system. The platform already has millions of users. As sub-Saharan Africa is the fastest growing region of unique mobile subscribers[9], these innovations can scale rapidly.
Private sector healthcare improves the sustainability of health financing. Approximately ten percent of Africa’s health care expenditure is financed directly by donor aid[10]. Just last month, the UK, a leading figure in global health, withdrew GDI on overseas development assistance as a result of the coronavirus crisis[11]. Others may follow suit as they feel the economic pinch of lockdowns and other containment measures over the coming years. Due to its independence from government subsidy, the private sector is less sensitive for economic shocks and crisis’s. Engaging the private sector should therefore be an important part of a country’s health financing strategy[12].
Both the public and private sectors face challenges providing quality care, especially in terms of financing. Whilst public providers suffer from chronic underfunding, private providers are unable to access capital. Small and medium enterprises (SME’s), especially those in the health sector, are poorly served by local banks. Interest rates and collateral requirements are out of reach. As a result, providers face broken equipment and inadequate drug stocks leading to business stagnation. Many will go under as a result of patients delaying health visits due to fear of getting COVID-19.
That is why the PharmAccess Medical Credit Fund (MCF), which to date has disbursed almost 5,000 loans to 1,800 healthcare providers amounting to $100 million in total, is needed now more than ever before. Together with SafeCare, an internationally accredited quality improvement program, MCF enables SMEs to improve the quality of services they provide and build trust in the health sector. This then creates a demand in the community whereby even the poorest are willing to pre-pay for healthcare as they know that they will get the service they require when they need it. All of this can be accelerated using state-of-the-art digital technology in which Africa is already a leader in terms of mobile payments.
This year’s UHC day marked one year since the first COVID-19 cases were reported. The message is clear: ‘To end this crisis and build a safer and healthier future, we must invest in health systems that protect us all — now’. Embracing the private sector would be a great place to start.
The Dutch Ministry of Foreign Affairs launched on December 11, 2020 a renewed partnership with MCF so that it can continue its services. To listen back to the webinar in the light of UHC and this new cooperation, click here.
[1] https://universalhealthcoverageday.org/
[2]‘The Business of Health in Africa. Partnering with the private sector to improve people’s lives’ International Finance Cooperation / World Bank Group (2007) https://www.unido.org/sites/default/files/2016-01/IFC_HealthinAfrica_Final_0.pdf
[3] ‘Supporting private sector engagement during COVID-19 — WHO’s approach’ https://www.who.int/docs/default-source/health-system-governance/role-of-who-in-covid-response.pdf?sfvrsn=9a5bcde0_2
[4]‘The Business of Health in Africa. Partnering with the private sector to improve people’s lives’ International Finance Cooperation / World Bank Group (2007) https://www.unido.org/sites/default/files/2016-01/IFC_HealthinAfrica_Final_0.pdf
[5] In the UK for example. About 25% of the richest income groups has private insurance, allowing access to private health facilities, against 3–5% of the lowest income group. https://www.euro.who.int/__data/assets/pdf_file/0010/373690/uk-fp-report-eng.pdf
[7] Read more about our approach to roll out health insurance in Tanzania: https://medium.com/pharmaccess/pharmaccess-lessons-learned-in-rolling-out-health-insurance-in-tanzania-1ceed03bca30. Further reading: Health Insurance Fund Evaluation, The Boston Consulting Group, April 2015: https://www.government.nl/documents/reports/2015/04/30/health-insurance-fund-evaluation-report
[8] Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review
[9]GSMA report (2019): The mobile economy, sub-Saharan Africa.
[10] The Business of Health in Africa. Partnering with the private sector to improve people’s lives’ International Finance Cooperation / World Bank Group (2007) https://www.unido.org/sites/default/files/2016-01/IFC_HealthinAfrica_Final_0.pdf
[11] Minister resigns as UK cuts foreign aid spending commitment. November 5, 2020: https://www.reuters.com/article/uk-health-coronavirus-britain-aid-idUSKBN2851UN
[12] The Business of Health in Africa. Partnering with the private sector to improve people’s lives’ International Finance Cooperation / World Bank Group (2007) https://www.unido.org/sites/default/files/2016-01/IFC_HealthinAfrica_Final_0.pdf
