It’s never too early to build strong mixed health systems

This blog is a part of PSI’s Health Systems Accelerator series: Big Ideas. Small Bites.
By Hilary Kinka, Private Sector Engagement Technical Advisor, Health Systems Accelerator, PSI

3.5 billion people worldwide still lack equitable access to quality, affordable health services.

Despite global government commitments to adopting the 2015 Sustainable Development Goals (SDGs) and achieving Universal Health Coverage (UHC), health systems are not yet optimized to meet consumer needs and preferences, to facilitate the consumer’s journey to care or to ensure that all people can access and afford health services when and where they need them.

That begs the question: how and when can we support countries to advance toward UHC? Our work in Somalia and Somaliland presents applicable learnings that can inform how we — across countries and contexts — can build the foundation needed to progress toward UHC.

How and When to Build the Foundation

The journey toward UHC is neither quick nor straightforward, and while some countries are earlier in their journey than others, it is never too early to begin building the foundation.

National plans, policies and strategies for UHC, private sector engagement and health financing do not necessarily need to already be in place—and if they are and implementation has stalled, we can still support governments to move toward their vision for strong, resilient mixed health systems.

In Focus: Somalia and Somaliland

There is a lot we can already do to support governments of countries with very low GDP per capita, limited government spending on health and weak stewardship of the private sector to shape stronger and more resilient mixed health systems – beginning now.

Take Somalia and Somaliland. Both experience severe constraints that have hindered progress toward the SDGs and UHC, and have poor health indicators.

  • The private sector provides health services to an estimated 90% of consumers, and a high percentage of health services (45%) are financed by consumer out-of-pocket payments, which can lead to catastrophic health expenditure.1
  • Private sector health data is not reported into the national Health Management Information System. Consequently, the Ministry of Health has no insight into the depth or breadth of private sector service delivery.
  • Although some national policies and plans are in place to support movement toward UHC, others have stalled. Implementation of these plans is hindered by resource constraints and security considerations.

Beginning in 2018, PSI partnered with the Federal Government of Somalia (FGS), Ministries of Health (MOH) in Puntland, Somaliland, and Jubaland, and other key development stakeholders to set strategy and introduce mechanisms to strengthen stewardship of the private health sector within mixed health systems through three interventions designed to accelerate progress toward UHC:

  1. Shaping Strategy: We supported the Heads of the Department of Planning in the Somaliland and Puntland Ministries of Health to finalize their Health Sector Strategic Plans (HSSPs), and the FGS and MOH of Somaliland to develop private sector engagement strategies.
  2. Setting up Systems for Data Collection & Visualization: PSI worked with the Puntland, Somaliland and Jubaland MOHs to develop work plans to rollout data-to-action (D2A) frameworks aligned to the HSSPs that define how to analyze, visualize and interpret health services data. The next step was to demonstrate how to develop national, regional and district level dashboards to measure progress against HSSP targets, and then to introduce an approach for MOH departments to assess the quality of public health services data entered into the Health Management Information Systems (HMIS) and to develop action plans to address gaps.
  3. Integrating the Private Sector into the national HMIS: PSI supported the Somaliland MOH to develop and test an approach to collect private sector data for the first time by launching a pilot with 17 private facilities, training their providers on the HMIS tools used by the public sector and co-conducting supportive supervision visits with the MOH. Private providers used WhatsApp to share data, which was then aggregated in District Health Information System 2 (DHIS2). With DHIS2 dashboards already setup, the MOH was able to view public and private sector data side by side for the first time in Somaliland, even if for just a sub-set of private health facilities at the outset.

Although a first step, reliable and timely health information is an important input for health systems to strengthen their performance. These activities set the foundation for government officials to make evidence-based decisions to improve overall population health and pave the way for improved governance of the private sector. They established a positive relationship between private and public sector actors where no relationship may have previously existed, and it helps move toward public-private data integration. As a result of our work in the private sector, the FGS and Puntland, Somaliland and Jubaland MOH officials now see PSI as a dynamic partner in helping to build a strong mixed health system.

Additionally, a functional health information system is a critical pre-condition for future health financing arrangements, and for the inclusion of the private sector in insurance mechanisms. The ability to participate in health financing options will also further incentivize private providers to regularly submit accurate data.

What We Learned

As we aim to scale how we strengthen mixed health systems, we are documenting the learnings that can apply to similar work across new contexts:

  1. Donor funding can be used to test and pilot systems on a small scale that can be affordably and efficiently adopted by governments and implemented across sectors and layers of the health system.
  2. In contexts with limited connectivity, digital health solutions can still be used in “offline mode” until internet is available.  This ‘wiring’ of the layers of the health system – across the public and private sectors – can better facilitate the consumer’s journey.

With a long journey toward UHC ahead, foundational activities such as those conducted in Somalia and Somaliland can help governments to accelerate progress and ensure every person has access to quality and affordable care.

We want to hear from you! How are you supporting governments to strengthen health systems? What have you learned?

1 “Improving Healthcare Services in Somalia (‘Damal Caafimad’ Project) ” Project Information Document (PID), World Bank, 15 Jan. 2020,

Banner photo credit: Sebastiano Rossi

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