 Hello, thank you so much CSIS for inviting us to this session on the role of the private sector. So I want to introduce my panelists first. So I've got Hoje Kaurasa, who is a senior economist at the World Bank Group. I know you focus on private sector involvement in health and education. And then we've got Dr. Ashok, pronounce your surname, Bata Chiraya. And I know that the details we have on the program is a bit different. Your role has changed. So you are now the Executive Director for Global Health Systems and Innovation Policy, World Wide Government Affairs and Policy for Johnson & Johnson. And then we have Dr. James Fitzgerald as well, who is with the Pan American Health Organization. And I know you're the Director for Health Systems and Services as well. So welcome. So before I get the group to start talking about the role, I'll just say briefly, I'll just read off some statistics. And in 2008, 57 million people died, you know, worldwide. And a quarter of those were under the age of 60. And 36 million, I wasn't going to use this figure, but when Nils talked about NCDs and such, treated different from child survival of child or child lives, I thought I mentioned this, 36 million out of the 57 million died from non-communicable diseases. Six million children under the age of five die each year. Thousand women die from preventable causes of death. Now go back to the question, do private sector have to be involved in health? Of course we do. Looking at these statistics, looking at the issues, we have to be part of the discussion. There are so many discussions going on at high level that private sector is left out. And I know we're there to make commercial gain. But the end of the day is a win-win situation. Without the private sector, universal health care coverage is going to be tough. In actual fact, and I can be honest, it probably won't be achieved in most countries if private sector is not involved. So I'll leave it at that point. Move on to Hoje, you're going to talk about private health insurance and how it can actually help achieve universal health coverage. Thank you, and thank you for the invitation to CSIS. So you have heard, hopefully Dr. Kim speak, the president of the World Bank. And Tim Evans, the director for health nutrition and population. So if you want official positions of the World Bank group, go to their interventions. So Dr. Kim has said before, if you have high ambitions for the poor, you have no option but to embrace the private sector. And this morning he basically implied that universal health coverage is no exception to this. The private sector should play a role. And most likely will play a role if the given conditions are set. Now I'm about to disappoint some people by saying that I was asked to talk about private health insurance. And private health insurance won't be, in my opinion, the biggest contribution or the main contribution that the private sector will make to universal health coverage. As Gina and others before me have said, government and publicly mandated finance will be, by far, the main avenue to mobilize the resources needed to pay for universal health coverage. And private finance in general, which includes, and in particular, private voluntary health insurance, will play a very secondary role, an ancillary role at best. And this is because private health insurance is a very problematic health financing tool from a population, from a policy perspective. It's not a problematic tool for an individual or a family. I have, I'm a policy holder of a private health insurance and I'm sure many of you are. And it's a very good tool to manage risk at the individual, at the household level. But at the population level is a very limited tool, especially when one has equity and the welfare of the poor at heart. So private voluntary health insurance will play a very limited role, should play a very limited role, and in most countries will play a very limited role. Now, does that mean that you should sell your stocks in private health insurance companies right away? Does this mean that private health insurance will not play a role at all in universal health coverage? No, the answer is not. There's a role to play for private health insurance. There's several possibilities. First, there are some countries where because of policy decisions of the past, before, because of different conditions, private health insurance already plays a significant role. There are seven countries in the world, there were in 2005, seven countries of the world where private health insurance represents more than 20% of total health expenditure. Brazil, Chile, Namibia, South Africa, the US, Uruguay and Zimbabwe. In these countries, the role to universal health coverage will be a very difficult conversation between the public sector, civil society and the health insurance industry. And the political economy of these is quite tough. I mean, we're in the US, I don't have to say much about it. So in these countries, many activists, many people say, well, private health insurance should just be closed down and make way for a single payer system and things like that. People might wish that are in theory, it might be a desirable situation, but it will be, in my opinion, almost impossible. And if you want to talk to people who have worked in South Africa, Gina is here, Robert Hegg. I mean, in South Africa, private health insurance represents over 40% of total health expenditure. There's an industry, there's an interest created that it will be very difficult to just have go away. And there, the challenge will be both for the insurance industry and for the government and for civil society to find a way to make this relationship be a cooperative one and to find a way to have private health insurance contribute positively to the universal health coverage quest. And obviously, the government trying to close down insurers and insurers blocking any initiative the government is trying to enact won't be the most productive situation. There are other countries that have found more productive relationships, the case of Chile, the case of Colombia, where the government plays a central role in financing health, but private health insurance was there from the outset and has been incorporated and so things like equalizing health plans between private health insurance companies and public options and things like that will become more productive conversations. Now besides those countries where private health insurance already plays a large role where there's a stakeholder in the health insurance industry, private health insurance can play other roles. For example, private health insurance can be used to provide supplemental finance to cover those things in the benefit package that are not included. Private health insurance can be used to provide complementary coverage. There are, as probably many of you have read the report on the Lancet Commission on Investment on Health, the two pathways that are proposed. One is a small package for everyone without complements. There one can think of supplemental private health insurance playing a role. The other pathway suggests to these a more generous package with some level of co-payment with the poor being exempt from that co-payment when one can imagine that private health insurance will have a role in offering complementary coverage and obviously there's a role in duplicative coverage and if we look at countries in the OECD, in Canada two thirds of people have supplementary coverage from private health insurance. In France 90% of people have complementary coverage from private health insurance and in Australia and Ireland around half people have duplicative coverage which means they buy a policy to cover the same things that are already covered mainly because they don't wanna wait in the public system. So for me the good news for the insurance industry is that the drive towards universal health coverage doesn't mean that there's not gonna be good business in emerging economies. It means that the insurance industry will have to find a way to play a positive