Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Improvement of Public Servisces in Health
- Julian López (1 September 2001)
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Strong public provision the only hope for health care in developing countries.
- Philip Crowley (4 September 2001)
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Increasing Access through Social Business
- Liliana Risi (7 September 2001)
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Private provision of care for conditions of public health importance: Need to wait.
- Debashis Dutt (20 September 2001)
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Irrational Combinations in India
- R Amarendra (22 September 2001)
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Public Health & Private Health Care in Developing Countries
- Ian Mather (26 September 2001)
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Julian López, Ob Gyn Private
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Excellent, article, the evaluation of the private services in ours countries it´s quite exactly. There is another issue to give further discussion, the ineffiency of the goverment in rule out the publics Healths Services, It would help to solve the problems raised om this editorial, to count on a efficient sistem of public health that includes control over the privates services, but when even the public services are uncontroled by the goverment, working frecuently in total caos, How they espect to control the private services ?. It seems they had more than enought problems with their inefficency at public level. The unregulated private practices it´s dangerous and sometimes, doesn´t help in solve the problems. Although, fortunatly, in the other side there is a lot of etical and helpers doctors that work in private with high standards of care, some of them sicks of trying to work in a public sistem with so many vices,and such a lack of resourses that it´s really hard to be a god provider. As you say the soluction it´s educational. |
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Philip Crowley, Specialist Registrar in Public Health Medicine Durham and Darlington Health Authority
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Dear Editor, The editorial by Zwi et al laying out principles for the involvement of private providers in delivering health care in developing countries is important. I worked for 5 years in northern Nicaragua between 1989 and 1994. During that time I witnessed the strengths of the primary health care system developed by the Sandinista government in partnership with powerful community and social organisations. I also witnessed the entry of the World Bank and the IMF into Nicaragua and its impact on health and health care. One of the central beliefs imposed by the Bank and Fund was that local people must pay “user fees” for health and education. Public sector funding was drastically reduced and the result was the effective conversion of free state health care into private, pay as you go, health care provided by the state. Local people, for example, had to sell their only cow (sole source of milk for the family) in order to pay for needed medications, thus leading to further malnutrition. In parallel to this doctors provided private health care in clinics. The effect of all of this was deprive the poor majority of local people of access to health care. The cut backs in public sector funding saw major reductions in malaria control and other public health measures. The result of this was significant increases in Malaria and dengue. In the light of all of this it is hard to imagine how the private sector can have anything but an inequitable effect on health care delivery in developing countries. Poor people will not be able to pay. This is particularly true when their livelihood is so vulnerable to international markets and so many people in Nicaragua have been devastated by the collapse in the international coffee market value (resulting from a coffee glut due to the IMF and World Bank recommending to many new countries to get into coffee production). The hope for health care in countries like Nicaragua is the phenomenal voluntary contribution made by the teams of health brigadistas up and down the country in combating common diseases such a diarrhoea and malaria. The international community can help by, promoting fair trade, encouraging debt cancellation swapped for public health sector investment and ensuring that vital drugs are not denied to poorer countries due to excessive costs and patent periods. Yours sincerely, Dr Philip Crowley, Specialist Registrar in Public Health Medicine, Durham and Darlington Health Authority. Email : philip.crowley@public-health.durham-ha.northy.nhs.uk |
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Liliana Risi, Research Division Director Marie Stopes International
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Marie Stopes International (MSI) is a not for profit social business (private sector provider) providing comprehensive well audited Reproductive Health Services. It is a global organisation with a presence in over 30 countries. As a social business with over 25 years of experience internationally, it uses modern management and marketing techniques to design branded services and products aimed at those at risk of having an unwanted birth. Through the application of innovative business tools, concepts and resources, quality services and/or commodities are delivered to segments of the population not served or not adequately served by existing services. These services are delivered in the most cost-effective way in order to ensure access and guarantee the sustainability of the programmes. MSI started within the United Kingdom where the National Health Service (NHS) currently contracts out 36% (17 785) of its TOPs annually to MSI, a substantial increase from 21% in 1996. There are currently eight clinics in the U.K. which employ over 500 employees. In South Africa, nearly a quarter of all legal abortions reported to date have been performed by Marie Stopes South Africa (MSSA). It is now the largest provider of abortion outside the public sector with clinics in all the major cities of South Africa The key difference between social business in the UK (developed world) compared with the example of South Africa and most of MSI’s other developing world programmes is that the state procures services from the not for profit sector in the UK (enabling the individual to access them for free) but individuals carry the burden of cost in the poorer parts of the world. In countries where government services are severely constrained, affordable collaborations with the private sector are being considered and Zwi et al have identified the constraints around doing this. Contracting out to well monitored social business is one strategy that can be adopted in resource poor, high demand contexts to guarantee access. |
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Debashis Dutt, Associate professor, Department of Public Health Administration All India Institute of Hygiene And Public Health, 110. C. R Avenue, Calcutta 700 003 India
