Volkan Yilmaz, Assistant Professor of Social Policy at Boğaziçi University, Turkey
As part of the Sustainable Development Goals, a United Nations (UN) initiative covering a broad range of development issues, all members of the UN set an ambitious and greatly welcomed target to be achieved in healthcare policy by 2030: achieving universal health coverage. The World Health Organisation (WHO) defines universal health coverage as a set of policies ensuring everyone in need of healthcare services and medications receive a quality service yet without facing financial hardship. This notion of universal health coverage leaves no room for denying services and medications to people in need.
The first indicator in particular seriously limits the scope of universal health coverage by leaving out healthcare services that are not defined as essential. For example, while cervical cancer screening is listed among essential services, cervical cancer treatment is not. The second indicator may help by putting an upper limit on the proportion of total household expenditure to be spent on non-essential health services, but it may still fail to capture how many people don’t seek medical help for these services.
Dr Margaret Chan, Director General of World Health Organization, clearly suggests that free markets do not work in health care. Chan’s emphasis is on the financing component. Specifically, if public funding of healthcare is weak, achieving universal health coverage is generally not possible. Therefore, she identifies increasing public expenditure on healthcare as the only way towards universal health coverage, which will result in less reliance on out-of-pocket payments.
But healthcare systems have two major components that are of importance in achieving universal health coverage: financing and provision. To achieve universal health coverage, while public funding of healthcare is key, exclusive focus on the financing component in ensuring universal health coverage might be misleading. I believe the significant role that the public sector can play in healthcare provision – and has already been playing in some countries – has been long overlooked. Failing to pay enough attention to the role of the public sector in healthcare provision can pose two obstacles in monitoring progress towards universal health coverage.
First, this focus may blind us to how the dominant role of private sector or privatisation trends in healthcare provision restrict access to healthcare services that are deemed non-essential. On the one hand, exclusive focus on essential health services may be interpreted as rationing, which is indeed necessary for all public policies due to budget constraints. On the other hand, the restrictive definition of essential health services may go beyond rationing especially for middle income and upper middle income countries with historically strong public provision systems. This restriction of the scope of universal health coverage to essential services may take the form of people’s aversion to seek medical help due to financial hardship and/or increasing expenditures on health as a proportion of total household incomes. In this regard, the proposed strategy of WHO to achieve universal health coverage may be implicitly granting approval to the privatisation of non-essential health services in countries with strong public actors in provision.
Second, this disregard for the ownership of providers in healthcare leaves out the possible impact of private sector dominance on provision in healthcare financing. Not all market designs foster competition and lead to lower prices for services. Not all countries have strong public regulatory capacity to protect patients from possible abusive practices of private providers. Finally, not all political actors in power are willing and strong enough to block private providers’ demand for higher out-of-pocket payments and/or switch to private health insurance based financing models. Concerning these, WHO’s strategy falls short of addressing these concerns which may well affect the prospect or viability of universal health coverage in different countries.
My forthcoming book entitled The Politics of Healthcare in Turkey demonstrates that despite significant achievements towards universal health coverage in Turkey in the last decade, a country that Dr Chan also lists among best performers, striking the right balance between public sector and private sector in healthcare provision remains a challenge for Turkey. Passive privatisation in healthcare provision and the political dynamics it has generated, cast doubt on viability of universal health coverage.
Setting a target for all countries is not easy, especially given the vast differences among them and the presence of strong global interest groups against reforms towards universal health coverage. But these challenges should not lead us to settle for a narrowly defined version of universal health coverage as a global policy direction for all countries. I suggest therefore that the lack of focus on the provision component of healthcare systems in the global health policy debate must be re-thought, especially if we want to reclaim the proper meaning of universal health coverage.
by Tessa Coombes, guest blogger for P&P conference
The final plenary session of the conference was delivered in energetic fashion by Prof Jacob Torfing, Roskilde University, who took us through a whistle-stop tour of what we can achieve through collaboration and how it enhances innovation. He explained that the last 30 years or so has seen a growing focus on public sector innovation, where previously this had been seen as something of a contradiction in terms, it is now seen as a means to boosting the private sector. Innovation is now pretty high on the public sector agenda.
