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EDUCATION AND DEBATE: Sam Agatre Okuonzi Learning from failed health reform in Uganda BMJ 2004; 329: 1173-1175 [Full text]

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CRITICISING HEALTH REFORM STRATEGIES

Sabahattin AYDIN, Sinan KORUKLUOGLU   (30 November 2004)

CRITICISING HEALTH REFORM STRATEGIES 30 November 2004
Sabahattin AYDIN, Deputy Undersecretary, Ministry of Health of Turkey Ministry of Health, 06434 Sihhiye Ankara, TURKEY, Sinan KORUKLUOGLU Send response to journal: Re: CRITICISING HEALTH REFORM STRATEGIES	Sabahattin AYDIN, Prof., M.D., Ph.D. sabahattin@saglik.gov.tr Sinan KORUKLUOGLU, M.D. skoruklu@saglik.gov.tr Reforming health system is in the agenda of almost all countries and political actions. Within the concept of globalization, most of these health reforms tend to have a lot of similarities. Of course market principles have great influence in these reform strategies. In a social state, equal and accessible health services are mainly organized by public sector under its responsibility. Health is regarded as one of the human rights which should be supplied by the administrative authorities that are formed to organize and keep the security and wellbeing of their people. So it does not seem to be wise to leave it in the mercy of extensive market principles. However, the inertia and bulkiness of the public sector should be activated with the dynamics of strictly controlled market activity. The main goals and responsibilities of the public sector should play a guiding monitoring, controlling and rewarding role while implementing health reforms that are mainly influenced by market principles. Okuonzi in his article about health reform in Uganda states that in developing countries, international donors have insisted on health reform as a precondition of providing external aid (1). If the health indicators and outcomes of the conventional healthcare facilities in the countries are not satisfying, there is nothing strange in this statement, became the donors have right to ask for more healthy people to be able to pay their money back. This does not mean to introduce ready made reform packages – as mentioned in the article (1) – defined by World Bank as market reform. World Bank is an investment bank. Instead of preparing a reform project and getting support for it after approval, if the countries import ready made World Bank Projects, it will probably result with failure. This is, in a way, a misuse of international organizations and donors. Without considering the countries own needs and the behaviors of the people of the country no health reform will be successful regardless of depending on market principles or not. As declared by Fişek (2) one of the main failure of health reforms is the commanding way of introducing it, which we had experienced in our country. So called market reforms introduced in Uganda, Bolivia, and Russia were reported to be based on four cardinal principles (1,3) First of all, individuals, charities and private organizations should be made responsible for health care. Public and private sectors have some disadvantages and also privileges of their own. Whenever the responsibility of health services is attributed to either side we can easily experience many problems. Individuals should bear the responsibility for their health, as much as the governments are responsible. The sources of private organizations should be delivered to health services with the regulations and direction of the public responsibility. When organizing this public-private partnership, countries should give priority to the habits of their people. The second principle is, public funding of health care should be restricted to health promotion and prevention of disease. Public funds are made up of the taxes or premiums paid by the individuals. Health services should be evaluated in a holistic manner. Funds, either public or private, should initially be responsible for health promotion, prevention and also treatment of diseases. If you stratify these services and share responsibilities between different fundings, the cost saving influence of these services will be lost. Moreover, there is always positive effect of each well done service to the others. Restricting some funds to some of these services will not get the benefit of this effect which will end with health services with increased health expenditures. On the other hand, fragmenting the population in terms of funding will also have the some deleterious effect on health services. If private organizations cover some group of people, mainly who can afford to pay, and public funding covers the rest, mainly the poor, this will restrict the sharing of the risks which is not convenient with the principles of insurance. The more people will be covered, the more risk will be shared. So, regardless of the type of the revenue, the insurance share should cover all the people in the country and share the risks as much as possible. In other terms, universal social health insurance scheme should be implemented. This type of funding would enable all the inhabitants to reach equal and accessible health services. However, health services have no certain limitations. Additional service demand exceeding the universally acceptable service supply can be covered by supplementary insurance scheme. Third principle describes the governments’ role. Central governments’ role