Health systems the world over are in transition and investment in the public and private sector is crucial to support the changes required to meet the health needs of populations, according to a new Lancet Series published this month.

Social, epidemiological, demographic and economic changes are placing changing and growing demands on health systems which are not able to respond with the speed and agility required to meet population needs.

The research, which draws on nearly a decade of analysis, comes at a critical time as countries around the world wrestle with the rising prominence of the private sector in healthcare delivery and the common patterns of failure in many areas of private provision.

Professor Barbara McPake, Director of the Nossal Institute for Global Health at the University of Melbourne, and co-editor of the series, said that it was vital to ensure that policy makers have a clear and shared understanding of the private sector as a starting point for investment decisions.

"Universal health coverage means fair and equitable access to services according to need and not according to resources or power."

Professor McPake says that "this is as achievable in Eritrea and Somalia as it is for the UK and Japan". However she noted that there are tensions between access to appropriate healthcare to resolve health problems and promote health across the lifespan, and vested interests which negatively impact upon policy decisions.

Co-editor of the series, Professor Kara Hanson from the London School of Hygiene & Tropical Medicine, recommends that "the way to manage the private sector in these mixed health systems is through an effective public sector. A strong commitment of public funds is needed to ensure that poor people have adequate services available to them when they are sick and don't need to resort to untrained providers and low quality services".

The public sector can also influence the actions of good quality private providers.

"Through strategic purchasing of services from the private sector, as well as creation and enforcement of a regulatory structure, it is possible to support the provision of affordable, effective care" says Professor Hanson.

The Lancet series includes four papers and provides four key messages:

1) Private health care in low and middle income countries (LMICs) is very extensive and wildly heterogeneous, ranging from itinerant medicine sellers, through millions of independent practitioners, unlicensed and licensed, to corporate hospital chains and large private insurers.

2) The objective of public health systems must be to provide universal health coverage (UHC) responding to need.

3) Countries which invest substantially in subsidised health care in the public sector are much better able to regulate the private sector since the poorest health consumers are not forced to access unqualified private sector providers.

4) In order to direct policies toward UHC, the private sector must be marshalled under a public sector rubric. In the Australian context, there is relatively little engagement by the public in the root causes of poor health.

Professor McPake noted that the "interest and ire of the public tends to be on interventions such as GP co-payments and the annual increase in health insurance premiums rather than the health system itself and this tends to reduce the capacity of political systems to implement long-term solutions and manage conflicts of interest".

"As the epidemiological mix continues to change and people suffer from multi-morbidity - not just diabetes or heart disease or hypertension but a mix of these -health systems must be supported to treat people through primary care wherever possible, rather than increasing the burden on the secondary and tertiary levels of the health system where patients are more expensive to treat and relatively fewer people can be treated," Professor McPake says.

While health systems are stuck for political, institutional and professional hierarchical reasons, the critical decisions that governments need to make are to invest substantially in health care and to direct that investment to primary care and workforce reorientation and development.

Health systems begin with the people in them and people are significantly shaped by their early training. Thus opportunities to reshape and realign health systems may lie in the investment that is made in training the next generation of healthcare professionals and the extent to which they are able to manage the private-public balance.

The Lancet Series, was published on 26 June 2016. The paper "Managing the public–private mix to achieve universal health coverage" was co-authored by Professor Barbara McPake from the University of Melbourne's Nossal Institute which is part of the Melbourne School of Population and Global Health. Along with Professor Kara Hanson from the London School of Hygiene & Tropical Medicine, a world-leading centre for research and postgraduate education in public and global health, with more than 4,000 students and 1,000 staff working in over 100 countries.

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