A lack of strategy, tools, and know-how about working with the private sector is impacting countries’ responses to COVID-19 and universal health coverage efforts, according to David Clarke, team leader for UHC and health systems law at the World Health Organization.
The private sector could be playing a critical role in providing maternal health and other essential health services, especially when the public sector is so overwhelmed, he said, but many countries don’t have the necessary governance know-how or infrastructure in place to allow this to happen.
“This is a really important issue because now more than ever, countries need a whole-of-government, whole-of-society approach if they're going to tackle COVID-19,” Clarke said, adding that many countries have large and growing private sectors that are major sources of services but that historically they have been weakly governed and poorly coordinated.
“We think private sector providers can and should be engaged in the [COVID-19] battle, but we do need to fix this long-standing governance problem. Otherwise, they can't be effectively engaged.”
As defined by the Organisation for Economic Co-operation and Development, this is an activity that aims to engage the private sector for development results, which involve the active participation of the private sector.
The definition is deliberately broad in order to capture all modalities for engaging the private sector in development cooperation, from informal collaborations to more formalized partnerships.
To read more about the definition and how Maternity Matters: Funding the Future is exploring the topic, click here.
To help its member states, WHO — having started working on this governance issue prior to the pandemic — has begun rolling out a new governance strategy on engaging the private health delivery sector in mixed health systems as part of its work on UHC that could be considered more vital now than ever.
In an interview with Devex, Clarke discussed the challenges countries face with private sector engagement amid COVID-19, how the new strategy might help, and how WHO itself is leveraging the private sector in pandemic response efforts.
This conversation has been edited for length and clarity.
WHO recently did some research on local private health providers, specifically around low- and middle-income countries, amid COVID-19. Are you able to share any of the findings from that?
We looked at the problems countries were facing so we could tailor our governance support. Some countries simply lacked experience working with the private sector, so they were understandably unwilling to work with them in the current emergency, and we are working to fix this. Many countries didn't have basic information about the private sector and so couldn't undertake resource-based planning about private sector resources that might be available for the response. So we issued a plan to help.
We also found problems with some emergency laws. For example, some laws stopped governments from contracting private providers to provide extra capacity.
One big issue is the financial viability of private health businesses who have suffered significant financial losses because of COVID. Many businesses may go bust and lay off health workers. This is worrying because it affects access to health services and reduces the size of the health workforce just when it is most needed most.
There isn't much known or discussed about this problem or its scale and severity. There is no guidance for governments on whether to support these businesses or on how to stem workforce losses. Because the private sector is such a big provider of health services to the poor, the prospect of large numbers of private providers going bust and health workers lost to the response could be catastrophic.
So we are conducting follow-up work to assess the scale and severity of the problem and provide guidance for governments on how to financially support the private sector where this makes sense because of domestic population health needs, including, of course, the needs of women and children.
An example of a possible solution is having the public sector focus its efforts on the COVID-19 response and contracting the private sector to provide essential health services, such as maternal health services. This model can be a win-win because it increases system capacity and also provides a financial lifeline to health businesses.
In its new strategy, what specific policies or practices is WHO recommending for private sector engagement?
In brief, [the strategy] outlines the importance of six governance behaviors critical to successful private sector governance. They represent a fundamental shift in approach and amount to doing governance in a new way.
A foundational behavior is building understanding through better data of private health sector activities. At the moment, we have a big data gap. The second thing we think is important is fostering relations between the public and private sector. Both groups need to understand each other’s priorities and activities if we want collaboration and collective health action.
The starting point for this is public-private dialogue — a structured mechanism that brings together public and private actors to identify, prioritize, implement, and measure policy reforms and actions. It's a very important tool, and it's already proven instrumental in bringing the private sector into the COVID response in countries we have supported, and we are writing up advice on how to do this.
We recommend that all countries have an agreed plan for private sector governance, setting direction and articulating roles and responsibilities for the public and private sector. Many countries don’t have this, and we have new guidance in development to help. We recognize that the key to implementing these plans are tools — regulatory tools, financing tools, and information tools — and so we will support governments here as well.
Two important and closely related aspects are aligning structures — to line up public and private structures, strategies, and activities — and creating an enabling legal, policy, and institutional environment that provides the governance infrastructure needed so the private and public sectors can fulfill their respective roles. This is very country-specific work, but we are planning to produce some models to help country efforts with this.
Last is the issue of how to build trust. When you talk about private sector engagement, the question of trust always comes up. We think that the best way to do that is sharing information and data using common metrics. We are currently working on a concept note about data-driven governance and how it can be used to build trust.
What's your recommendation for tracking engagement with the private sector?
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I think it's fair to say that there's a major gap when it comes to data and information sharing, not just in the maternal and child health area but across the board.
As I said, this is a high-priority area for our governance support work. For example, if you're going to work with private providers to provide maternity services, we need common standards and guidelines for care and quality which are applicable to all providers. We need the public and private sector to report on care practices, and we need integration of private providers in countries' referral systems. This is a big governance challenge that we need to grapple with.
How is WHO strategically leveraging the private sector?
First of all, we're looking to convene global health actors to build more political will to work on this topic because there are still countries who are unwilling to work with the private sector. We want to work with our member states and our global health partners, like the World Bank, using platforms like UHC2030 to discuss how we can help countries to work with the private sector.
We also need to ensure the governance behaviors we have developed are embedded in all work with the private health sector. So, we're having a series of conversations at the moment with partners who are implementers at the country level about how to do this.
Obviously, WHO is a norms- and standards-setting organization, so we're embarking on new work to look at the norms and standards that are necessary for private sector engagement, with a big focus on this whole question of data and the important topic of accountability.
We're [also] talking to the research community about research topics that they should be looking at in relation to the private sector, especially looking at action research on engagement models. One [piece of research], funded by MSD for Mothers, is an example of this, looking at how the private sector can be engaged to help improve access to sustainably delivered quality care for mothers, newborns, and children.
The Funding the Future series is supported by funding from MSD, through its MSD for Mothers program and is the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co., Inc., Kenilworth, NJ, U.S.A.