Is private provision key to delivering universal health coverage?

Opinion

By Gijs Walraven, Director for Health, Aga Khan Development Network

• The global goal towards universal health coverage, a theme of this year’s World Health Day, is far from being achieved, driven by inequity between less and more well-off communities.
• The best way to achieve the global goal of universal access to health care is to centre primary care in the overall service delivery model.
• Private, non-profit healthcare providers aligned to a shared strategy can facilitate access, ensuring more people receive care.

This World Health Day – themed "My Health, My Right" – hones in on the global ambition to see universal access to needed health services without financial hardship, a goal that is far from being achieved.

According to the World Health Organization (WHO), in 2021, about 4.5 billion people, more than half of the global population, were not fully covered by essential health services. With governments balancing health spending against other priorities such as education, social security and national defence, alternate solutions are needed.

Private, not-for-profit healthcare providers can play a critical role but only in an enabling environment, which has been difficult to cultivate.

Elusive universal health coverage

Recent WHO data suggest that improvements in health service delivery coverage have stagnated since 2015. The world is “off-track” in reaching the UN Sustainable Development Goals to deliver universal health coverage by 2030.

At the heart of the issue is inequity. Health services are still more accessible in wealthier, developed nations and within more affluent and educated urban communities in low- and middle-income countries. Women and indigenous or migrant populations face particular barriers.

As healthcare systems grapple with these issues, alongside post-pandemic backlogs and funding constraints driven by uncertain geopolitics and macroeconomics, universal health coverage grows ever more elusive. The WHO suggests that the best way of staying on course is to centre primary care within the overall health system, providing a full spectrum of services as close to people as possible.

In this model, prevention is as important as cure – health education starts at home, with progressive levels of care provided through local clinics, followed by regional and national hospitals. Enabling this shift, however, can be difficult in many countries. It requires a carefully constructed approach and rational resource investment across the different levels of care. So, how do we achieve this?

Private health care as an asset

One solution is integrating privately-run institutions into healthcare systems – a practice that has existed for centuries. Charitable, philanthropic and faith-based communities have provided health care since late antiquity. The sixth-century Academy of Gondishapur in Persia, the sixth- and seventh-century mediaeval monastic hospitals in Italy and Spain, the ninth-century Hôtel-Dieu in Paris and the 12th-century St. Bartholomew’s Hospital in London are examples.

Recently, many private providers in low- and middle-income countries have been superseded by state-run public systems that seek to provide affordable, quality health care. This system has prompted debate about the relevance of private provision, as some argue that health care should be a government responsibility.

However, private health care has not gone away, partly because it can provide a broader range of services than government-funded health care. In fact, around a third of the world’s health spending is on private health care, a figure often far higher in poorer countries, according to the World Bank.

The right focus for debate is not whether private providers remain relevant but how they can best complement national healthcare goals. Not all private healthcare providers seek to generate a profit for their owners or shareholders. In private, not-for-profit healthcare systems like ours, which run almost 900 health centres and 30 hospitals in Asia, Africa and the Middle East, fees are reinvested in the hospital or health system to better respond to the needs of the local community.

To properly complement public services, these systems must collaborate with the government. Likewise, the state must provide the policies, incentives and standards that enable the private sector to invest.

Many real-world examples demonstrate the success of this approach. Cambodia has seen significant success since 1998 by contracting out government health care to private providers. Evidence from Brazil’s São Paulo state also suggests a range of positive outcomes from contracting non-profit organisations to deliver primary healthcare services.

One of the Aga Khan Development Network’s partners, La Chaîne de l’Espoir, has made high-end medical-surgical expertise available in more than 30 countries since 1994, saving thousands of lives and transmitting critical knowledge to local medical teams. In Syria and Afghanistan, we have supported struggling public health systems through recent crises, ensuring provision where public services were absent and bolstering capacity to deal with mass casualties and disease outbreaks.

Bringing private providers into the fold

Private healthcare providers vary greatly and the right blend of private and public provision will always be country-specific. However, as countries aspire to universal health coverage, all providers must be aligned with a shared strategy. Governments can help achieve this alignment while creating a level playing field. Tools include licensure, joint planning with all stakeholders, performance measurement, process monitoring, complaints systems and social health insurance schemes.

Government stewardship of such tools can enable fair participation by both public and private providers. In Egypt, a family health fund has been established to contract with public and private providers and purchase services for insured and uninsured users. Health facilities must meet accreditation criteria and have their patient care assessed by the Ministry of Health. Low-scoring facilities are barred from accreditation.

Public-private partnerships (PPPs) are another powerful tool to ensure alignment. They enable governments to contract private providers to offer specific services with well-defined outcomes and regulatory compliance. We have engaged in PPPs to establish and upgrade facilities in Afghanistan, Pakistan and Tanzania, achieving a positive impact on health throughout.

In one Afghan provincial hospital we saw admissions rise from 1,900 in 2004 to more than 12,000 in 2023, and outpatient attendances from 43,000 to 244,000 in the same period, with good patient outcomes. It became Afghanistan’s first public hospital to acquire SafeCare certification based on international quality standards.

Outcomes, not ideology

With the world off-track to achieving universal health coverage by 2030, governments cannot continue with business as usual. Private providers, especially those in the high-quality, not-for-profit sector, offer a lifeline to countries seeking to leverage scant resources. Creating an enabling environment for such providers can facilitate better health outcomes for all.

Policymakers should not be bound by ideological objections to non-state provision because the alternative is too often no provision at all.

Dr Gijs Walraven

Dr Gijs Walraven is the Director for Health of the Aga Khan Development Network (AKDN), and the General Manager of the Aga Khan Health Service (AKHS) companies which are located in South and Central Asia, East Africa and the Middle East. He is also Honorary Professor in Community Health Sciences at the Aga Khan University. Before joining AKDN in 2003, Dr Walraven spent 15 years working in Africa in healthcare provision, management and research, with a major emphasis on district health systems.

This article has been published on World Health Day 2024 in coordination with the World Economic Forum Agenda.