Thinking differently about how to harness health markets could provide more health for more people, says Jeffrey L Sturchio
The global healthcare market is now estimated to be worth some $10tn (£7.7tn; €8.9tn) and is growing at a faster rate than GDP in many countries.  This market spans both the public and the private sectors. In some cases, like vaccine procurement, it operates mainly in the public sector, whereas in others, such as digital innovations, we are seeing an explosion of private sector entrepreneurship that is leapfrogging health system gaps in many countries.
Traditional health industries are being reshaped by new opportunities arising from breakthroughs in science, technology, policy, and finance. Other industries, including nutrition, sports and fitness, telecommunications, and banking, are broadening the reach and impact of global healthcare markets. The production and provision of health related goods and services, employment in the health workforce, new technologies, and capital invested in hospitals, clinics, and other health infrastructure affect the prospects for stable economic growth and employment in economies around the world. And these effects in turn lead to improvements in population health. 
Many in the global health community see this as problematic. If access to healthcare is a human right, how, they ask, can the private sector play a constructive role in helping to ensure health for all? But health outcomes are necessarily linked to the healthcare markets that supply interventions to the populations that need them. This complex global economy of health is already creating disruptions in traditional practices in global health delivery, as the scale, scope, and efficiency of the private sector create and shape markets in new ways. Making markets work better for health—by reducing transaction costs, increasing market information, balancing buyer and supplier risks, and using innovative business models to reach underserved populations—will lead to better use of resources and continued improvements in health in both rich and poor countries. [3,4]
What implications will these disruptive effects have for global health governance? As Tedros Adhanom Ghebreyesus, director general of the World Health Organization has observed, “Health cannot be left to health ministers alone. Ministers of finance and of the economy need to be involved, too. Their policies can have a profound impact on the health of the population and on an equitable outcome to health system reforms.”  This was highlighted by the 2008 Tallinn Charter on health systems for health and wealth, which defined a health system as “the ensemble of all public and private organisations, institutions, and resources mandated to improve, maintain, or restore health.”  This encourages us to think of health systems as ecosystems of different actors bringing complementary skills and resources together to achieve more than the sum of their parts. Rather than ask whether healthcare markets have a role in improving global health, we should be asking how to make the private sector work for innovation and equity.
What possibilities do healthcare markets offer for improving countries’ prospects of achieving universal health coverage and the sustainable development goals? Consider the scale of financial flows in the global health marketplace: the World Health Organization’s investment case for the next five years is $14bn or about $2.8bn a year—a tiny fraction of annual global financial flows in the health economy.  What if we could disrupt the usual patterns of investment in global public health by thinking differently about how to harness health markets in the service of health for all? A small change in the allocation of these resources could be transformative for billions of people around the world. A good start would be to encourage bankers, institutional investors, and corporations in all sectors to understand better the robust returns to investment in health versus other potential investments, thus mainstreaming health into financial decision making in a sustainable way. 
What does the future hold? The challenge will be to find appropriate ways to adapt stewardship mechanisms for mixed health systems in which both public and private actors and resources are deployed to provide more health for more people. We will need to pay attention to transparency, equity, and accountability—for public and private sector actors alike. The recent report of the Independent Accountability Panel for Every Woman, Every Child, Every Adolescent acknowledges that this is contested terrain but concludes that “when the public sector is strong and government is responsive to its citizens, the private sector can thrive, enhance growth and wellbeing, and accelerate innovation to achieve the 2030 agenda.”  By working together in new ways, in the spirit of collaboration and cooperation, we can develop new mechanisms of global health governance that incorporate the potential of the global healthcare marketplace in ways that will make a real difference in tackling the health challenges that all countries will face on the path to universal health coverage.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare: I am the CEO of Rabin Martin, a global health strategy consultancy that receives fees for advice on a range of global health topics from numerous private sector entities (both for-profit and not-for-profit.). But none of these fees are directly related to the topic on which I have contributed an essay to The BMJ.
1 World Health Organization. Together on the road to universal health coverage: a call to action, WHO/HIS/HGF/17.1. World Health Organization, 2017: 3.
2 Kickbusch I, Franz C. Conceptualizing the health economy. In: Sturchio JL, Kickbusch I, Galambos L, eds. The road to universal health coverage: innovation, equity and the new health economy. Johns Hopkins University Press, 2018: 16–40.
3 US Agency for International Development. Healthy markets for global health: a market shaping primer. USAID, 2014.
4 Clayton M. Christensen, Michael E. Raynor and Rory McDonald. What is disruptive innovation? Harv Bus Rev 2015;(December):44–53. https://hbr.org/2015/12/what-is-disruptive-innovation.
5 Ghebreyesus TA. Foreword. In Sturchio JL, Kickbusch I, Galambos L, eds., The road to universal health coverage: innovation, equity and the new health economy. Johns Hopkins University Press, 2018): v.
6 Kutzin J, Sparkes SP. Health systems strengthening, universal health coverage, health security and resilience. Bull World Health Organ 2016;94:2. http://www.who.int/bulletin/volumes/94/1/15-165050.pdf. PubMed doi:10.2471/BLT.15.165050
7 Ghebreyesus TA. Launch of WHO investment case. Remarks at WHO Headquarters. 19 September 2018. http://www.who/int/dg/speeches/2018/launch-of-who-investment-case/en/
8 Krech R, Kickbusch I, Franz C, Wells N. Banking for health: the role of financial sector actors in investing in global health. BMJ Glob Health 2018;3(Suppl 1):e000597. doi:10.1136/bmjgh-2017-000597. PubMed
9 Independent Accountability Panel for Every Woman. Every Child, Every Adolescent. Private sector: who is accountable? for women’s, children’s and adolescents’ health. 2018 Report. http://iapreport.org/img/pdf/IAP18001_REPORT_B_020_WEB.pdf