role and to find a role and my guess is that countries where the public sector and civil society push for universal health coverage and that shapes the insurance industry will have better outcomes than those where the insurance industry shapes the universal health coverage debate. So do I have five minutes remaining? Okay, I thought I have only five minutes in the beginning. So I'll stop there and hopefully we can come back to some points in the next round. Thank you very much. Yeah, it's really interesting in terms of private health insurance and I think your point about the fact that if insurance companies work with governments or other governments work with insurance companies, it will definitely shape it and make it more affordable and make the system actually improve health outcomes as well. So I now call on Ashok to talk about the role of private companies in improving and achieving universal health coverage. And J&J I know are really global. You've done a lot of work both in drug and medical technology and that's an area obviously that I think is also really important as well in terms of improving access, improving the quality as well and reducing the cost because we know that's one of the key issues in terms of addressing and achieving universal health coverage is getting care to the remote areas even in middle income countries and I think we've heard it here, there are areas and I won't talk about a particular country where it was really surprising to find out a middle income country. They had one of the worst survival rates for mothers and babies in a particular area and it was only brought to the fore a few years ago and the government had to quickly work with us and other companies to try and see what we could do to actually develop a pathway to improve their antenatal care and basically the way mothers and babies were looked after. So I think it's really important from the call from Dr. Kim that we look at every country whether it's middle or low income and say what is universal health care coverage? How can we improve their access and how can the private sector actually make a difference? So I'll pass it on to you now. Well, thank you very much and good afternoon. First of all, I'd like to thank CSIS and the organizers for the opportunity to participate on this panel and to represent the views of many of my colleagues in the private sector. At the very outset I would say that the private sector including the pharmaceutical industry and the medical technology industry is supportive of broad access to health care in all of these countries. I mean the low income countries, the middle income countries and so on based on certain basic principles that I will touch upon briefly. While we certainly agree with the notion and the objectives, the fundamental objectives of universal health care as has been discussed extensively today in terms of ensuring a safety net or providing a safety net, providing access to basic care and so forth, we also believe that it should include access to quality and that word has been used quite a bit. Quality, secondary and tertiary care that depends on innovative treatments and so forth. And therefore once we define, we take this broader approach to universal health care, I think it becomes incumbent upon us to understand or appreciate how actually it's going to be achieved. As has been discussed a great deal today, universal health care for it to succeed. I mean there are a number of ingredients or elements that have to come into place and work effectively. One is how do you, how is the health care system designed? The role of the public sector, the private sector. I mean here I would really echo the sentiments and the points made by Horay about the complementarity between the public and the private. I mean clearly there are instances where the public sector has to play a dominant role in making sure that primary care and basic care is provided. But there are by definition need situations where the private sector will also play a crucial role and that's a key element. The other one is about the point about strengthening the infrastructure capacity building, making sure that there are clinics, primary health care centers, also hospitals, not that hospitals are the solution as we have clearly heard this morning, but they do play a role. And also the staff, medical care, medical professionals, whether it's doctors, surgeons, but also community workers, community activists in the health care space, allowing them to be trained nurses. And in all of these areas, the private sector is engaged directly and plays a role. And so that's, I mean, to the point that has been made earlier, the private sector is not limited merely to providing products and services. I mean, there is a clear and direct interest in the architecture of the health care system. How the health care system works in terms of financing both the public sector as well as the private. Having said that, I will say that over the last two decades, but several years for sure, there are numerous examples, mirrored examples where the public sector has worked, the private sector has worked with the public sector in terms of public-private partnerships. And I mean, I won't go through a long list, but I mean, all of you may be familiar with a lot of them. Some of the public health initiatives have already been mentioned, whether it's in the area of tuberculosis, malaria, other infectious diseases, but it certainly goes beyond that. I mean, in the area of diabetes, for example, the notion of the growing prevalence of non-communicable diseases. Private sectors, companies, whether it's us or others, have been establishing diabetes education centers, working with local professionals to train staff. And there are numerous examples both on the communicable side as well as the NCD side of things. There is also the idea of bringing market-appropriate products. I mean, I know, I mean, we have Gisela from GE, we have our own, many other companies are bringing products to the market that are suitable for that particular environment in terms of cost, in terms of the capacity of the infrastructure to absorb the products, the technologies, and that's already underway. So, I mean, that's happening. Other companies, and not all, but other companies have pursued the tack of tiered pricing, for example. It's not something that everyone does, but there are instances. And what I mean to suggest is that there are multiple approaches, depending on the local circumstance, the kinds of products that are being brought and the milieu in which they're introduced, there are a number of opportunities. And last but not least, in terms of what's being happening is the role that the private sector plays in training medical staff and professionals. I mean, I can tell you, certainly, from our own experience, but as well as those of many others, that in many countries, and training people in basic sort of procedures, techniques, in hygiene, launching programs in feminine hygiene and so on, and the idea of maternal mortality and infant mortality program support, those are all areas in which a lot of training is already provided by the private sector. And so it is not as if it's only about the products and services that we are developing or the numerous targeted programs, access programs that I think you heard Dr. Kim mentioned this morning in terms of promoting access in other specific disease areas and so forth. I think it's a lot broader than some of those things. So as I said earlier, just to build on some points about the financing issue, I mean, while all of this is true, we are particularly concerned about how the healthcare system, the universal healthcare system will be designed. And I say this because there are, I think there are valid theoretical as well as practical reasons for wondering why a sort of monolithic single-payer system will necessarily succeed in emerging economies and the theoretical reasons, I think we heard Tim Evans talk about the tax base, the fact that it's fairly limited in many of these countries, the