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Putting governance into practice: The engagement of private health sector for Universal Health Coverage and health security

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Editorial

Hanan Balkhy1 and Bruce Aylward2

1Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Assistant Director-General of the Universal Health Coverage, Life Course Division, World Health Organization Headquarters, Geneva.

Keywords: health systems, health security, private sector engagement, multi-sectoral, private health sector, governance, health policy, health for all.

Citation: Balkhy H, Aylward B. Putting governance into practice: The engagement of private health sector for Universal Health Coverage and health security. East Mediterr Health J. 2024;30(12):807–809. https://doi.org/10.26719/2024.30.12.807.

Copyright: © Authors 2024; Licensee: World Health Organization. EMHJ is an open access journal. All papers published in EMHJ are available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction

The private sector’s involvement in health systems is expanding globally and in the Eastern Mediterranean Region (EMR). This involvement includes a wide range of activities, from the provision of health services, medicines and medical products to workforce development and training, health financing, information technology and infrastructure development, and support services such as provision of catering and laundry services for health facilities. Contributions by the private sector are prominent in various contexts, including in fragile, conflict-affected and vulnerable settings where the sector has been playing significant roles in responding to population needs, especially in maintaining essential health services and in trauma response (2–4). In 2019, WHO estimated the private sector’s contribution to health services delivery to reach 62% in the WHO Eastern Mediterranean Region, 57% in the South-East Asia Region, and around 40% in the Americas Region, the African Region and the Western Pacific Region (5).

As the public sector has historically been the main provider of health services in many low- and middle-income countries, the recent emergence of the private sector has introduced new dynamics and created a myriad of policy vacuums. The lack of effective private sector engagement strategies has posed several challenges to patient outcomes, safety and equity due to the associated out-of-pocket payments, lack of oversight of clinical practice and limited enforcement of regulations (6). As a result, the private sector's contribution to health systems often raises concerns about regulation, quality of care and equitable access to services (7). These concerns are particularly pronounced in fragile, conflict-affected and vulnerable settings, where institutional and governance capacities can be extremely low (7–9). Consequently, national governments may find themselves with reduced influence, while other powerful actors, such as donors, foreign governments and the private sector, play a significant role in shaping the national health agenda and health systems, sometimes with little or no oversight (10). To fill the vacuum, WHO has issued a call to action to enhance private sector engagement in the health sector as part of the Sustainable Development Agenda, with strong emphasis on the need for effective governance of the whole health system (11).

Shifting mindsets towards health systems governance

The approach to health systems governance is now shifting towards a more inclusive governance model that integrates both public and private sectors within mixed health systems (12–14). This shift in approach is currently being observed globally and in some EMR countries. For example, the Sultanate of Oman recently conducted a comprehensive assessment of the health system with a focus on the private health sector, to inform the development of its 11th 5-year plan for health development (2026–2031). The renewed call to re-orient health systems towards the primary health care approach gives new impetus to this shift (15) and this necessitates substantial transformation in policy prioritization, funding and implementation, and calls for robust health system governance that oversees the entire health system to protect public interests and achieve national and global health goals (16–18).

WHO has been at the forefront of efforts to increase engagement with the private health sector. The 2010 World Health Assembly Resolution WHA A63.27 called for improved engagement, oversight and regulation of private health care providers, in recognition of the increasing and largely unregulated role of the private sector in providing essential health services (19). And in 2018, the Regional Committee for the Eastern Mediterranean became the first region to endorse a resolution on private sector engagement for advancing Universal Health Covergae (UHC) (20).

In response to the global and regional resolutions, in 2019 WHO published the "Private Sector Landscape in Mixed Health Systems", highlighting the contributions of the private health sector to service delivery globally (21), which was followed by the 2020 strategy report: "Engaging the Private Health Service Delivery Sector through Governance in Mixed Health Systems". The strategy proposed a socioecological and practice-based approach to effective governance of mixed health systems through the introduction of 6 governance behaviours (12). In parallel, WHO Regional Office for the Eastern Mediterranean conducted an extensive assessment of the operational environment of the private health sector and its contributions to specific programme areas in the EMR (7,22). A review of the role of the private health sector during the first year of the COVID-19 pandemic was completed in 8 EMR countries to support efforts by Member States to implement WHO’s interim guidance on the whole-of-society response to the pandemic (23). WHO is also developing the “Progression Pathway for the Governance of Mixed Health Systems” to provide guidelines for further support to countries. The Progression Pathway is a tool that will help countries in aligning behaviours, capacities and instruments to better govern public and private sectors as a whole (24).

In July 2024, WHO held its first inter-regional meeting on advancing private sector engagement for UHC and health security in Cairo, Egypt. The meeting was attended by representatives of 5 WHO regions and presented WHO’s guidance on governing mixed health systems and the role of the private health sector in health financing and fragile, conflict-affected and vulnerable settings. The meeting explored strategies and lessons learnt from engaging the private sector through the flagship initiatives of the regional director for WHO Regional Office for the Eastern Mediterranean, which aim to enhance access and supply chain and strengthen the health workforce. Following the meeting, a joint statement was released on behalf of the participants reinforcing the need for strong government leadership and inclusive governance for efficient operation of the whole health system. Such inclusion is to ensure that health services are available, accessible, affordable, acceptable, and of good quality wherever people can and choose to access them. The statement affirmed the value of the Progression Pathway approach for enhancing governments' capacity to create a conducive and enabling policy and regulatory environment for effective engagement with private health actors to achieve national UHC and health security goals.

Future directions

The Fourteenth General Programme of Work (GPW14) of the WHO emphasizes the critical importance of strengthening the governance of mixed health systems and effectively integrating the private sector into primary health care-oriented models of care. This work will prioritize support to governments in identifying private health sector engagement strategies such as exchange of data, contracting and establishment of inter-sectoral communication channels. In this regard, WHO will support Member States in developing the required policy and regulatory frameworks to ensure the alignment of the engagement strategies with UHC principles. This entails assisting Member States in leveraging purchasing mechanisms to align incentives and facilitate compliance with health system goals, and supporting them in enhancing the inclusion of the private health sector within routine health information systems to facilitate productive exchanges and evidence-based policymaking.

At the regional level, WHO will focus more on governance of the private sector in fragile, conflict-affected and vulnerable settings and to addressing the unique challenges these settings present through adapting the Progression Pathway to this context. Efforts will be made towards strengthening the role of the private health sector in supply chain and health workforce development.

Conclusion

The United Nations General Assembly, the World Health Assembly and the Regional Committee of the EMR acknowledge the indispensable role of the private health sector in advancing UHC and other health-related Sustainable Development Goals. However, the evolving role of the private sector presents certain challenges and opportunities. Therefore, having a clear nationally defined vision for the private sector’s role in the delivery of UHC goals, and ensuring the capacity for effective governance, optimal synergies and engagement are essential to align private sector contributions with national health priorities and UHC goals. WHO has been proactive in supporting national efforts to enhance private sector engagement by providing technical guidance and tools, including the forthcoming Progression Pathway for the Governance of Mixed Health Systems.

Moving forward, it is imperative to promote government leadership and stewardship to create a conducive policy and regulatory environment with the private sector and the strategic partnerships needed for achieving UHC and health security.

References

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