Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Oxfam must shed its ideological bias to be taken seriously
- Dominic Montague, Richard Feachem, Neelam Sekhri Feachem, Tracey Perez Koehlmoos, Heather Kinlaw , Richard Smith (5 March 2009)
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The fallacy of impartiality: competing interest bias in academic publications
- Richard Smith (5 March 2009)
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Critique of Oxfam paper inaccurate, unconstructive and ideologically biased
- Barbara Stocking (7 April 2009)
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Agreements and disagreements with Oxfam
- Dominic Montagu, Richard Feachem, Neelam Sekhri Feachem, Tracey Perez Koehlmoos, Heather Kinlaw , Richard Smith (17 April 2009)
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Ideological Blinders on the Role of the IMF in Restricting Public Sector Health Capacity
- Brook K. Baker (25 April 2009)
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The fallacy of competing interest bias
- Kara G. Hanson, Anne Mills, Lucy Gilson, and Catherine Goodman (29 April 2009)
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Double standards
- Roger England (7 May 2009)
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Dominic Montague, Lead, Health Systems Initiative UCSF Global Health Sciences, Global Health Group, San Francisco, CA 94105, Richard Feachem, Neelam Sekhri Feachem, Tracey Perez Koehlmoos, Heather Kinlaw , Richard Smith
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Oxfam has called for better information on the role of the private sector in health care in developing countries, while simultaneously demanding that the World Bank, bilateral donors, and private foundations cease to support programmes or policies that would work with the private sector. (1) The irony is that Oxfam makes this call on the basis of data that are thin, selective, and distorted. Oxfam notes, for example, that “data from 44 middle- and low-income countries suggests that the higher the level of private sector participation in primary health care, the higher the overall level of exclusion from treatment and care.” The data come from an unpublished study that shows that for pediatric respiratory and diarrhoea treatment, “the higher the share of private in total consultations, the lower the rate of consultations. The data thus suggest that commercialisation in this sense is associated with higher levels of exclusion from access to care.” (2) An alternative interpretation is that poor government provision has led to higher rates of private sector provision. In other words, it is not because the private sector treats patients that many people go without health care; rather it is because governments do little that private services make up a larger percentage of all care. The data do not indicate causality, but Oxfam fail to acknowledge this. Later Oxfam cites its own “analysis of data from Demographic and Health Surveys (DHS) in 15 sub-Saharan Africa countries with comparable data categories for private providers.” (3) It shows that only 3% of all patients visiting the private sector go to doctors and that 40% of private provision in Africa is “just small shops selling drugs of unknown quality.” But the authors mislead through being selective. Their source of data includes 21 countries, but they select 15 that support their thesis. The more complete information shows that shops represent 29% of the source of care and that among the poorest quintile 11% (not 3% as Oxfam reported from a sub-section of data) of patients were seen by a doctor. Then an additional 24% were treated in a ‘private facility,’ which, as Oxfam must have known, means a multiprovider facility where there is a doctor plus other providers. So 37% of patients were seen by a doctor or better. Oxfam has distorted the data tenfold. These examples illustrate why the Oxfam report will never be taken seriously as a contribution to the important debate over what role, if any, the private sector should play in health systems. Oxfam should put its ideological bias aside so that its voice can be appreciated in the debate. It should also recognize the contradiction in their core thesis: if “money would be better invested in health services provided by governments” then Oxfam, a private organisation, should give back the money it receives from the British government to provide services. (1)Oxfam. (2009) Blind Optimism: Challenging the myths about private healthcare in poor countries. Oxfam Briefing Paper 125. February 2009 (2)Koivusalo,M. and Mackintosh, M. (2004), ‘Health Systems and Commercialisation: In Search of Good Sense’. Paper prepared for the UNRISD International Conference on Commercialization of Health Care: Global and Local Dynamics and Policy Responses www.unrisd.org, accessed 23 February 2009 (3) T.Marek, C. O’Farrell, C. Yamamoto and Zable, I. (2005) ‘Trends and Opportunities in Public-private Partnerships to Improve Health Service Delivery’, Africa Region Human Development Series, Washington DC: World Bank Competing interests: DM is an academic with research and consulting experience