informal sector so you don't have the wherewithal necessarily to mobilize the resources to be able to make it all available. And I think the recent developments in China attest to these challenges in a very clear way. I think the plenum that occurred in November in China, whereby there was a direct call for by the Chinese government to bring the private sector and market mechanisms into place as a complementary. So these are not mutually exclusive, it's not one or the other, it's both. And I think the Chinese experience is particularly telling because it may well be the template for a lot of other countries that are now looking at universal healthcare as we go forward. And I think some of the unintended consequences of this one-size-fits-all approach, I think we've heard about the stories, the horror stories about the public finance, the health, the hospital financing challenges that we have in China and all the attacks on the doctors and so forth. And that's also because of this sort of very wide but shallow lack of effective coverage, which has been a major issue. So I think in light of that, it's fair to say that we need to really take a considered look at how the health system is designed and why the private sector comes in is to say that, and as I say it, I mean I hope to speak for most of our colleagues and there's general consensus on this that we are willing to be a part of the solution, work with governments, the public sector, work with international organizations as well as play a crucial role so that these are all working in tandem as opposed to sort of thinking of it as just one solution. And to do this early on, because as some people have already noted, the earlier on, rather than go down this path and kind of walk back as the Chinese experience to some extent is just suggesting, we may be well advised to take this sort of more combined eclectic approach so that perhaps learn the lessons that other experiences have taught us. So thank you. Thank you, Ashok, that's really great. Now James, if you'd talk about the role of healthcare providers in achieving universal health coverage programs, thank you. So thank you, thank you very much and thank you to the center for inviting me here to participate in this panel. I think the whole discussion around universal health coverage has really presented some very important challenges for health systems within the Americas. Obviously, we heard Niels talking about the ACA and the patient protection, the health reform process in the United States. But throughout the Americas, what we're really seeing is a complex and dynamic discussion around the trade-offs between population services, population coverage and financial protection mechanisms. And unfortunately, I wasn't with you this morning, but I imagine that came out in some of the discussions as well in some of the other panels. What this is bringing to the region of the Americas, particularly, is a discussion around what is the political commitment of the countries in terms of defining the fiscal space in healthcare provision, the development of the social protection mechanisms and then what enabling conditions need to be developed to ensure that in terms of addressing the regulatory environment and the social dialogue. So the question comes and what is the role of the private sector in that in terms of service provision? And one of the complex issues that I know all countries face and not only in Latin America and the Caribbean, but there is no simple definition of the private sector. The private sector can be anybody from a family practitioner working by himself, contracted with a HMO or a government. It could be a non-for-profit religious-based organization or it can be a major private health insurance, a HMO. And so when we talk about private health care providers, we have to be very aware that there is a very broad spectrum of providers that we're actually talking about and the participation of those providers in the health system is often very complex. In the Americas, what we've seen over the last 20 to 30 years is a significant growth in the economies, a significant increase in the number of the percentage of population within the middle class. And that middle class has increased wealth and is looking for increased opportunity to access health care and coverage. And when I talk about coverage is from health promotion through curative services. And so they are turning in many cases to the private sector. With the perception that the private sector can provide more, they can provide it better in terms of more efficient and in terms of quality and they can provide it in somewhat of a more rational way. And I think that's something that we need to be very careful about as health systems develop within the Americas because there is a growing body of evidence that that is not always the case, that we do face important challenges in terms of private health sector providers in ensuring efficient, quality, evidence-based care for the population as a whole. And this speaks to the issue then of what type of health systems do we have? Because there is no such thing as a, I suppose, a generalized health system. Health systems are highly complex. In the Americas, we have everything from what we call unified health systems in Brazil to highly segmented health systems with multiple sources, financing, regulatory systems and providers. And the private sector participation within each of those diverse structures can be as well significantly different. There is a perception, for example, that in Brazil, the SUS, which is a unified health system, is one of the, and it is the principal provider of healthcare, ensuring coverage of 80% of the population. However, it's not well known that that SUS contracts out a very significant and high percentage of hospital care services to the private sector. And so when we're talking about private sector engagement, it really is, I think, for the Pan American Health Organization an issue whereby we need to engage and discuss with the private sector what they can offer and then once it's been defined within the health system what can be offered, what policy environments can be established and what regulatory frameworks can be established to ensure that we are providing quality, evidence-based care. The region has a significant experience, I think, in that going back to Brazil, the ANS, it's a national regulatory agency for health services. Ecuador is looking at a similar mechanism as we speak. Most of ministry health are now developing their capacity to ensure that the services provided not only in the public and private sector are quality services. And there are significant discussions then in this issue of equalization around benefits packages. I mean, there is a misconception that the public sector as it's expanding coverage is offering a basic package. And within Latin America that is a very difficult discussion because there has been a rejection of this concept of social protection floors and minimum packages of services because many of the countries have a rights-based approach to health. And so there has to be this level of equalization and to do that, the approach that's been developed is to defining health benefits packages that can be essentially, hopefully, equalized between the public and private sectors. The private sector can deliver, but it has to be based on norms, guidelines, protocols developed by the national body. And then in the pharmaceutical vaccine area, of course, we have the health technologies. And I think the region really has moved forward in promoting access to health technologies as part of the benefits packages and services throughout the region. And they're doing this in two ways. One, they're strengthening the regulatory capacity of national regulatory authorities, the envisors, the unmats, the envemas, the coffee producers, and of course the US FDA and Health Canada models. And the other is that we're beginning to see very active health technology assessment processes whereby through an independent process, countries are