The experience of health care in mixed health systems

KABIR SHEIKH: The previous sessions will have oriented you to the public/private split in financing and delivery. Most health systems in high income countries can be understood to fall somewhere on this chart based on the financing model that predominantly applies and the major source of service delivery. Here are some examples of how the public/private split applies in selected high income countries. We have, for example, Denmark, Finland, Portugal, and the UK as countries with predominantly public financing and also government-provided services. On the other hand, in Canada, the government financially supports citizens to utilise private health care services. Switzerland has a predominantly private model for service delivery and financing.

Of course, while these appear to be discrete categories, there’s always a mix, and the box is mainly referred to the dominant modes of financing and delivery. Low and middle income countries also have a split between public and private financing. However, this is where things get a little more complicated. In many low and middle income countries, for a range of reasons, we need a more nuanced understanding of the public/private mix than these simple categories can explain. The concept of mixed health systems gives us a more accurate understanding of people’s experiences in low and middle income countries, both the users and providers of care.

Mixed health systems are described in this paper as entailing centrally-planned government health services that operate side by side with private markets for similar or complementary products and services. This is a useful way of appreciating that the demarcation between public and private health services and financing is not always planned, or sometimes it doesn’t always work as planned. Mixed health systems in low and middle income countries

often share these four characteristics: diverse types of health care services and providers; private health care markets that are dominant but poorly organised and regulated; public services that are compromised in different ways, and; a blurring of the distinction between public and private services. This might all sound a bit confusing at this stage, so let’s unpack these phenomena one by one starting with what we mean by diversity in health care services and providers. What does health service diversity mean to you? Different types of facilities? Coexisting public and private service providers? Let’s look at some of the ways in which health care provision is diverse.

First of all, as we have already established, there’s a public/private mix in types of ownership of health care facilities and also in how people pay for services, sometimes, but not always, corresponding to ownership. Second, health care facilities range from the formal to the informal. Why do we use the word range here? Because it’s often a spectrum and not a binary. There are many types of health care providers who may not be fully licenced yet receive some form of accreditation or recognition. Others exist completely outside of the formal system and flourish only on the basis of client demand and the absence of regulation. Third, invariably in different parts of the world, entire systems of knowledge about health and medicine may vary.

This is important, for example, in many Asian settings but also in other parts of the world. Can we make a clear distinction between Western and non-Western forms of medicine? Again, not necessarily since many practitioners of Western medicine use non-Western medications and approaches and vice versa. Fourth, we see a spectrum from highly specialised physicians to medical and nurse assistants, community health workers, and home-based care providers on the front lines of health care services. So what do we take away in terms of our understanding of the diversity in health care provision? It’s evident that health workforce diversity has multiple overlapping dimensions. Further, it’s probably closer to reality to represent these different dimensions as spectra rather than as clear categories.

This brings us to what we can call the policy attention anomaly of mixed health care provision. Look at the right side of the figure– informal and lay providers and those practicing local and indigenous health care systems. Formal, global, and national policies are seldom drawn up with these sections of the workforce in mind. Yet, paradoxically, these sections of providers are the ones who are often physically, socially, and culturally closest to the communities most in need of services and are hands-off and in an advantageous position to have an impact on population health. The second key characteristic of mixed health systems is the dominance of poorly regulated private markets.

Patients, even poor patients, often prefer private health care when it’s available. Patients perceive non-state sector health care providers to be more responsive to their preferences in terms of privacy and speed of service. And they are often also more geographically accessible than public sector providers. Drugs are sold to general retail outlets with convenient opening hours. However, private health care in LMIC has a number of problems. It is often unregulated, and this leads to a range of quality, safety, and ethical concerns. Notably, also, the more trained formal, private provider naturally tends to locate themselves away from areas where they’re needed most. The third characteristic of mixed health systems is compromised public services.

Public expenditures on health care in low and middle income countries are a small proportion of total health expenditures. And, in many of these countries, public financing for health is typically lower than out-of-pocket expenses. Furthermore, there is often disproportionately high expenditure on large capital investments, leaving recurrent costs underfunded. As important as the low overall financing commitment in the public sector is the inefficient application of those funds. We often see poor standard of services and also problems of unfilled vacancies, absenteeism, lack of procedural transparency and accountability, poor management – all ultimately leading to the low credibility of public services in communities. The fourth important characteristic of mixed health systems is blurring of the public/private distinction.

The fact is we often see private behaviour in the public sector and, conversely, often public-minded behaviour in the private sector. Two prominent examples of such behaviours are informal payments and dual job holding. In addition to these sometimes informal behaviours, there are also a range of partnerships and associations that are deliberately made between the public and private sector. Here is a summary of the four key characteristics of mixed health systems. As you will have gathered, the true picture of mixed health systems as they’re experienced is more nuanced than the simple characterisation of a public/private split across financing and delivery. In terms of the implications for users of care, mixed health systems can sometimes mean more choices.

However, we can also see the attendant problems of high expenses related to health care, variability in the quality of care provided, irregularities in the ethical conduct of health care providers, and the unavailability or unequal availability of health care providers.