Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Heath care in poor countries should be improved first, and ownership formats debated second
- Dominic D Montagu (7 July 2009)
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No cost healthcare for the poor, shibboleths should not detract from reality
- Tracey Perez Koehlmoos (8 July 2009)
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Oxfam campaign is naïve, shallow, unsupported by evidence, and colonial
- Richard Smith (10 July 2009)
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Increase access to health services by the poor, but don’t blame “privatisation” or export British prescriptions to developing countries
- David H Peters, Hilary Standing, Gerard Bloom (12 July 2009)
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Dominic D Montagu, Assistant Professor UCSF, USA, 94707
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Oxfam's new campaign to support government provision of health services in developing countries is a laudable initiative and should be exactly one- half of any comprehensive response to increasing services to the poor. People go to private pharmacies, shops, and clinics for a number of reasons, but most often because there is no government supply of medicines or doctors. Privatization of government run services is a chimera: in low and middle-income countries around the world governments are bit-players in health service delivery and the risk is not that government service facilities will be sold to private corporations, but that they are becoming irrelevant to the poor who need them most. The private sector exists as a more nimble and adaptive supply system to government in many many countries. So one could fix and expand government provision - worthwhile goals - or one could fix and improve private sector providers - also worthwhile goals - but one would not want to ignore the current reality in thinking where to go next. As Barbara Stocking, CEO of Oxfam, wrote in the BMJ oneline on April 7, there is no correlation between the ratio of a country's private and public health delivery sectors, and the access that a country's citizens have to healthcare. Given that, I wonder what basis Oxfam gives for now arguing that THIS windmill, the private sector, is really the one that, if properly skewered, will cure the world’s ills? In some countries it will be; in many countries it won't be. Public health services in developing countries should be improved and governments should devote more funding and more attention to assuring access to health services for all. This does not mean that the villages in Bangladesh or Uganda or Vietnam that have only a sole and imperfect private pharmacist would be better served by removing that pharmacist. Rather the current, imperfect, system should be improved while that government system, also imperfect in that it has no presence in that village, is concurrently improved. The status quo may be a very bad way of delivering aspirin, anti-malarials, attended deliveries, and antibiotics, but not having any way of delivering those same medicines or services would be worse. Let us make them better while we wait for the good, free, predictable government services that have been promised for the past many decades. In India in 50 years the government has gone from supporting 30% of health services at Independence, to 15% in the 1980s, and back up to about 19% today. In Oxfam's press release they worry about support for "risky and ineffective private healthcare services". I would go farther and argue that DFID should not support risky and ineffective healthcare services of any kind - public or private. Certainly the government of Nigeria where only 31% of healthcare is provided in government facilities, would not be listed first for effectiveness. But this narrow vision of delivery misses the point. The government of Nigeria has been visionary in many ways: supporting NGO and private expansion of care for tuberculosis, malnutrition, and ante-natal care to assure that citizens have access to care. Should not these initiatives be supported even though they work through private providers? The goal ought to be access to quality affordable care. The vehicle should matter less than the end result, and where Nigeria has embraced a multi-sectoral delivery mechanism, and it seems to be working, Britain should support that. We hope, as we assume Oxfam does, that getting the Indian government investment in health back to the level of 30%-of-all-financing will not take another 50 years. While we wait to see how that turns out, let us also agree to do something that will improve the services provided to the 1.2 Billion people who, at present trends, are unlikely to benefit from the current glacial expansion of government delivered care in their lifetimes. With DFID support to improving quality and affordability of both the government and the private sector (that provides currently 81% of all healthcare in India), we can all feel assured that appropriate responses to the real problems of the poor are being addressed. Competing interests: The author is a researcher of health systems focusing on issues of private delivery of public health services. |
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Tracey Perez Koehlmoos, Programme Head, Health and Family Planning Systems Programme ICDDR,B Dhaka-1212