looking at the value added of newer health technologies coming into the market vis-a-vis the established treatments to look at quality, safety, efficacy, and cost effectiveness of the interventions so that costs don't explode as newer health technologies come in. These bodies are being established in order to ensure that there is that evidence base in order to take the necessary decision and cooperation of health technologies within health systems. And so these are some of the mechanisms coming back to a comment that Niels made earlier on that ensured that as a private sector increases its participation in health service delivery within the Americas, the principles of equity and social justice are maintained to ensure that everybody has a right to health services that are affordable under the principles of financial protection. Thank you. Thank you to the three panelists for really articulating some of these areas and some of the issues in relation to the role of the private sector. So going forward, looking at where we are at, and I'm sure you have some countries where you have some examples, what are some of the opportunities for the private sector to actually engage and collaborate with the public sector? And I think because we have enough time, I'll open it up to the three of you, if any of you have any ideas or suggestions. Let me stick to the private health insurance. And so I covered some of the more traditional roles that private health insurance can play even in the presence of a strong public or publicly mandated finance. But there's some, first of all, even in these countries where an extensive private health insurance already exists, there are mechanisms to go beyond private voluntary health insurance and so there are mandates and there are subsidies that can be introduced to alleviate some of the shortcomings of private voluntary health insurance and to make private health insurance an instrument of universal health coverage. Even with mandates and subsidies, there are still problems of risk selection and others. Professor Bill Schau of Harvard School of Public Health likes to tell us this story about Colombia where he was advising the government on this managed competition model that they have and somebody was saying, well, it's great they're offering coverage even to the elderly. In fact, I'll take you to this event that this insurance company is organizing. They're organizing a really big dance for people who are interested to enroll in this health scheme. And of course, if you think two minutes about it, an elderly person who's able to get up and dance and enjoy a party is probably not the toughest risk you'll have in your pool. So insurance companies will go to great lengths to select risk even in the presence of regulation and you have seen here in the US how things that would seem obvious to me like you can't deny coverage based on pre-existing conditions have been a battle to getting the regulation. And that's in part because, as Mark Polly from Wharton says, insurance companies perceive, insurance companies' perception of adverse election is actually bigger than the actual adverse election in the market. But going beyond those traditional roles, there are countries and there are companies that are playing more innovative roles. You can have, and you have several examples of public insurance programs where the carrier is actually a private company and you have these with mutual organizations in Belgium. You have these in Nigeria with the HMOs that were created with the National Health Insurance Scheme Reform. You have these in India. I mean, many people don't know that the RSBY is actually administered and in some states actually the risk is shared between the state agencies and private health insurance companies, IFC, colleagues of mine in India have helped the state of Megalaya do a very transparent, very well-structured process to beat out management of the state health insurance scheme to a private insurance company. So the nice thing about the private sector is that most innovation happens in the private sector and so there are innovative ways that the private sector can contribute and in many countries it's not like private entrepreneurs are watching this via a web stream and are waiting to see if they can go out and go after a market they perceive as profitable. They are actually doing it and so the private sector is in many ways way ahead of us here in Washington who are thinking about what the role of the private sector should be and who knows maybe some of them will surprise us and will actually find ways to provide low-cost packages that actually serve the poor and so on. There are a couple other roles that some people have argued that the private sector can play. For example, some people have argued that while governments get their act together and launch universal health coverage schemes, then the private sector can play sort of a transitional role. This is happening and this is true. It has the problem that then this stakeholder is creative and these transitional things tend to be sticky and so it might be that down the line that creates some problems. Now going beyond private health insurance, the private sector has a massive role to play and it's playing it. The Americas has been referred to but in India, no one can imagine universal health coverage without the private sector provision of services. It's difficult to measure the public-private mix but in India we're pretty confident to say that about 80% of contacts, at least in outpatient care, happen in the private sector. In Africa, we don't have good measures of comprehensive health systems but at least for the diseases that the DHS measures, maternal, neonatal and child healthcare, HIV-AIDS, tuberculosis and others. On average in Africa, 50% of these key services are provided by the private sector. So the private sector, it's not something aspirational that will play a role, is playing a key role and governments who are smart about one understanding the role the private sector is playing in their countries and two smart regulations and policies to leverage the capacity, the management talent and the innovation and the capital of the private sector might find it easier to expand and achieve universal health coverage than governments of which there are many that are still in denial and think that the private sector provision of services and the private sector role in input markets can be ignored. Well, you made a number of excellent points, sorry that I was thinking of touching upon as well. But in addition to that, there are a couple of things that the public and the private sector can work on in a number of these countries towards the attainment of universal health coverage but also access and affordability more generally. One particular issue is really acknowledging what some of the real problems are. So there is a, and for good reasons, there is a gradual concern about costs and prices and so on and those have to be addressed and I think some of the things I mentioned before in terms of different kinds of mechanisms to your pricing policies or different types of products or other kinds of access programs already are directed at that particular problem or challenge. So clearly that's an issue that we need to confront directly but beyond that, in the dialogue, in the discourse, it's important to be clear and here's where both the public and the private sector but the public sector as well as well as other civil society and others can also play a constructive role and that is to sort of disabuse people of the notion that the core problem is only about the availability at prices because often you'll find and whether it's in India and China and many other countries around Asia and I would imagine I think Latin America as well and Africa, the availability of the products, a wide spectrum of products in a particular therapeutic area, in a particular disease area is not typically the problem. I can tell you from experience in the medical technology area and others that you have sort of current, perfectly