related to health provision in developing countries. His professional work is largely focused on issues related to private sector delivery of care. The elimination of all private providers in developing countries would cause potential disruption to his career. RS is the Director of the Ovations Chronic Disease Initiative, a corporate social responsibility campaign that funds eight centers in low- and middle-income countries to respond to chronic disease. Ovations is part of the UnitedHealth Group, a for-profit health and wellbeing company that operates in 40 countries. RS has stock in UnitedHealth Group. RS is also a member of the board of the Public Library of Science. RF leads the Global Health Group, an action tank at the University of California San Francisco, supported by the Bill & Melinda Gates Foundation and ExxonMobil. The Global Health Group is in part dedicated to the understanding and development of the role of the private sector in health systems strengthening. RF also advises public and private organizations on this topic. RF is married to NSF. NSF is the founder and Chief Executive of The Healthcare Redesign Group, a for-profit consultancy dedicated to assisting governments and private clients to improve access to, and quality of, health services around the world. NSF was formerly Health Financing Advisor at the World Health Organization, has served on the Commercial Advisory Board of the UK National Health Service, and has held executive positions with Kaiser Permanente. NSF is married to RF. TPK is the Programme Head for Health and Family Planning Systems at ICDDR,B, a center of excellence for health and population research based in Dhaka, Bangladesh. ICDDR,B works closely with the public and non-state sectors and the interface between the two on a national and global level. TPK leads a Centre for Systematic Review that focuses on health systems and policy issues in the non-state sector in low- and middle-income countries. HK is Program Coordinator, Health Systems Initiative for the Global Health Group. |
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Richard Smith, Director UnitedHealth Chronic Disease Initiative, London SW4
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I have just posted a rapid response from a group of us that includes a spectacularly long competing interest statement. The statement is close to the one that many of us declared when writing half of a debate in PLoS Medicine where we argued that the private sector (or non-state sector as it’s known in WHO jargon) has an important role to play in providing health care to the world’s poorest—not least because it provides most of it at the moment. (1) A group from the London School of Hygiene argued the opposite, but we agreed on much. We were struck, however, when reading the article that our competing interest statement was huge, whereas the other group had no competing interests. On reflection we decided that it’s naïve to think that those connected with the private sector have many competing interests whereas those from academia or public bodies have none. We thus developed the idea of “competing interest bias” and have published an elaboration of our thoughts in the Journal of the Royal Society of Medicine. (2) Our argument is not that authors should cease declaring competing interests but rather editors and others need to become more thoughtful about the process. An editorial in PLoS Medicine takes a similar line. (3) 1 Is Private Health Care the Answer to the Health Problems of the World's Poor? Hanson K, Gilson L, Goodman C, Mills A, Smith R, et al. PLoS Medicine Vol. 5, No. 11, e233 doi:10.1371/journal.pmed.0050233 2 Richard Smith, Richard Feachem, Neelam Sekhri Feachem, Tracey Perez Koehlmoos, and Heather Kinlaw The fallacy of impartiality: competing interest bias in academic publications J R Soc Med 102(2): 44-45; doi:10.1258/jrsm.2009.080400 3 Making Sense of Non-Financial Competing Interests The PLoS Medicine Editors PLoS Medicine Vol. 5, No. 9, e199 doi:10.1371/journal.pmed.0050199 Competing interests: I have a heap of competing interests, many of which are listed in the rapid response above. I was also once the editor of the BMJ (back in its boring days) and am the editor of Cases Journal and on the board of the Public Library of Science. |
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Barbara Stocking, Chief Executive, Oxfam GB Oxfam GB, Oxfam House, John Smith Drive, Cowley, Oxford, England, OX4 2JY
