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Hi everyone, welcome back to Health Systems Pathways. This podcast shares insights to inform, inspire, and spark discussions about making health systems easier to navigate in low and middle-income countries. I'm Alex Ergo, PSI's Director of Health Systems, and I'm really excited to bring you another special episode recorded live at the Health Systems Research Symposium in Nagasaki.
In today's episode, we focus on governance in mixed health systems, an area that's essential for ensuring health systems work for everyone. First, we'll hear from Catherine Goodman, who shares findings from a scoping review on governance in the private health sector. Her research highlights the need for clear government vision and better integration of governance tools. Then David Clarke from WHO introduces the progression pathway tool, which is helping countries improve governance step by step.
So, let's dive right into these fascinating conversations. Hi, everyone. I'm now with Catherine Goodman. Very nice to have you with us. Would you mind just briefly introducing yourself?
Yeah, great to be here, Alex. So I'm Catherine Goodman, and I'm a professor. I do health economics and health systems research, and I'm based at the London School of Hygiene and Tropical Medicine.
Yeah, thank you. And this morning you presented on a paper that was just issued on the governance of the private health care sector in low and middle-income countries. And there was a scoping review. Would you mind saying a few words about that?
Yeah, sure. So this is a review that was commissioned by WHO and they were keen to really understand the evidence base on governance of the private health sector in low and middle-income countries. So we were charged with trying to search for and synthesize the published and grey literature in that area.
And what were the main findings?
Well, there are a lot of findings across many different areas, stretching from regulation to purchasing to stakeholder engagement and data. But I think probably easier if I jump to some of the take home messages across all of that. I think one of them was that when you're involved in governance, you really need to start with a clear vision of where you want to end up.
If the government doesn't have a clear vision of that, the private sector will have many of their own visions, which they may impose through their own activities, and it may not lead you to the UHC destination you want to go to. So, the government needs to start with a very clear vision of what it would like the private sector's role to be. I think another real message that came from the review was the importance of exploiting synergies between different governance mechanisms.
So, for instance, we may think of regulatory mechanisms or contracting mechanisms or data system mechanisms, but it's really important to make them work together. So, for example, thinking about making empanelment into a contracting mechanism contingent on compliance with a regulatory mechanism or making licensing contingent on compliance with reporting your data. So really thinking of these different mechanisms as part of one system interacting with each other.
¶ Challenges in Mixed Health System Governance
One finding, I think, which did surprise us a bit was how much governance is done at a devolved level within health systems. So you've got governance at a national level, but in many countries, their devolution to states or counties is really important in health care. And so, it's a real challenge at that level to undertake the governance function, and you often find real gaps in capacity there. There having said that capacity can be a problem throughout the whole health system.
And we really saw that in terms of the skills that you need to govern. A lot of people who work in ministries of health have always worked in the public sector. They're not necessarily used to dealing with private sector commercial entities, and they don't have the skills needed to, say, think about designing good contracts and incentivizing appropriate behavior. So we really need to work out how to address some of those capacity gaps.
And did the scoping mission also come up with recommendations?
Well, I guess the scoping review was designed to support WHO's work in developing a progression pathway for the governance of mixed health systems. So WHO have designed this document which helps countries assess themselves on how they're doing on their governance, governance activities, and assess themselves under different categories of how well they're performing from a sort of nascent level up to a really strong level in different areas.
So this review was designed to inform that and help them design that progression pathway.
That's great. And that's the work that's being led by WHO Dave Clarke's team, right?
So, they're working with countries at the moment to try that out and see how it can support them in really strengthening their governance mechanisms.
I think we'll have a chance to talk to Dave as well, so thank you so much for sharing that. Was there anything else you thought would be worth sharing with the audience?
I guess one thing we've been talking a lot about is a fine balance that every government has to try and tread when working with the private sector. On the one hand, you want to really build trusting relationships and partnerships and listen to the private sector and understand their needs, their constraints.
But at the same time, you've got to be constantly guarding against undue influence by private sector actors over the direction of government policy and really trying to make sure you have systems in place that avoid conflicts of interest. And I think that is one of the hardest challenges as government operators in this area to try and keep both of those things in mind.
That is indeed a great challenge that I've seen myself in several countries. So yes, thank you so much for sharing that and thank you for joining this podcast.
¶ WHO’s Progression Pathway with David Clarke
So we just heard from Catherine Goodman about the scoping review that she conducted and a nice follow on now is our new guest, David Clarke. So David, would you like to introduce yourself first?
Hi Alex, I'm David Clarke. I work at WHO headquarters in Geneva and one of the topics I work on is private sector engagement.
As I understand, you've been basically building on this work that Catherine described to build this progression pathway. Could you say a few words about what exactly that is?
So we commissioned Catherine and her colleagues to carry out the scoping review for us to help us to put the progression pathway together. So the progression pathway is, I guess, it's a maturity model for looking at how governance can be built over time in countries. The idea behind it came from our expert advisory group on the private sector, who told us that we needed to do more to explain in a very granular way to countries what they needed to do to strengthen their governance.