Using an analogy of the ‘good’, the ‘bad’ and the ‘ugly’ he took us through three key areas of innovation narratives. The ‘good’ was used to describe the existence of high political ambitions, which is a good thing, but where there is the need to invent new practices in order to achieve those ambitions. The ‘bad’ referred to the ‘wicked problems’ that exist and can’t be solved through standard solutions or by just throwing money at the problem. In this case, creative problem solving is needed. The ‘ugly’ related to the disconnect between expectations and ability to deliver, where there are increasing expectations from citizens at a time when public resources are limited. This disconnect is driving the need to pursue innovation in order to deliver more for less.
Jacob then raised the key question, that is, can the public sector innovate? To which the answer is obviously yes, but where there are various caveats. The public sector is far more innovative and dynamic than its reputation would suggest but it is often episodic and accidental, so as a result enhanced organisational capacity doesn’t always follow. He then added a word of caution, reminding us that innovation is not an end in itself, it is about providing solutions to problems and improving performance and it doesn’t always work!
According to Jacob, one of the biggest problem with public sector innovation is the search for innovation heroes, an approach that is well known in and translated from the private sector. In the public sector it works less well, who are the innovation heroes, are they the elected politicians, the public managers, private contractors, public employees or service users? There are just too many options in the public sector and it is important to remember that innovation is rarely triggered by single individuals, but is more of a team sport. There is greater potential for innovation where multi actors are involved, providing different perspectives and generating joint ownership of bold solutions.
The question then arises of how we lead and manage collaborative innovation and the need to explore the link between theories of collaborative governance and theories of innovation. There’s a massive literature out there on leadership that can be drawn into the debate on innovation, from pragmatic and adaptive leadership to distributive and collaborative leadership, there’s plenty to offer the discussion.
Perhaps one of the key points of this discussion is what this means for public managers and how it changes their role? Jacob describe three new roles for public managers – the convenor, facilitator and catalyst – with all three needed to generate collaborative innovation. A big challenge for the future for all those in the public sector.
Tessa Coombes has just completed the MSc in Public Policy at Bristol University, is a former Bristol City Councillor and regularly blogs about policy, politics and place.
In recent months alone we need look no further than the Co-op bank, the UK Border Agency or Staffordshire hospital to find a systemic breakdown in performance, raising the question: why do institutions fail? Where failure is too harsh a judgement, we may nevertheless ask why we so regularly see a marked gap in the private and state sectors between public expectations and the outputs and outcomes that are achieved.
Is it an internal matter – a failure of leadership, poor management, or inadequate resources? If those factors play a part, do they merely reflect structural flaws in systems of regulation and accountability? Or should we be looking more to the external context: a hostile economic or political climate perhaps, or inflated public and media expectations which mean that the institution operates in an environment in which will inevitably and unfairly be seen to fail?
Teasing out the balance of factors that account for the performance of any institution is no easy matter where so many variables are at play and few impacts are measurable. It is necessary, however, if we are to avoid making simplistic assumptions that poor leadership is to blame, let’s say, or harsh budget cuts.
One set of institutions provides ripe territory for exploring these questions: statutory human rights and equality bodies. Britain’s troubled Equality and Human Rights Commission has not been alone in facing criticism of its performance since it was established in 2007: that of its counterparts in Northern Ireland and Ireland have likewise come under fire. The literature on the proliferating number of these bodies world wide, moreover, suggests the challenges they are facing, internally and externally, display some common themes.
The establishment of these institutions over the past two decades coincided with a renewed confidence in arms’ length regulatory bodies using standard setting, monitoring and enforcement to improve the performance of others. The UN, Council of Europe and European Commission, within their respective mandates, encouraged the global expansion of such bodies, setting minimum standards of independence, accountability and mandate with which they should comply. Expectations in civil society often ran high in the early days, anticipating a step change in the protection of human rights and equality of opportunity. What happened next, the varying strengths (evident in many cases) but also the limitations in delivery require an explanation.
We found no single factor accounted for the performance of the six bodies in our study but differing combinations of positive and negative factors. Comparative analysis was revealing: for instance the more supportive political context in Scotland than that in Northern Ireland, and the accountability of the Scottish Human Rights Commission to the legislature rather than, as for the other bodies, to the executive. Institutional architecture, statutory duties, powers and resources differ markedly, as do the significance of relationships with the UN and European bodies on the one hand and civil society groups on the other.
Beyond the significance of each institution’s varying remit, powers, structure and resource constraints, leadership and effective management were found to be crucial factors, alongside the political acumen necessary to steer the ship through turbulent times. The institutions may take some comfort from the fact that it is those factors which are those most within their control.
Dr Sarah Spencer CBE
Centre on Migration, Policy and Society
University of Oxford