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A primary objective of our new paper Blind Optimism is to encourage and advance an evidence-based debate on the appropriate role of the private sector in health care delivery in poor countries. Not only does your response detract from this important debate by misrepresenting the paper, you incorrectly accuse Oxfam of purposively distorting the data to support our arguments. Firstly, we do advise against investing in risky and unproven private -sector approaches to expand health care in poor countries. You are wrong to suggest that this is the same as advocating that all engagement with the private sector should cease. In the paper Oxfam is explicit that the ‘private sector can play a role in health’, that it ‘will continue to exist in many different forms and involves both costs that must be eliminated and potential benefits that need to be further understood and capitalised upon’. Government capacity to regulate the existing private sector and ensure its positive contribution to equity is prioritised as one of our core recommendations. On the other hand, unchallenged enthusiasm for private sector solutions is neither justified nor helpful. Based on the evidence available there is an urgent need for more honesty about the significant risks to efficiency and equity associated with private sector growth in health care, and more openness about the paucity of comprehensive evaluations of private sector approaches and the lack of evidence that these approaches can be scaled up. Secondly, you also claim that Oxfam uses data from DHS surveys to imply when poor countries have a large private sector this causes greater overall exclusion from health care. This is not true. We do say there is a correlation but we do not claim causality. In fact we state clearly in the paper that: "…Although this correlation does not clarify whether high levels of private participation cause exclusion, it at least suggests that the private sector does not in general reduce it…" Your final point questions our analysis of what the private sector looks like for poor people in Africa, which finds that 36% of private provision is just small shops selling drugs of unknown quality. You claim that we deliberately exclude countries that don’t support our position. Instead we compared only those countries where survey data was directly comparable(1). Your calculation includes countries with differing data categories, for example countries that do not include a category for private doctor. By doing this you are not comparing like with like and this distorts your findings. You also appear naively optimistic with your suggestion that seeking care from a private facility always means seeing a “doctor or better”. Even if we assume, as you do, that every private facility in sub-Saharan Africa has a qualified doctor or better, using the comparable data the total proportion of the poorest quintile that seek private care that get to see a private doctor is still only 29%, not 37% as you suggest. More importantly, you also avoid addressing the most pressing issue we highlight; that over half of the poorest children in Africa do not receive any health care at all – public or private. The real question is how we are going to reach them, and here the evidence for promoting private sector expansion is very thin indeed. We do agree with you that the private sector in health often proliferates in the absence of a well functioning and accessible public health system. This can be compared to the way private bodyguards expand in a failed state. Does this mean we abandon the public health system or does it mean we need to reverse decades of under-investment and focus on making the public sector work better? Governments have historically intervened to provide health services precisely because the market fails to deliver decent health care for everyone. In more successful countries government provision of decent health care free of charge has played a direct role in crowding out the worst elements of private sector provision. A recent paper by Dr Mead Over from the Centre for Global Development on anti-retroviral therapy in India(1) argues that we should take this government role seriously. The author states that "public sector delivery of ART can be justified not only because it protects poor AIDS patients from catastrophic health expenditures, but also because it might differentially 'crowd out' the cheapest (and therefore perhaps the worst) of the private sector AIDS treatment"(2). Whilst we appreciate there are many different points of view in this debate your critique of Oxfam’s paper is unfounded and inaccurate and your tone unfairly and unhelpfully dismissive. We would urge you to take more time to look at the evidence of what works for the poorest people and enter into a more constructive debate. (1) Mead Over. 2009. "AIDS Treatment in South Asia: Equity and Efficiency Arguments for Shouldering the Fiscal Burden When Prevalence Rates Are Low." Working Paper 161. Washington, D.C.: Center for Global Development. http://www.cgdev.org/content/publications/detail/1421119/ (2) http://blogs.cgdev.org/globalhealth/2009/03/public-delivery-of- aids-treatment-in-south-asia-a-timidly-heroic-assumption.php Competing interests: None declared |
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Dominic Montagu, Lead, Health Systems Initiative UCSF Global Health Sciences, Global Health Group, San Francisco, CA 94105,, Richard Feachem, Neelam Sekhri Feachem, Tracey Perez Koehlmoos, Heather Kinlaw , Richard Smith
