David Clarke, Team Leader, Systems Governance and Stewardship, World Health Organization, Geneva, Switzerland. Photo: Courtesy of David Clarke
Interview with David Clarke
Team Leader of Systems Governance and Stewardship, World Health Organization (WHO), Geneva, Switzerland
Collaboration with the private sector is essential to achieving public health system goals, says David Clarke, Team Leader of Systems Governance and Stewardship at the World Health Organization (WHO). He spearheaded WHO’s Progression Pathway to help countries strengthen governance systems to properly utilize the private sector to fill gaps in health services and improve quality of care. In an interview with IFC, Clarke explains what led WHO to create the Progression Pathway, the dangers of providing health services in silos, and what it takes to make public and private health sector collaboration truly effective.
“Ministers of Health must decide what they want to achieve with the private sector and recognize that the private sector can be a great source of capacity and innovation.”
What is your perspective on the private sector's role in healthcare?
I have worked in the public health sector for most of my career, and every health system I've worked in is public and private. I don't think any government intended to set up a system configured that way; it just happens in most cases. So, we need to deal with health systems as they are. For instance, when I was a lawyer in the Ministry of Health in New Zealand, the private sector provided all primary healthcare, the public sector provided most of the secondary and tertiary care, and the government worked to ensure the two systems worked in synergy for the benefit of the public. What's important—and this is the crux of our work at WHO— we want an outcome that is equitable, quality care for all and for the government to ensure that happens. They need to organize health systems with contracts and regulations and other policy tools like partnerships and dialogue platforms to ensure that all the providers and actors in the system, whether public or private, work collectively toward achieving a government's health system goals and not work in silos or undermine these goals.
What led WHO to develop the Progression Pathway? And why now?
In 2019, we commissioned a landscape report to understand the context for working with the private sector. That report revealed that many projects that the public sector had attempted to work on with the private sector stopped or failed because once the donors and implementing team exited and it was time for the government to take over, they didn’t have the capacity to do so.
The second reason is that we are very conscious that we are miles behind on the Sustainable Development Goals (SDGs) and targets, particularly regarding universal health coverage. We will only fix this if we work with the whole system, not just the public system. For us, improving people's health is a huge imperative.
The third reason is that the private sector is growing like crazy. If governments want to ensure that the private sector aligns with their health goals, they need to ensure that it is governed appropriately. For example, they should make sure private providers and public providers work from the same rule book and have the same referral guidelines.
What are you hoping to achieve with this guidance?
We recognized that guidance from WHO had been framework-based for a long time and was heavy on theory. We wanted to shift our work on governance into a practice-based approach. I was a practitioner in public health systems for a long time and wanted to help countries with very practical advice on how to engage with the private sector. We used an old WHO framework, developed in 2000—the World Health Report about health systems. And one of the things in the report was this much-quoted concept of health system stewardship. The idea behind stewardship is that governments must take responsibility for protecting the public interest in health systems.
We built on this original work on stewardship to develop a new strategy report in 2020 that introduced the six governance behaviors highlighted in the Progression Pathway document. We really want to stress that working in governance is like a behavior. You have to do it systematically and make it something that is done on a routine basis. You have to work on this continually, take stock of what’s working and what’s not, and adjust.
What can Ministers of Health achieve by working more closely with the private sector?
Ultimately, they can ensure people have more access to health services and improve financial protections. If they leave the private sector be, as many countries have historically done, they won't achieve their health goals and targets, and that's for two reasons. One is that the private sector is not set up to support public health goals by closing gaps in care, such as expanding health equity. However, for private providers to support public health goals, there needs to be an enabling environment created by policy tools that governments use to steer systems toward health for all goals. The second thing is that the private sector brings considerable expertise and resources. Not using them means governments miss out on great health improvement opportunities.
However, I think many countries lack situational awareness of what's going on with the private sector in their particular country to their detriment. So, more needs to be done to generate the data required for situational awareness and to govern effectively.
What barriers could governments and state authorities face when engaging with private healthcare providers?
We hear time and time again that countries don't have public-private dialogue platforms. Sometimes, they'll do a one-off consulting exercise with the private sector. However, one of the problems with that is it is fleeting, and the private sector gets very frustrated with the government when they come and talk to them about a single issue and then don't talk to them again. When it comes to expanding access to quality healthcare, the most important thing in the world is dialog and relationship building. There needs to be an institutionalized mechanism for discussing expectations and problems between the government and the private sector. That also goes to one of the topics we always hear about—that there isn't trust between the government and the private sector. You can only build trust through discussion, negotiation, and ongoing interaction.
What advice would you give to Ministers of Health as they foray into private-sector engagement?
My advice is don't be passive when it comes to the private sector. Ministers of Health must decide what they want to achieve with the private sector and recognize that the private sector can be a great source of capacity and innovation. Going back to what we said at the beginning of the interview about WHO’s 2000 Health Report and the need for governments to take responsibility for managing the public interest, they also need to govern effectively for their context. Create an environment in your country that ensures you can leverage the private sector for public health goals. But, the government also needs to step in where necessary through regulation and other policy instruments that address activities that are contrary to the public interest.
And please access the country connector website for more information and work with us on the Progression Pathway. We produced it to improve health systems, one system at a time.
How can private healthcare providers prepare to work more effectively with the public sector to achieve universal health coverage?
The private sector can proactively tell governments they understand the problems and gaps in healthcare delivery and offer solutions to these challenges. Be prepared to ask public sector players, “What can we do to support your national health policy.” This goes back to the principle of open dialogue and committing to routine engagement. Generally speaking, quite a lot of national health policies mention how the private sector can help achieve goals. The private sector contributions need to be meaningfully reflected in these plans and policies.
This interview has been edited for length and clarity.
Publish in October 2024
About David Clarke
David Clarke is the Team Leader of Systems Governance and Stewardship at the World Health Organization in Geneva, Switzerland. David is from Wellington, New Zealand, and is a lawyer and a health system governance and health policy specialist.
David worked for the New Zealand Ministry of Health from 1989 to 2001. While at the Ministry, David provided legal advice to Ministers of Health and to Ministry staff and worked on the legal and institutional design issues connected with the country’s various health reforms and the Ministry’s legislation program.
He left the Ministry in 2000 to work on Trinidad and Tobago’s health reforms before returning to the Ministry to lead institutional design work on a special project to establish a Trans-Tasman regulator. In 2001, David co-founded a consulting company where he worked for various clients, including governments, NGOs, the private sector, and various development agencies (Commonwealth Secretariat, Inter-American Development Bank, NZAID, Secretariat of Pacific Communities, UNICEF, UNMIK, USAID, World Bank, and WHO).