That both, both their governance norms, but also their institutional arrangements and the idea behind the progression pathway is that the strengthening process isn't a one off process. It is a continuum where we want to ask governments to look at how they can strengthen their governance over time and as part of a continuing strengthening process. The idea behind the progression pathway is that, of course, we can't come up with a standard guide for all country contexts.
So instead, we decided it was best to provide a framework which allowed countries to make their own decisions about how they wanted to govern.
Has the progression pathway already been tested in some countries or what's the status right now?
Yes. So we, we pretty, pretty much started working with countries in March. So we've worked in Egypt and Oman in the Emirate region. We've worked in Georgia in our European region. We've worked with Ghana in our African region. And we're about to work with Ethiopia, uh, Syria and Somalia and Tunisia.
And any insights from this work?
Yes. There's a couple of things I wanted to highlight. All of these countries have used the progression pathway in a different way. They've chosen different entry points which was really great. We designed this document and this approach to be fully flexible. So we're very happy that countries have made their own decisions about how to use it. They've all come to very different conclusions about how they want to take this work forward.
And they've all describe for us, both the Ministry of Health colleagues and also people from our country offices, how useful they find it. They find it a very practical tool. They've also told us that it seems to cover off all of the key issues that they'd expect to have to think about when it comes to this topic. So we're very gratified that it seems to be well received and working well.
And what's next now? So, it's being tested in a number of countries. So, what's the next step?
Well, the next step, I think, is to complete some more testing. And then, once we have a critical mass of countries who've undertaken this first round of work, we're going to convene a meeting of all the countries, both, both the consultants who are involved and also the Ministry of Health people, to get some feedback from them on what we can do to improve the document.
It's a document which we recognize we're going to have to continue to improve over time, taking into account country experiences with it but I think we already have some ideas about what we need to do to support countries further with this work.
And initial reactions from Ministry of Health people?
They're all really delighted by it. They find the concepts very familiar, they find the way it's put together very logical, and they find it very helpful for their interactions with their stakeholders in their countries.
So what we are doing in each country is bringing together, under the guidance of the Ministry of Health, stakeholders from both the private and the public sector, and we're getting good feedback from all of these stakeholders about how useful the document is and how comprehensive the framework is.
And does this convening that's happening at country level also involve the voice of the individuals, the beneficiaries, the patients?
Yes, there are consumers involved in these discussions. I think we need to look at how this has been done. All the countries are doing the different way. So some of them are bringing in consumer representatives, some of them bringing in consumer organizations, but we always thought that this process should involve the end user, the people who need to be benefiting from our efforts to work with the private sector.
And when you say private sector, what kind of representation from the private sector do you see in the countries when, when those convenings happen?
Okay, so just to clarify, when we talk about the private sector, we're talking about all of the non-state actors who aren't part of the government. So, we'll have the not for profit private sector, but also the for profit private sector. And it really depends on the country context which private sector is, is heavily engaged.
So for example, we're doing work in Ghana at the moment, and a lot of the efforts that the Ghana Ministry of Health are undertaking a focus on the not for profit private sector, because of course they've long had this relationship with faith based providers in Ghana, whereas in some other countries, so for example, we're doing work in in Georgia. The focus is more on the for profit private sector and on hospitals.
This is the beauty of this document and the approach is it can be used in a variety of contexts with a variety of different private sector actors.
And are there examples of countries where these private sector representatives also includes, for example, private pharmacies or GP clinics or even informal drug vendors?
Um, not yet. No, none of the countries that we've worked with yet have focused on those issues, but of course, I'm sure some of them will. We've designed the document in the way which allows but we've really left it to the countries to decide what the entry point should be for this work.
And that's great. So thank you for sharing that. A last question, you had the session this morning. What was the key takeaway from the session or any surprise that you heard there?
I think that we got really g reat feedback about the utility of the document, which is, of course, a huge relief. We had some really experienced health systems people in the room, so it was great to have their endorsement of this.
Uh, they also came up with some really great ideas about how we can support countries to undertake the ranking process that's part of the progression pathway, because the progression pathway has countries look at where they sit on a continuum of capacities, so there was some really great feedback about how we could do that, and there was also some really great feedback about how we could enhance the process, maybe by developing some tools that could be used for the process, such as patient pathway analysis.
Also there was some great discussions about whether or not we could come up with some tools for implementation of the decisions that could be made using the process. So, we have lots of takeaways and lots of, lots of work to do.
Great insights from Catherine Goodman and David Clarke. Catherine outlined the importance of a strong, clear vision and coordinated governance mechanisms, while David shared how the progression pathway is already helping countries strengthen governance in practical and flexible ways. Thank you for tuning into Health Systems Pathways. If you enjoyed this episode, don't forget to subscribe or follow us wherever you get your podcasts.
We'll bring you more fresh insights straight from the halls of the HSR symposium in Nagasaki very soon. Until next time, I'm Alex Ergo. Let's keep working together to build stronger health systems that work for people.