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We responded vigorously to the Oxfam report because we believe that it owes too much to ideology and too little to evidence. We make our criticisms in the hope that Oxfam will not prematurely adopt an extreme position regarding public or private health services, but join in an objective search for critical evidence on all systems of financing and delivery of health care. The point made by Oxfam’s chief executive concerning failed states and the proliferation of private security firms is indicative of the ideological predisposition that impedes an open debate regarding healthcare delivery in developing countries. It is universally agreed that the provision of law and order is a fundamental responsibility of the State and must be largely provided by agencies of the State. The view that this may also be true of health care is not accepted outside of the UK, and is increasingly being challenged within the UK. We agree with Oxfam regarding the proliferation of the private sector in the absence of a well functioning and accessible public healthcare system. We would add, however, that the private sector also proliferates in the presence of well functioning and accessible public health care services. This is demonstrated in most European countries, across Latin America, in Thailand, South Korea, Vietnam, and many other countries at various income levels. Two of us are Britons, and it is our experience outside of Britain that has made us realize the peculiarity of British organisations in being so skeptical of the private sector. Elsewhere, the important role of the private sector in health systems, in countries both with and without well functioning state health programs, is widely acknowledged. Public versus private provision is not a binary choice facing governments, donors, patients, and global policy makers. We believe that the goal should be the best alignment of public and private capabilities and strengths, to achieve public policy objectives. Regarding the specific issues of data analysis and interpretation that are pointed out in our first letter, clearly we are analyzing the data differently. We are pleased to note, however, that both we and Oxfam are in agreement that there is no causal link between the size of the private sector and access to health services. We fully agree with Oxfam that attention and action is needed to provide care to the more than fifty percent of children in developing countries who receive no medical care at all when ill. We know that in both the poorest and wealthiest quintiles, three quarters of children who receive health care get it from the private sector. The difference is that 55% of the wealthier children received care when sick, but only 33% of the poorer children. , To us, this inequity in access must be addressed by supporting all providers - public and private - who can bring quality care to poor children. Unfortunately the evidence, sketchy though it is, suggests that there is no delivery system, public or private, that is doing this now. It is disappointing to note that across the developing world, despite billions of dollars of public subsidies and fully salaried government doctors backed up by armies of nurses, clinical officers, technicians, and bureaucrats, public systems have not outperformed a rag-tag bunch of private operators with no subsidy or support from governments and donors. Public delivery must be assessed through the same critical lens as private delivery, and the best approaches pursued in each country according to context. We do not suggest that private provision is inherently preferable to other delivery models, or that private provision should be expanded. We recommend that both public and private sectors should work together to achieve public policy goals, harnessing the unique capabilities of each. Significant rates of private provision are the reality in all developing countries today, and calling for a statist revolution in health care, rather than calling for improvements in the status quo, is not justified by evidence. Despite being superficially attractive, people get hurt in pursuit of extreme or ideological positions. Ignoring private care will not improve the performance of the public sector or provide better access to good quality services for the poor. Seeking to improve care by private providers and better align private activity with public policy goals may not be sexy, but it is right and responsible. As our ends are the same we feel that debate and engagement on these issues serves us all well. We join Oxfam in its call for more and better information on the effectiveness of a range of health delivery models - public, private and mixed - and for investment in those approaches that are most effective at improving access to high quality services for those most in need. Competing interests: Competing interests: DM is an academic with research and consulting experience related to health provision in developing countries. His professional work is largely focused on issues related to private sector delivery of care. The elimination of all private providers in developing countries would cause potential disruption to his career. RS is the Director of the UnitedHealth Chronic Disease Initiative, a corporate social responsibility campaign that funds eight centers in low- and middle-income countries to respond to chronic