good, safe products that are available for treating patients in cardiovascular diseases in other areas and yet there is a certain preoccupation with the sort of high value target and as I said, not to discount the challenge there and the importance of saying that certain treatments that are life saving are important ought to be made available and at an affordable price that I think is a legitimate point but having said that, it is not the only and core issue. Often of course there is the issue of the infrastructure and let's sort of talk about why so in the RSBY scheme in India, for example, right now you can get, for example, I'll give you the example of medical stents and I think Dr. Reddy is here and can hopefully confirm. There are bare metal stents that are available at a one tenth of the price they were about four or five years ago. You know, at under $200, maybe $150 a stent when in fact it was closer to $1,500 to $2,000, not that long ago and that's already available and as it is the case for many other products and yet the discourse, the debate is often about the cutting-edge stuff that everybody wants to aspire to in an urban setting but that's not the solution. So if we can have an honest and open dialogue about what are the real needs, so make it sort of more relevant to the needs and requirements that are appropriate, available and perfectly good and I think here I invoke the Clay Christiansen argument about let the good not be, perfect not be the enemy of the good and I think this has been discussed a lot. So if we can apply that not only in certain contexts but more generally in terms of the kinds of solutions we bring forward, I think the public and the private sector can certainly do a much better job. The other point I will make is also sort of the identification of the problem and a related one and I'll go back to the Chinese example. I mean, we talked a little bit about the hospital financing situation. As many of us may know, more than 50% of hospital funds public hospital funding comes from markups on drugs and devices in China, right? And yet this is not, while it is known in the policy circle the when a certain issue happens, you know, there is a lot of finger pointing that goes on which I think is entirely unhelpful and therefore I think in the dialogue we need to have to be candid and I think that is beginning to happen in China it may well happen in other situations. So I think a big part of it is not only to work on programs like the malaria program or the TB program or many others where we are already actively engaged and I'm sure more can be done but also to sort of dispel some of these myths and misconceptions and not all of it so that we can have a more transparent discussion. Yeah, I think, I mean, as we look at health systems again, we need to be careful not to overly segment them that the private sector has a clear role to play in integrated, in the development and provision of services within integrated health networks. The question I think that countries face is okay, when I'm organizing my health system, how do I ensure that I can through a transparent process define what the role of the private sector is in providing those services? Example, if there's a primary healthcare clinic, somebody goes, needs laboratory tests, okay, there may be a public laboratory, there may be a private laboratory. Are there any issues with contracting a private laboratory vis-a-vis a public laboratory? In principle, no, but there has to be a defined structure and decision-making process at the national level to say that these services I will contract out and these other services I may not and that from the public health perspective is extremely important and that decision-making process and the regulatory capacity of the National Health Authority. So we are fully convinced that the private sector has a fundamental role in service provision. What I think we do need to be careful is as that service provision is insured, how do we avoid the perverse incentives that unfortunately come into a private, often for profit health service delivery system? How do we ensure that people are not over-treated, that result in issues relating to patient safety? And so that is where we really need to have systems that look at performance outcomes and performance indicators. I mean, in Guatemala, we've seen that primary healthcare providers are meeting almost 38% of the needs in terms of primary healthcare and rural settings. In Rio de Janeiro, South Paolo, there's some innovation programs in terms of primary healthcare delivery there as well, but they're highly structured. And they're highly structured, they're organized within a process, within a policy environment and within a regulatory structure. And I think that is key. There needs to be that balance, the clear rules of engagement, organized financing, and then the private sector, I think, has a extremely important role to play in the provision of public health services. Thank you very much. And actually it brings me to the next question James, I think you've already started answering it, which, what are some of the likely causes of contention between obviously the public and private sector? And I think I'll just leave you to answer that because I think you've started already talking about it. And then Ashok and Oje can answer the next question. So just taking up on the previous comment, there may be a tendency within the private sector to be over, I will air on the side of caution, to be over cautious, to over diagnose, to seek additional diagnostics and to over treat. This obviously leads to significant increase in costs in terms of diagnostics, particularly in radiology. We're seeing a massive proliferation of high technology radiological equipment coming into health systems now within the region of the Americas. Instead, perhaps of an X-ray being recommended, the patient has automatically been sent for a full CT scan. Is that necessary? Is that justified? That's questionable. The other component and part associated with the health technologies is the pharmaceuticals, the use of the latest, the concept that newer is better. And I think Ashok mentioned the importance of medicines, essential medicines that have been tried and trusted, that have existed for over 30 years within our health systems and that produce the necessary health outcomes. Obviously there is a gradient of therapeutics that are required to ensure delivery. But it's extremely important that in ensuring the provision of these therapeutics, there's effective competition in the market and when there's not effective competition in the market, whether our sole suppliers, we're not so sure about tiered pricing, is the right answer because there are issues of equity associated with tiered pricing where the provider does not participate in the tiers. So there's a question around principles of equity and tiered pricing, but in the sense of what price is affordable, what price is equitable for a provider to actually pay for a new health technology coming onto the market. So again, I come back to the issue of the private sector has an extremely important role. There are perverse incentives that do exist perhaps to over diagnose, to overtreat that can result in issues of patient safety. I mean, here in the United States, we have to remember that the recent law is not just called the Affordable Care Act, it's the Patient Protection and Affordable Care Act. So there's a core principle of patient protection associated with provision of care here as coverage is expanded. And I think that is really extremely important as we see how the private sector will participate in the universal health coverage agenda. Thank you. And actually that's a good example, but on the reverse in some other countries is actually the opposites where patients don't actually get any diagnosis or treatment early enough, or it takes a long time. So I think to your point, Ashok, which you mentioned earlier, the one size doesn't fit all and multiple approaches are needed. So I think the final question