Towards a whole system approach for meeting health needs in the time of COVID-19

Gerald Bloom is a member of the WHO Advisory Group on the Governance of the Private Sector for UHC.

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Many low- and middle-income countries (LMIC) have mixed health systems in which people seek care from different types of public and private healthcare providers. Although most governments have made commitments to progress towards the sustainability development goal of universal health coverage (UHC), public and private health systems have operated in parallel, with little effort by government to influence the latter. There is an increasing recognition that this will need to change if UHC commitments are to be achieved.

In the face of the COVID-19 pandemic, governments have become increasingly interested in finding ways to involve the private sector in efforts to ensure that people have access to care. The performance of these emergency arrangements will strongly influence future relationships between the public and private health sectors and the degree to which they contribute to progress towards UHC. The drive to strengthen cooperation between the public and private health sectors reflects a concern that government facilities may not be able to meet a potential surge in demand associated with the spread of COVID-19. The agreements already reached in some LMICs include the provision of inpatient care, diagnostic tests, digital services for outpatients and so forth. If all goes well, this could increase LMIC health system capacity to meet population needs. However, there are risks that serious problems could arise with unnecessarily high costs, low quality, or increased inequality in access to care. These problems could jeopardize future efforts to strengthen mixed health systems.

In many countries the government and private healthcare providers have little experience of collaboration and there is often a certain amount of mutual distrust. On the one hand, the government and civil society organizations may fear that private healthcare providers will prioritize economic considerations at the expense of the public interest. On the other hand, private healthcare providers may be concerned that government regulations will create problems for the provision of services. One approach for overcoming this lack of experience is the provision of guidelines and training on a number of technical aspects of collaboration agreements between governments and private healthcare providers. However, it is important to recognize that new institutional arrangements will be needed to enable effective collaboration between state and non-state actors in the health sector and secure political support. The COVID-19 emergency response needs to take this into account at national and international levels.

At national level, it will be important to organize consultations with all relevant stakeholders to define the objectives of collaboration in addressing the challenge of COVID-19, while adhering to the principles of UHC (universality, equity, non-exclusion and non-discrimination, comprehensive care, financial protection, and protection of patient’s rights). The participants in these consultations should include representatives of providers of services currently used by most of the population, including the most vulnerable. In many cases, this means drug shops or providers of basic outpatient care. A major outcome of these consultations should be an agreement on the roles and responsibilities of government, private healthcare providers and representatives of the public in ensuring progress towards access to essential health services for all. It will be important to agree on mechanisms for monitoring performance to avoid the problems indicated previously.

At international level, it will be important to provide opportunities for mutual learning between countries about what works well and where problems have arisen. This could include mechanisms to monitor the price of goods and services, quality of services and equity of access. In the case of transnational providers of services, it will be important to agree principles of engagement that consider the goal of UHC and the need for indicators of good performance.

It is short sighted to view the COVID-19 pandemic as a discrete emergency after which countries can return to “normal”. It is impossible to predict how long the virus will continue to affect health and health service delivery. The economic disruption associated with the measures to control the pandemic may last for a long time and there is a risk of major health problems associated with poverty and disruption of health services. It will be important to view the agreements reached for improving the performance of mixed health systems in meeting the challenges associated with COVID-19 and the associated economic crisis as the beginning of a sustained process of health system strengthening and reform.

About the Author

Gerald Bloom, Institute of Development Studies

Gerald Bloom is a medical doctor and health system analyst with expertise in health policy, planning and finance. He is co-convenor of the Health and Nutrition Cluster at the Institute of Development Studies in the UK.

His work focuses on the management of health sector development and reform in countries experiencing rapid change. He is particularly interested in the policy implications of the emergence of pluralistic health systems in which people seek advice and drug treatment of health problems from a variety of providers in terms of their training, their ownership and their relationship to the formal regulatory framework. His recent work on the topic is exploring strategies for the treatment of common infections while reducing the risk of emergence of antimicrobial resistance in countries, where informal markets are an important source of antibiotics. He is part of a team focusing on this issue in West Bengal.

He is also interested in the implications for the health sector of the development of digital health services and the major investments by a number of internet platforms on health-related services His institute is part of a consortium that has organised consultative meetings on innovation for UHC in Asia and Africa to explore the new kinds of partnership that are emerging to take these innovations to scale, and the changing regulatory role of governments.

For several years, he has been a member of the coordinating committee of the Thematic Working Group on the Private Sector of Health Systems Global. This is a grouping of health system researchers with a special interest in the private sector. It has organised a number of activities linked to the biennial conferences of Health systems Global.

This blog is a product of the World Health Organization’s Private Health Sector Engagement for COVID-19 Initiative (WHO-PCI).