should be restricted to policy formulation and technical guidance with delivery of services left to the private sector and local authorities. The central governments’ role should be described in terms of the size of the country and number of the population. In a country like Turkey central governments delivering almost all the health and education services can not pay enough attention to policy formulation and technical adequacy. In spite of the central distribution of the sources, the difference between the districts can not be stopped for health status, is not free from the other, social and economical aspects. If the services are run by other authorities than the central government, the risk of increased difference between the districts become higher. However, the preparedness and readiness of the local authorities has great influence in solving the problem. Additionally, local authorities or governments are more close to the feedback of the people who demand the services. Thus, the effectivity and quality of the services are even controlled by the users. Customer satisfaction and user friendly arrangements become more important than “in the office made decisions”. Within this context, together policy formulation and technical guidance, central government should also keep the power of distributing the sources supporting some districts when needed and also monitoring the system. Moreover, monitoring should include some sanctions in case of diversion from the regulations. The fourth cardinal principle of health reforms based on market principles is to increase the power of non-governmental organizations and private sector. The private sector and non-governmental organizations should be supported to become the key providers of health and social services (1,4) In a broad way of thinking private sector and non- governmental organizations are the key elements of democracy. Government being dominant in all sectors leads the society to a totalitarian regime, whatever the name of the system is. So to establish more democratic way of living, the power should be shared by different representatives of society. The more the power is distributed to individuals further we go away from totalitarism. In this context, the aim of increasing the power of private sector and non-governmental organizations seems reasonable. As health and welfare services are mainly among the public duties, they can not be thoroughly left to the private sector that mainly works for profit making. On the contrary, when the services run by the public sector and organized as money loosing systems, the development of the services decreases. The services become focused on the organization itself rather than the users. Non-governmental organizations, -in case of not being the front of page of private sector- may become quite important actors of health and welfare service delivery, as non-profit organizations. They may carry the benefits of both private and public sector if well organized. However, some non-governmental organization which acts as side organization of some private sector makes this issue debatable. Within the light of these criticisms, we can conclude that public sector should still keep its position in health service delivery especially in countries where gaps between areas are predominant. Public sector should be included in the system and given equal opportunities with the sector to form competition that will increase the development of the services. In true meaning of the term, non-governmental organizations may play key role in delivering these services. They can be supported, or even be given equal opportunities to play active role. Their part in the area will increase by the time as more democratic life style is appropriated. Meanwhile regulating and monitoring function of the central government should always be active and efficient. Turkey has initiated Health Transformation Program (5) under the light of recent reform studies, and forty years’ experience of her running health system. The positive and negative experiences of many countries were examined during the preparation of this programme. Although the market principles mentioned above have a great influence in this program; they are not adopted in many areas. Social policies are never neglected As McKee and McPake (6) warns, this is an area where more evidence rather than ideology is needed. After long discussions and negotations a project to support health reforms is accepted by the World Bank. As a conclusion, countries should prepare their reform projects and keep relations with the World Bank as a financial supplier (donor) not as a project imposer. Support of evidence based projects is prone to success for both sides. We can prepare more realistic reform strategies sharing our own experiences and capacities. 1. Okuonzi SA. Learning from failed health reform in Uganda. BMJ. 2004 Nov 13;329(7475):1173-5. 2. Prof. Dr. Nusret Fişek’in Kitaplaşmamış Yazıları III. ed. Rahmi Dirican, TTB Yayınları, Ankara. 1999 3. World Bank. Staff appraisal report: district health services pilot and demonstration project. Washington, DC: World Bank, 1994. 4. World Bank. World development report: investing in health. Oxford: Oxford University Press, 1993. 5. Ministry of Health of Turkey. Health Transition Program. Ankara. Saglik Bakanligi, 2003 6. McKee M, McPake B. The devil is in the detail. BMJ 2004 329: 1175-1176. Competing interests: None declared