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Sir, Responding to private provision of health care for conditions of Public Health Importance (PHI)(1), for example contraceptive services, control of Malaria/Tuberculosis/ Sexually Transmitted Disesases (STD)..,immunisation services and others in developing countries, I would like to raise the following points: The objective of the private sector would be to make profits, and as has been experienced in several countries (2)the private sector is likely to concentrate on curative aspects like treatment and sale of products. Prevention and control are likely to be neglected. For example, the private sector would be reluctant to spend resources on awareness building or conduction of Information Education and Communication (IEC) regarding the spread and prevention of Malaria/ TB/ AIDS.. which would have been a priority in the public sector. Again, vector control measures are likely to be neglected which would have been considered to be very important in the public sector. Since the control of many of these conditions of PHI have collateral benefits or have positive externalities(3) neglect of their preventive measures (by the private sector) would be deleterious to the developing countries in general. Fees for services or user fees levied by the private sector may force poorer sections of the society to delay treatment or take incomplete treatment causing individual as well as public harm (by spread of infection) as has been observed in China (4) and in other countries(2) trying privatisation. Equity would suffer. Since the focus of the private sector would be make profits from individual "clients", the private sector is also likely to like be insensitive to community health issues like immunisation coverage, community fertility rates, overall morbidity and mortality rates, which would have been "top priority" in the public sector. Record keeping, monitoring and survillance of conditions of PHI would also probably get little attention in the private sector thus weakening the Management Information System (MIS)which is essential for planning for health services. As has already been pointed out by the authors (1) community education strategies to enable people in developing countries to choose and demand quality health services is very difficult in context to the present health- socio-economic situation in developing countries. Also accredition of service providers (for the multitude and various forms that exist at present) in developing countries,in the existing regulatory framework, seems a far task. Though in few selected areas with better health-socio-economic framework private provision of care for conditions of PHI may bring wider choice and better quality, in most parts of developing countries, care for these conditions probably still requires to be provided by the state. (1) Zwi A,Brugha R, Smith E. Private health care in developing countries- if it is to work it must start from what users need. BMJ 2001, 323:463-464. (2)World Health Organisation (WHO). Evaluation of recent changes in the financing of health services . Report of a WHO study group. ( Technical Report Series No. 829).Geneva World Health Organisation,1993. (3)The World Bank. World Development Report 1993:Investing in Health. New York, Oxford University Press,1993. (4) Liu Y, Hsiao WC, Li Q, Liu X, Ren M. Transformation of China's Rural Health Care financing. Social Science and Medicine,1995;41(8):1085- 1093. (5) World Health Organisation (WHO). The World Health Report 1998, Life in the 21st century:A vision for all. Geneva, World Health Organisation,1998:220-232. Competing Interests: None. |
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R Amarendra, medopharm Bangalore
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Sir, Of-late many Indian pharmaceutical companies have come out with Combination of Antibiotic (Amoxycillin, Amoxycillin with Cloxacillin) with Lactobacillous. Is there any rational behind the above combinations. The antibiotic destroys both pathogenic and non-pathogenic bacteria. Hence the Antibiotic destroys Lactobacillous as soon as lactobacillous is released in gastro-intestinal tract. The companies claim as the lactobacillous is enteric-coated, hence it is released only in the lower end of the intestine. However the antibiotic remains in the gastro-intestinal tract for atleast 2 hours. Before the antibiotic is absorbed the lactobacillous is released and the lactobaccillous is destroyed. The purpose of Lactobacillous treatment is wasted. Hence it is advisible to take Lactobacillous separately after 2 hours or in between the antibiotic doses for effective implantation of lactobacillous in gastro-intestinal flora if needed. Any coments please... Amarendra. R. |
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Ian Mather, Public Health Scientist Walsall Health Authority
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Sir The editorial by Zwi et al1 points to the growth of private health care provision in developing countries and suggests means by which governments should try to harness these providers to improve the health of their citizens. Whilst this aim might be laudable, their view gives little grounds for optimism as the means of achieving the desired ends are fraught with difficulties. Also we need to question whether some of the supposed benefits associated with using private providers - such as offering the consumer greater choice - have any relevance when it comes to issues of public health importance in poorer nations. Therefore, the main challenge must surely to be improve public health services and make sure that they are financed in an equitable way which allows the poorest sections of society to obtain the health care they need - these are the two main conclusions of a recent report by Whitehead et al.2 Their review of the consequences of privatisation policies in health care points to a 'medical poverty trap' created by a combination of the introduction of user fees for public services and the growth of out-of- pocket expenses for private services. One of the countries which has experienced a massive growth in private health provision, particularly private pharmacies, over the last few decades is India. The apparent willingness of the population to pay for health care contrasts with the fact, compared to other countries with similar GDP, India spends a relatively high proportion of its income on health. However, study after study has shown that there is a marked reluctance to use free facilities even amongst the poorest sections in Indian society. For example, a study of health and health care amongst scheduled castes (ie the lowest social groups in the Indian caste hierarchy) revealed that 38% sought private medical help when their children became ill, as compared to 28% for government health facilities. Another study, which focused on the urban poor in Calcutta, concluded that public health facilities were used for emergency purposes, but there was a preference for private practitioners for all other types of care.3 This is certainly true, for example, in the case of treatment for tuberculosis.4 The implication of these studies is that public health resources are not being used effectively; consequently there is a need to find out why people do not use services provided and to try to improve access. It is clear that access cannot be equated simply with supply, but is dependent on location, wealth and quality. As well as trying to make public services more responsive, it is vital that resources are used efficiently in areas that maximise health improvement. This is likely to mean more money being spent on cost effective public health interventions as opposed to medical interventions. At present, in India, over half of the health budget is spent on secondary and tertiary curative services, whereas better health outcomes could be achieved by investing in preventive measures. The emphasis on private health care provision can only serve to perpetuate this situation. Yours faithfully MR IAN MATHER
DR SAM RAMAIAH
REFERENCES 1. Zwi AB, Brugha R, Smith E. Private health care in developing countries. British Medical Journal, 2001, 323: 463-464. 2. Whitehead M, Dahlgren G, Evans T. Equity and health sector reforms: can low-income countries escape the medical poverty trap? British Medical Journal, 2001, 358: 833-836. 3. Health, poverty and development in India. Eds: Das Gupta M, Chen L, Krishnan TN. Oxford University Press, Delhi, 1996. 4. Uplekar M, Pathania V, Raviglione M. Private practitioners and public health: weak links in tuberculosis control. The Lancet, 2001, 358: 912- 916. |
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