disease. The UnitedHealth Groupis a for-profit health and wellbeing company that operates in 40 countries. RS has stock in UnitedHealth Group. RS is also a member of the board of the Public Library of Science. RS also contributes over 1% of his salary to Oxfam and plans to continue. RF leads the Global Health Group, an action tank at the University of California San Francisco, supported by the Bill & Melinda Gates Foundation and ExxonMobil. The Global Health Group is in part dedicated to the understanding and development of the role of the private sector in health systems strengthening. RF also advises public and private organizations on this topic. RF is married to NSF. NSF is the founder and Chief Executive of The Healthcare Redesign Group, a for-profit consultancy dedicated to assisting governments and private clients to improve access to, and quality of, health services around the world. NSF was formerly Health Financing Advisor at the World Health Organization, has served on the Commercial Advisory Board of the UK National Health Service, and has held executive positions with Kaiser Permanente. NSF is married to RF. TPK is the Programme Head for Health and Family Planning Systems at ICDDR,B, a center of excellence for health and population research based in Dhaka, Bangladesh. ICDDR,B works closely with the public and non-state sectors and the interface between the two on a national and global level. TPK leads a Centre for Systematic Review that focuses on health systems and policy issues in the non-state sector in low- and middle-income countries. HK is Program Coordinator, Health Systems Initiative for the Global Health Group. |
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Brook K. Baker, Law Professor Northeastern U. School of Law, 400 Huntington Ave., Boston MA 02115
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It seems at least partially disingenuous for those accusing Oxfam(1) of ideological bias and favoritism towards public sector provision of health care(2) not to address the shackles that have been put on public sector health delivery by the International Monetary Fund and compliant Ministries of Finance. The IMF’s historic macroeconomic restraint policies, including inflation targets of 5% or less, fiscal deficit targets of 3% or less, budget and wage ceilings, and high currency reserve targets(3) have had multiple negative impacts on the efficacy of public health systems and their ability to both scale up and provide quality care. One reason there has been space for the development of a for-profit private sector in low- and middle-income countries receiving loans from the IMF is that the public sector has been starved of funds first by structural adjustment policies in the 1980’s and 1990s and now by nearly identical poverty reduction strategies in the late 90’s and 2000’s(4). These policies continue to restrict domestic spending on health and have even resulted in substitution effects with respect to donor financing such that a significant portion of donor funding effectively goes towards building foreign currency reserves and paying down domestic debt(5). It also seems disingenuous not to acknowledge that the private health sector in most developing countries has primarily served the interests of colonial and local elites, employees in the formal economy, and more recently medical tourists. Although there is certainly some commercial private sector health services offered to poor people, there is little evidence to date that it is improving equitable access to quality care. (1) Oxfam. 2009. Blind Optimism: Challenging the myths about private healthcare in poor countries. Oxfam Briefing Paper 125. February 2009. http://www.oxfam.org/sites/www.oxfam.org/files/bp125-blind-optimism- 0902.pdf (2) Montague D., Feachem R., Feachem N., Koehlmoos T., Kinlaw H and Smith R. (2009) BMJ Rapid Response. http://www.bmj.com/cgi/eletters/338/feb16_2/b667 (March 15, 2009) (3) Independent Evaluation Office. 2007. The IMF and Aid to Sub- Saharan Africa. International Monetary Fund, Washington D.C. http://www.imf.org/external/np/ieo/2007/ssa/eng/pdf/report.pdf (4) Labonte R. and Schrecker T. 2006. Globalization and social determinant of health: Analytic and strategic review paper. Globalization Knowledge Network, U. Ottawa, Institute of Population Health. http://www.who.int/social_determinants/resources/globalization.pdf (5) Independent Evaluation Office. 2007. The IMF and Aid to Sub- Saharan Africa. International Monetary Fund, Washington D.C. http://www.imf.org/external/np/ieo/2007/ssa/eng/pdf/report.pdf Competing interests: Board Co-Chair and Policy Analyst for Health Global Access Project, Inc., an AIDS activist organization based in the United States. |
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Kara G. Hanson, Reader, Health System Economics London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, Anne Mills, Lucy Gilson, and Catherine Goodman