before I open it up to the audience, what are the unique challenges you think emerging economies are facing in actually bringing public and private sector together to achieve universal health coverage? And Fujia and Ashok, if you can give some comments on that. Yeah, so I mean, a lot of it has to do with quality and how we define quality and some misperceptions about quality between the public and the private sector. So in Africa, where I do a lot of work, we often have conversations with ministries of health. We show them that the private sector is actually playing a large role. The first concern that comes up is the automatic assumption is well, okay, but what about the quality in the private sector? There's, from the public sector, there's this perception that because the private sector is first profit oriented and second is out on its own, the quality will be low. And what's interesting is that most serious studies about any measure of patient safety or quality that have been done in Africa and India in a number of other places have shown that there's no intrinsic difference in quality or patient safety between the public and the private. And unfortunately, in many cases, the quality is actually quite low in both, equally. So there's gonna be a tension between the public and the private when the public attempts to regulate for safety and for quality. Because often the public sector assumes that in the publicly provided services, quality is a given. And as Danielle Kotler earlier mentioned, you see the cases of many accreditation agencies or public insurance agencies that have an accreditation role where if you're a public facility, well, you're automatically accredited. So that's gonna be one tension. Another big challenge is that the private sector is a very heterogeneous collection of individuals and institutions. And so there is the visible private sector, you know, the hospitals in the Apollos and the Forties in India, the private hospitals in all the major capitals in Africa, the laboratories, the private practices. But that's the tip of the iceberg of the private sector. There is a large private sector that's made out from a range of between nurses and clinical officers and medical assistants practicing in small outpatient clinics all the way down to the roving medicine vendor, all the way down to the straight quack, right? And so one of the key challenges is what are the roles of these private providers that are harder to see and that are harder to organize in healthcare? And often the compulsion from government is well, we'll establish regulation that weeds out the quacks. We'll only allow care to be offered by qualified health workers. And a colleague of mine, Jishnudas, has done a lot of research in India. And one of the things he has found is that when measuring the practice what health workers actually do, not so much the infrastructure that they have, but what they do, often or in cases you can find that an unqualified provider gives better care than a qualified provider, because effort is as important as knowledge in quality. So if you're serious about a regulation that leaves only qualified providers in and leaves unqualified providers out and you actually chase them and put them in jail, you might find a situation where actually the average quality in the system goes down because you left bad provider seen and you took not so bad providers out. So these are challenges that the only way to address them is to go out there and investigate them and get the data and be as unbiased and open to the results of that data as possible. I think very briefly in the interest of time, at least some of the challenges faced in these middle and low income countries vis-a-vis the private sector have a lot to do at least from our perspective to do with the failure to appreciate the value of health in general and certainly the value of innovation overall and that has implications for what is considered to be useful or value for money defined in any particular way. And I think that's a major gap. I mean clearly there's an education component to it and we are engaged in that effort but making sure that people understand what the connection, so in general the health story about the health is wealth piece that I think we heard a great deal about and I think that's something that needs to be reinforced. And the one other point I'd like to certainly highlight here is as much as there's a lot of talk about the US healthcare system and how much we spend and we don't get enough back for it but it's a bit of a counterfactual that can be a little bit problematic because it seems to suggest that the alternative is not to spend on health. I mean if you follow it logically, right? So if you spend too much on health you don't get anything for it so don't spend. And I'm not, I'm being a little facetious but my point is there is clearly an argument to be made about more investment in health. What is the right number? Is it seven percent? Is it 10? That I think we can maybe figure out at some point and iterate but the number is not three or two or whatever it is either on the public side or on the private. So I think raising sort of consciousness and awareness about the importance of investment in health in general and especially with the private sector in terms of the kinds of products and innovations that are brought forward. I think that is a key challenge that we will continue to face. Obviously because of the concerns about costs and prices and so on but I think once we are able to articulate that in the context of the kind of value that can be brought forward. I mean one example I'll give is unlike in the US context where let's say drugs save hospital days and hospitals are very expensive so that's a great trade off. And not so much in these other countries where hospitalization is not that expensive but it's not always a monetary metric. It's not about the dollars, the rupees or the yuan. It's about the fact that in many of the places in again I'll give the example of India and others. I mean there are top notch medical institutes where everybody wants to go and get treated. I'm talking about the public ones that are where the treatment is relatively free. So if you have technologies and so on that allow for quick treatment and shorten hospitalization that's about capacity utilization and turnover. So the argument is not there is that you're saving money. The argument is that you're actually doing a public good, I mean a good for the public. You're treating more people more effectively. I think those are things that I don't are not well understood at all. So I think those are some of the challenges that we'll continue to have to grapple with but hopefully with education we'll get there. Thank you so much, thank you. So we only have 10 minutes left. I can see a sheet reminding me. So I better open it up for questions. I'm sorry I wanted a bit more time but we all got, at least me got up in the discussion but it's great. So I think we'll take a first round of three questions. Okay, the lady there. Thank you. My name is Marie Jifatunde. I am currently transitioning from the medical device unit at WHO to McKinsey and Company. During my time in Geneva we were very interested in the role of medical devices and other health products in setting up the health infrastructure that's necessary to expand universal coverage of quality services. Now many of the countries that are currently kind of pursuing universal health coverage, many of the low and middle income countries are not sourced countries for medical devices. They're kind of produced in the USA and Japan and the Netherlands and they arrive in countries in Sub-Saharan Africa and elsewhere either through intentional acquisition or accidentally via donations and other ways. And it seems to be very important that health technologies are present not through blind kind of investment because as somebody mentioned earlier they'll always be used when they're present but through really intentional adoption of appropriate health technologies. There's kind of