Curious bedfellows: private capital and universal health coverage 

Picture credit: CC BY-SA 3.0, via Wikimedia Commons

The imminent UN General Assembly High-Level Meeting on Universal Health Coverage (23rd September) will provide a global platform for discussions on access to healthcare and the issue of private investment is likely to feature prominently. In this post Dr Ben Hunter argues that the repurposing of healthcare development to meet the needs of private investors is a harmful policy position that needs to be challenged.

A new ‘common-sense’

Next week the UN General Assembly will convene in New York for a High-Level Meeting on Universal Health Coverage. Representatives from member states, and from a range of public and private organisations, will debate progress towards achievement of universal health coverage. It marks an important moment for critical reflection and deliberation on attempts to improve health, with one eye on the Sustainable Development Goal end-date of 2030.

One element that will likely be raised during the meeting is private investment in healthcare, on the basis of ‘looking at options for aligning business objectives of the private sector to provide return on investment with public policy objectives of improved equitable access and financial protection’. These planned discussions build upon claims from policy commentators that well-designed projects can meet the ‘mutual interests’ of investors and public health agencies (Krech et al., 2018), but also the increasingly coordinated promotion of private investment and provision by the same companies that hope to profit from such arrangements. These discussions mark an attempt to craft a new ‘common-sense’ around the necessity of private capital to finance an expansion of healthcare infrastructure.

Pursuit of equity, or pursuit of equity?

Susan Murray and I recently raised concerns with a ‘financialisation’ in healthcare which is characterised by attempts to repackage infrastructure projects as investment opportunities for global private financial capital. Health systems are being actively reconstructed as an infrastructure asset class; as businesses that can be bought and traded. That this process is now being deliberated as part of ‘universal health coverage’ shows how far UHC has strayed from notions of equity; pursuit of ‘equity’ in healthcare may now just as well refer to the courting of potential investors as it does to any interest in health needs. Yet there are important reasons to be worried about the likely adverse consequences of this trend for health and wellbeing, making private capital and universal health coverage rather curious bedfellows. We highlight three below:

  1. Private investment in fee-based providers is liable to deepen poverty

Many of the healthcare providers expanding rapidly with private investment have systems of user fees to pay for their services. This is a seemingly logical option in settings with limited government resources and embryonic health insurance systems. But have we still not learnt from four decades of user fees since they were advocated by the World Bank and other during the 1980s and 1990s? They exclude the poorest and most marginalised groups and undermine population health. Worse still, they impoverish those who in desperation sell their belongings and take high-interest loans to pay for life-saving treatments.

  1. Expansion of chains will exacerbate social segregation and inequality

Some of the healthcare chains pursuing aggressive international expansion specifically target wealthier groups, while others market their ‘affordable’ services to the lower middle-class. They target their expansion to geographic areas and healthcare specialities (such as childbirth, cardiology and ophthalmology) where demand is predictable and revenue assured. Other populations and services are left to public providers. This expansion is thus predicated on entrenching segmented healthcare systems in ways that reduce opportunities for resource redistribution and solidarity.

  1. There are powerful incentives for cost inflation

Senior management in corporate healthcare providers answer primarily to their shareholders, whose concern lies with dividends and returns on investment. As our recent work in India has shown, that commercialised logic permeates through healthcare provision and drives unnecessary testing and treatment. Governments and social health insurance funds – be warned.

The clock is ticking

Perhaps of greatest concern is the current policy drift into a scenario that will be difficult to reverse. Sen and Dreze (2013) rightly noted the propensity for healthcare industry lobbying to become embedded in public policy processes once companies gain a foothold in the sector. As private ownership of healthcare infrastructure grows, so too will the bargaining power of this sector vis á vis governments, potentially skewing public policy in favour of the former.

Activists and academics based in countries around the world are resisting this trend and pushing back against the use of development aid to facilitate these kinds of investments in healthcare. They point to the need for decommodified approaches in healthcare provision, and for interpretations of universal health coverage that are grounded in social solidarity. Over the coming weeks we’ll see whether these arguments can gain traction, or whether the drift towards exclusionary, segmented and expensive healthcare systems continues unabated.

This blogpost is based on an article published in Development and Change in September 2019.