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Richard Smith's response mentions the issue of competing interest bias in exchanges on the role the private sector should play in health systems in low- and middle-income settings. Readers might be interested in our response to him and his colleagues in the Journal of the Royal Society of Medicine(1) which argues that competing interest bias is a distraction from the more central point about the need to ensure rigour in the conduct and presentation of health policies and systems research(2). A strengthened evidence base on the performance of the public and private health sectors is essential to to guide decisionmakers towards policy choices that are appropriate for their contexts. Hanson K, Gilson L, Goodman C, Mills A. 2009. Letter. The fallacy of competing interest statements: no shortcut to rigour in research. Journal of the Royal Society of Medicine, 102: 1. Mills A, Gilson L, Hanson K, Palmer N, Lagarde M. 2008. Commentary: What do we mean by rigorous health system research? The Lancet. 372 (9649) 1 Nov: 1527-1529. Competing interests: None declared |
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Roger England, Chair Health Systems Workshop, Grenada WI
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To make its case, Oxfam (1) demands a standard of proof for the quality and cost effectiveness of private providers that is not demanded for public services. Paying private providers to serve public patients (through social insurance funds for example) is condemned because there is insufficient proof that private services will provide adequate quality. This implies there is proof that the public sector provides better quality, when we know this to be largely untrue. A study of 278,000 children in 45 countries by Boone and Zhan (2) found "no evidence that nations . . . with relatively large public health systems perform better or worse than those with larger private systems”. It found that both serve well-educated, wealthy people better than less educated, poor people. Oxfam dismisses engaging the private sector through contracting as too difficult for governments. But if governments can’t specify the services needed and their costs, how can they run the public sector efficiently? The answer, of course, is that they don’t. Oxfam provides no insight into how the structural problems of the public sector can be overcome and its incentives reoriented. This matters, because not only is public care no better than private, its coverage is lower. Sadly, the reality is that for most sick rural kids, there is no government service for several miles and mum knows there will be no one there to see them if they make the trip. Instead, she goes to the local drugs shop, just as people do in Europe and North America for painkillers and simple medication. She may not be sold the best anti- malarial but, unlike at the public facility, she gets a ‘can do’ attitude. She trusts them precisely because they are not government - her best option is to pay a price for the accessible drugs in the shop rather than spend a day seeking government care which may be no better and end up costing her more through ‘informal’ charges. And 80% or more of treatment goes on in this or similar ways. As in Germany and the Netherlands, around 85% of India relies on private care, and the story is similar across most of Africa and Asia. The great difference is that in Germany or the Netherlands government will pay for that privately provided care if a patient cannot. The private drug shops, doctors, hospitals and traditional healers in developing countries make up the bulk of the delivery system. There is a massive infrastructure of solo health workers and shops supplying the poor that the public sector could never build, staff or operate. It cannot be ignored; it has to be improved, and the way to improve it is to work with it to reward quality and performance and curb excesses. That is why progressive agencies, donors and governments are studying and experimenting with ways to harness private provision for public good. These include the transfer of subsidy to the poor through vouchers that can be exchanged for care at approved private providers, the networking of solo providers into franchising organisations providing training and demanding standards, and the contracting of private providers to deliver care to public patients. There are genuine problems with private providers, and challenging issues to address in assuring that the private sector works for public good. But ideology, blind or calculated, is a step backwards. It does no service to the poor. Extracted from: Oxfam’s blind faith in the public sector is doing the poor no favours. Health Student Network, blog 12.02.09 http://www.healthstudentnetwork.com (1) ‘Blind Optimism: Challenging the myths about private health care in poor countries’. Oxfam International. February 2009. http://www.oxfam.org.uk/resources/policy/health/bp125_blind_optimism.ht ml (2) Peter Boone and Zhaoguo Zhan. Lowering Child Mortality in Poor Countries: The Power of Knowledgeable Parents. CEP Discussion Paper No 751. October 2006. http://cep.lse.ac.uk/pubs/download/dp0751.pdf Competing interests: RE does research, evaluations and advisory work in health systems in public and private sectors. |
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