Last weekend, on 12 December, the world celebrated UHC Day, with a call for greater action and progress on delivering Universal Health Coverage (UHC). Countries all over the world need to take further steps toward ensuring access to essential, affordable, quality health care for every person, everywhere. As you might recall, end of September, at the launch of the Sustainable Development Goals (SDG) agenda in New York, UHC was included among the SDG health targets (as part of SDG goal 3). UHC is considered by many key global health stakeholders as an ‘umbrella target’. In short, there is clearly a growing movement to ensure realization of this UHC agenda across the globe, with the ‘very high-level’ conference on ‘UHC in the new development area’ in Tokyo from earlier this week as the latest case in point. The focus is now firmly on the ‘how’.
What is the picture in Uganda? Let’s first go back to last summer. In August 2015, Makerere University School of Public Health hosted various health stakeholders at a symposium in Kampala, under the EU funded Supporting Policy Engagement for Evidence-based Decisions (SPEED) Project. The discussion centered on how Uganda can achieve UHC and what policy reforms will be critical in this pursuit. The symposium closed with a resounding call for policy reforms in areas such as prioritization and use of evidence in policy making. Symposium participants also called for strong political commitment to effectively and successfully implement UHC, and stressed the need to streamline leadership and governance for health and political commitment to the UHC agenda.
In Uganda, the Health Sector Development Plan (HSDP 2016-2020) emphasizes the need “to accelerate movement towards Universal Health Coverage”. The debate on UHC and how Uganda should proceed towards the realization of this goal is currently in full swing. While it is true that the Ugandan government has the greatest responsibility and role in this pursuit, in this article I call for a strong engagement with non-state actors (which clearly include the private sector) as they are also important stakeholders on the path towards UHC in Uganda. Both the sheer size of the private sector in health service delivery in Uganda as well as their unique capacities and advantages should be capitalized upon for furthering UHC, in my opinion, while making sure about avoiding pitfalls. In this article, the private sector includes both private health providers and the business sector in general.
To understand this point further, let’s look at some of the facts. In Uganda, non-state actors are big in the health sector and they continue to expand. Non-state actors include private for profit (PFP) entities (private hospitals, clinics, drug shops and pharmacies) and not-for-profit (PNFP) entities (faith based hospitals and institutions as well as non-governmental organization (NGO) health service delivery institutions or organizations). Data from the Ministry of Health (2010) indicated that about 40% of health facilities at all levels were privately owned and almost 50% of health services were delivered by these non-state actors. In as far as child health is concerned, recent studies by Makerere University School of Public Health on health seeking behavior for under-five children reported that more than 60% of sick children visit private drug shops (first point of care). A sizeable number are referred from public facilities to private drug shops particularly if medicine stocks in the public sector are insufficient. Yet, these studies have also found a number of challenges relating to the quality of services that some non-state actors provide. Carefully designed interventions and regulation are needed to address them. In addition, there are other limitations and pitfalls of the private sector that need to be taken into account and dealt with, if the private sector is to play a positive role on Uganda’s journey towards UHC.
As is true in other settings, key questions are: how can the private sector deliver a public good (health care) in a traditionally profit motivated environment, and ensure improved access to care for impoverished rural Ugandan people – an equity concern. The answers to these questions are never straightforward, but by and large, three facts stand out: 1) while health may be conceived as a public good – and indeed, a basic human right – this does not imply that its provision and delivery is an exclusive responsibility of government, and 2) while it is important that the private sector is extensively engaged in the UHC discussion as an important stakeholder, at the same time adequate mechanisms to address the sector’s inherent limitations in as far as provision and delivery of public goods are concerned must be put in place, and 3) it is the exclusive responsibility of government to create mechanisms as well as build its own capacity to regulate the private sector.
In addition to private providers of health services, let’s also reflect on what the private commercial sector could offer to public health. The private commercial sector is very instrumental in the area of innovation, with pharmaceutical companies, insurance companies, the telecommunication sector, and the banks all constantly trying to innovate. The sector boasts vast strategic opportunities for innovation, resource mobilization and efficiency, and at least in some there’s quite some trust. The discussion on achieving UHC should not lose sight of these rather important players within the private sector and the unique opportunities they present. Two quick – yet critical – examples may illustrate this: A recent report by the Uganda Communications Commission (UCC) indicated that about 53.2% of Ugandans owned a mobile telephone (Daily Monitor, February 26, 2015). Public health policy makers should be discussing how to take advantage of this mobile phone proliferation for public health education messaging, consumer empowerment and participation in health, awareness on new health technologies, community accountability, etc. – all issues that are clearly important for the UHC agenda. The second (and related) example concerns the growth of mobile money platforms – i.e. e-banking that uses mobile phones to send and receive money. The discussion should be focused on how to capitalize on these new platforms for health financing reforms in Uganda, particularly related to payment of health providers or premiums for insurance companies or third party payers.
While it is clear that the private sector has great potential to innovate and thus presents a huge public health dividend in principle, we must not be oblivious to the (many) intrinsic challenges that come with working with it. As already mentioned, most private players are profit motivated and the aggressive pursuit of their interests often “collides” with the “public interest”. Advocates of UHC must face this fact, and should thus explore how this important sector can be engaged, without distorting resource allocation from the public good to private good.
Many private sector skeptics have argued that the private sector cannot be relied upon for health care delivery. Their skepticism is often premised on two arguments: 1) health is a public good and this is even more true for certain elements of preventive care such as pest (vector) control, immunization, public health education, etc. and 2) health is universal, hence leaving its delivery to the market may compromise (financial and access) equity. While they have a point, we should also acknowledge the vast public sector (government) failure in many LMICs. Underfinancing, inadequate workforce size and motivation and bureaucratic inefficiencies all play a role in this.
In short, we must recognize the constraints and strengths of both government and the private sector. Instead of pitting them against each other, let’s try to work together to harness the synergies. Involving the private sector will ensure that everyone’s choices are best served, provide room for innovation, enhance mobilization of additional resources, and ensure buy-in for the UHC agenda from a broader spectrum of stakeholders. However, for this to happen, private sector engagement requires the creation of an appropriate regulatory framework and building of capacity within government to effectively implement regulations, and create adequate checks and balances for stakeholder interests.