been the whole campaign of essential medicines to make sure that drugs are present as much as needed in low and middle income countries but for devices the conversation about essential medical devices is really just starting and some might even argue that that's thought an appropriate framework because devices are so different from drugs. My question is what incentives are needed for the private sector for people like Johnson and Johnson and GE to establish a presence in low and middle income countries both geographically yes but more importantly strategically in order to produce kind of context appropriate medical devices. What incentives are needed what regulatory framework is needed to enable local production and technology transfer of appropriate medical devices for universal health coverage. Okay, thank you. Next question, yeah. Hi, Lydia Ogdenmark, thank you. You all have talked about the private sector as providers and as purchasers but I'm interested in your thoughts on the private sector as payers either as large employers and as policy advocates particularly around health and all policies and primary prevention. Thank you. Adepaka. Hi, my name is Andrea Estrano. I'm from the Department of State. I work in the International Organizations Bureau where we focus on the United Nations that includes WHO. A lot of what I spent this past fall doing was trying to change language that the G77 countries wanted to put in resolutions saying that we will have absolute technology transfer and just leaving it at that and no conditions on it, no protections for intellectual property rights. So I wanted to ask the private sector first of all just very generally what you think about sort of the low less developed countries constantly reaching for that and what you would see our policy should be. Thank you. Okay, so for the first question I think the lady mentioned G as well. So I'll start about local production and emerging countries. Now the reason I'll just be frank looking at it and I know we've had a discussion with WHO the reason why companies like ourselves would not initially, obviously, develop or set up local production in every country is because you end up even having a higher cost. So it's about efficiencies, it's about scale. We manufacture and we have local production and we ship to where we can actually send affordable equipment. So if we, for example, we set up in and I'll mention any country maybe in sub-Saharan Africa because of the amount of products or services that are being bought we would actually have to have a higher cost because even though we've talked about technology transfer you still need the staff, the resources and everything to actually get to running. So I know people talk about it but I think that some economies are still not at the level where you can have that kind of role unless obviously the government invests and I don't think it's a worthwhile government investing in local production when there are other areas like maternal and infant child, you know, survival rates that need to be dealt with. But I'll ask Ashok to speak on that as well. I think you've mentioned most of the main points but I'll just say that in addition to that of course it depends on the country so there are certain countries where in principle local production may be possible recognizing the constraints that you've already identified in terms of scale and relevance and so forth but the other point is that in many countries there is this issue of even you need to bring in while we can develop certain technologies you need to bring in certain inputs and so on that are subject to tariffs and customs and duties and the like. So I think a number of factors have to be considered but I think the main point was the one that you already mentioned. And then questions two and three, Hojje and James. I'll jump in on the last one actually because it's... Okay, techno, okay. It's an issue as well, we've been following very closely. Again, similar to the concept of private sector, the concept of local production is a very broad concept. It can be anything from a small manufacturer who's a national of that country starting up a startup to an international coming in and establishing an agreement with, I mean, what is national production? But there's the, I suppose, some principles around the concept of autonomy, independence in terms of what is manufactured, I suppose that would be key to the concept. I think it links in very well with the question on intellectual property and innovation because much of the decisions that are taken around what gets manufactured where is really, as Aschke was mentioning, really dependent on the policy environment, the regulatory framework, the incentives, the national capacity for research and innovation that exists already. And that's how industry takes decisions, I think. I am Irish 30 years ago. We didn't have a pharmaceutical base in Ireland and now within Europe we have one of the largest pharmaceutical bases because the policy environments, the structure, the infrastructure, the capacity was developed to incentivize the industry to come in. That is happening in the region of the Americas with Brazil, with Costa Rica, in Argentina, in Chile. So developing countries and emerging economies are seeing this. The tech transfer issue is more complex around innovation and the intellectual property frameworks that do exist because there has been, as many of you know, discussions within the World Health Assembly that have gone on for over 10 years around the issue of public health innovation and intellectual property. And it was interesting to see 10 years, almost 10 years from the beginning of that discussion we now have a process within the World Health Organization where demonstration projects attempting to delink the concept of price from the access model, from the development model, are being put forward and for the consideration of the executive board. So in the region of the Americas, the Americas submitted, countries in the Americas submitted over 24 projects for innovative health technologies that have gone forward to those projects selected. And so it's gonna be really interesting to see how that issue of intellectual property delinkage from pricing, delinkage from the research and development model actually proceeds. It's a question mark, so we'd love to watch this space. I'm not sure if I understood the question about the role of private sector as payers. But you also said employers. I mean, there's a number of roles the private sector plays. For example, it wasn't known to me until I spent time living in Africa. In the fight against AIDS, how important some workplace-based programs were. And of course, to the extent that formal private sector are employers, they play a large role. In Kenya, for example, the way the National Hospital Insurance Fund works is the employers directly deduct contributions and transfer them to the fund. There's a number of roles. In many countries, large private employers run their own health systems. And here I have a personal anecdote that a friend of mine was climbing in a national park in Kenya and fell some 12 meters. And the only reason he's alive and well today is because next to the National Park there was a large tea company that had its own clinic. And so they were able to stabilize in there and they had an ambulance that was able to transport him to a hospital in Nairobi. So there are many unobvious roles the private sector plays in health. IFC with DFID and the World Bank, they've been looking at the role of mining companies in tuberculosis in South Africa, for example. And mining companies as providers of health services often when a mining company sets up the only services available are those provided by the company itself. So I'm not sure if that answered your question. There was a second part of that question on the private sector as policy advocates. And this is a very important question because organized private sector can play a very positive role in policy discussions. It can play a not so positive role and it