Public vs private health care: time to call a truce?

The consequences of the challenge to the Affordable Care Act will extend beyond the US. Whilst woefully inadequate, the Act at least tried to address some of the inequities in health care in the US. On the side lines, countries such as the UK which have national health schemes, have remained silent and self-righteous, resting on the remnants of their social justice laurels. It is a poorly held position, when in fact, the situation in the Western world is becoming remarkably similar – irrespective of the whether the health insurer is public or private. Worldwide, the unmet need in health is growing and the resources are shrinking.

Ten percent of GDP from both public and private sectors for ten years is needed to ensure that global health is protected.

Rather than widen the gulf between public and private sectors, we should be calling a truce and finding ways for effective and efficient partnerships between them. Public–private partnerships (PPPs) are an important way forward. These partnerships are already working in developing and underdeveloped countries e.g. to introduce vaccines (HIV) and drugs against communicable diseases (malaria and TB).

Sadly, they have been less successful in service delivery – especially in the Western world. Ideological differences leave many partnerships paralysed by political debates or public opposition; either because of their focus (profit versus people is a familiar catch cry) or the subject matter of those projects (essential versus non-essential services).

The goodwill is there. There are many examples of effective partnerships in research, genomics, large datasets and telemedicine, where there are large potential health gains and profits to be made. It just hasn’t transferred to service delivery in hospitals and the community. That is because health insurance and health service delivery are as not profitable as other joint ventures.

Also, the legal and regulatory frameworks which apply to both public and private sectors do not help partnerships between the public and private sectors. Government watchdogs, such as quality care commissions, regularly identify inadequacies in both sectors but governments’ capacity to enforce changes in the private sector are limited.

The private sector has a primary responsibility to its shareholders and owners to provide an efficient and profitable business. If this is not possible, they are obliged to cut their losses. The public sector that must then step in to provide the service. These differences in accountability make partnerships difficult to set and to maintain.

It is about time that accountability was shared. This requires both the sharing of risks and the long term investment in health systems. For example, the private sector is very adept at excluding services and care to patients who are very sick and costly. Transfer of these patients to the public sector, which often occurs should incur a penalty or subsidy from the private sector.

Any initiatives require a sustained commitment in real terms to funding of health care. This is a global issue. The WHO, under its new Director General, should actively engage in an International commitment of 10% of GDP from both public and private sectors for 10 years to ensure that global health is protected.

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