also, there's a risk that the organized visible private sector sort of takes up the space of the not so visible, not so organized private sector. And so what we see in many cases is a deliberate kind of step one government realizes and accepts at the private sector. And this will be my final statement. It plays a role. Step two is okay, why don't we get at the table and have a dialogue. And often what we see is that at least the first stages of that dialogue, it is the more visible, the more powerful private sector, the owners of the hospitals in the cities, the owners of the pharmaceutical companies and so on. And it usually takes a while for the retired nurse that went back to her village and opened the clinic to have her voice be heard in these policy forums. So it's in addition to what Tim Evans and others have said, it's a role for international organizations to be good facilitators of these dialogues to make sure the whole private sector participate and is heard and all in all, the dialogue has a positive contribution to the country. Thank you. How long do we have? Pardon? We have, oh, let's go, we take one more question. Oh, okay, the last question, and then we use it for everyone to sort of sum up, please. Yeah. I did have one comment on the last question, though, quickly. I mean, in addition to all of that, there are all the wellness programs that a lot of private sector companies, I mean, we certainly have them in this country, but when they operate in emerging markets, they have them as well. So that plays a critical role in prevention and promoting awareness. But also a lot of local companies, so in India, there'll be companies like Tata and so on, they are all taking that on as part of their employer plans. Very short, please. Okay, thank you to the panel for the presentations. A question and a comment. The question is about a remark that was made about countries with existing private systems and the difficulty of rolling out universal coverage that doesn't preserve that private system. And it was implied sort of that it's desirable to roll it all up into a single pair, system, but it will be difficult politically. And I'm just curious why you would think a government that's taking on the responsibility of and the financial and logistical responsibility of providing additional care to, you know, 20%, 50%, 80% of the population, depending on the country, would want to make that 100% and fix something that doesn't need fixing. So that's sort of one question. A good example would be, for example, South Africa with a pretty functioning, well-functioning private market for a proportion of the population and the government having the intention to roll out national health insurance, which would roll all this up together. The comment was about overuse as a feature of private sector providers. And I think that has nothing to do with, overuse has nothing to do with the private sector. I think that has to do with incentives. So, you know, in a private sector provider system, if you have a fee-for-service system, the incentive is to provide more services. If you have a capitated system, the incentive is actually provide less services. And we also have examples of public sectors being guilty of the idea of overuse, saying the problem of the incentive structure, for example, in Chinese hospitals where a major source of their income is based on margins in terms of prescribing expensive drugs. And I say this is a, I'm sorry, I didn't identify myself, I work at Pfizer. So that would demonstrate that the issue of overuse, whether it's drugs or imaging is really a feature of incentives that has nothing to do really with the private sector. So comment on that point. Okay, thank you. So this is our last question. And if you just sum up two minutes each, oh, actually a minute each, please. Thank you. So let me start. And thanks again, first of all, on behalf of the Pan American Organization for inviting us to participate in this discussion. I think speaking to the last comment, I mean, how this system is financed is, again, there is no individual universal recommended health financing system. There are some core recommendations around pooling of resources and pooling of risk. We would consider that there are multiple roads towards universal health coverage and the questions of equity and social justice have to be core to that. So whatever health financing mechanism that links in with those three kind of the core axis of population services coverage and financial protection, that is key, financial protection is key to the discussion. And then how the health system is moved towards less segmentation, less fragmentation and pooling of resources are the key principles around which the national discussion can take place. That's something we're going to be working at, at PAHO on the next year. We are presenting to our ministers a regional strategy for universal health coverage in October, so it's going to be a lively and active base, I think, in the Americas this year. Thank you. Well, I mean, as I have stated before and as we have all discussed, I mean, we certainly support the idea of universal health coverage, but in the sort of this, my striking and balance between public, private, as well as other stakeholders and really based on these principles of inclusiveness, of quality, of, you know, while I mean, fully recognizing the basic thing which is the premise of financial protection, basic equity and so on at the bottom, at a minimum level and that should be guaranteed and we have no, absolutely no argument with that. But I think over and above that to recognize the value of the other elements and sustaining innovation. So sustainability I think is the one that we are most concerned about. But hopefully we'll get there. Yeah, so to answer the question I think in general clarification, I'm not advocating for every single country pursuing a single payer system. In fact, if you Google my name and read the blogs I've written recently for the World Bank blog, quite the opposite. I advocate governments mixing and matching different instruments to respond to their initial conditions, their systems of values, their existing institutions and their political realities. So I in no way advocate for a single, there's no single path, there's no silver bullet, there's no easy answer basically. In the case of South Africa, I think it could be a very contentious debate. I'm not an expert on South Africa but from what I understand, the statement that the system doesn't need fixing, some people could have an issue with it. Because it's a system that works really well for about 40% of the population, not so well for the rest. Now is the answer closing down the private insurance companies and pushing a single payer system? I personally don't think, even if that was the desirable answer, it's a possible answer, right? What I think is that the government, the civil society and the private sector in South Africa will have to come up with a very creative solution to use the policy instruments that the government has at its disposal and take advantage of the capacity that the private sector is there in order to fix the gaps that do exist in terms of equity and quality and others. But it's, if there's ever a World Bank economist who stands in a forum like this and tells you, oh, it's easy, don't believe it because it's quite complex. Okay, thank you so much for the panelists, for your really good analysis and discussion on the role of the private sector. And since we've run out of time, I'll just say all in all, I think a system-wide approach is what is needed, bringing in the private sector, being involved in policy discussion. If each country, as we said, would differ in terms of the mechanisms for achieving universal healthcare coverage. So I hope that, especially those from the international organizations, you remember that in the discussion with UHC, you actually bring in private sector, hear viewpoints and see how we can work to actually improve outcomes globally. Thank you, and please join me in thanking the panel.