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In the 2009-2010 budget, the government of Bangladesh firmly establishes the need for developing more public-private partnerships. Although this is one example, it represents the recognition by a low income country that the government cannot meet the healthcare needs of the population alone even after thirty years of development and investment in a large public health sector. Again in Bangladesh, a single NGO (BRAC) touches the lives of 100 million population. Other large NGOs through contracting out, new mechanisms such as social franchising and through donor support, deliver health services to the poor. Oxfam would have us ignore or disregard the enormous resources that serve more than three- quarters of the population as opposed to attempting to develop effective models of stewardship and accountability. No cost healthcare for the poor is more than the shibboleth it has become in the hands of Oxfam. It is optimistic to the point of being counterintuitive for Oxfam to apply the success of the UK National Health Service and all of the principles and institutions that support its success to developing countries. It is not the health service delivery sector alone that determines the successful implementation of a large scale public sector vision, but in the somewhat fragile health systems that struggle to meet the needs of the world's poor, there may not be comparable development in the education, financial, and justice systems to create the milieu in which public services can be provided free of cost by employees of the state working in facilities funded by the state. Competing interests: The author is engaged with the public and non-state sectors for health in Bangladesh. |
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Richard Smith, Editor Cases Journal, London WC1
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The campaign of Oxfam and Unison to “defend health care in poor countries against privatization” seems naïve, shallow, and unsupported by evidence. Plus ironically it’s colonial. It’s naïve because well over 50% of health care in most very poor countries is delivered by the private sector. The idea that the public sector could promptly take over all health care delivery is wholly unrealistic. The only tenable strategy in many of these countries is to work creatively with the private sector, which is what many of them are doing. The analysis is shallow because “private sector” is implied to mean multinational, for profit companies—hence Dave Prentis’s reference to “private companies…creaming [ing] off their cut.” But most of the private sector in poor countries is non-government organisations, faith based organisations, and local healers of many kinds. Oxfam refers to its research but fails to acknowledge how that research has been thoroughly deconstructed. (1) Nor does it acknowledge growing evidence that the private sector can be effective in reaching the poorest. (2 3) Finally, Oxfam is trying to impose a 1950s British view of the world on poor countries in a way that feels patronising and colonial. Britain is highly unusual in having a health system that is funded, provided, and regulated by government. In most countries much of the provision is private. Indeed, the NHS depends on private sector general practice, and the English NHS is encouraging the role of the private sector just as Oxfam is pushing its outdated ideas on an unimpressed world. 1 Standing H, Bloom G, Peters D, Hawkins K, Lucas H. Who are the “blind optimists”? A comment on the Oxfam report. http://www.futurehealthsystems.org/themes/themes2008/healthmarkets/Markets%20response.html 2 Loevinsohn B, Harding A. Buying results? Contracting for health service delivery in developing countries. Lancet 2005; 366: 676-81. 3 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 Competing interests: RS is employed by a for profit health company to run a philanthropic campaign in low and middle income countries but is writing in a private capacity. He is also the chairman of the board of a for profit start up that aims to improve clinician patient partnership through information technology. He gives £150 a month to Oxfam and has given monthly to Oxfam for over 10 years but is thinking that it may be time to change. |
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David H Peters, Director, Health Systems Program, Department of International Health Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 21205, Hilary Standing, Gerard Bloom
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Oxfam’s current campaign demanding free health care for all in poor countries energetically proclaims the laudable goal of increasing access to health care by the poor, and follows on their recent publication: "Blind Optimism: Challenging the myths about private health care in poor countries" (1). Many in the UK public and developing countries share these ambitions, along with the important concerns raised about the poor state of health services in developing countries. But blaming “privatisation” and its alleged proponents is unfair and misleading. Unfortunately, the “evidence” presented about the private sector is highly selective, and supports neither the conclusions nor the certainty around which these prescriptions are offered to the poor living around the world. The term “privatisation” does not accurately describe the diverse, complex and rapidly changing environments found in most country’s health sectors. The terms “public” and ”private” as understood in the UK, for instance, provide little insight about the nature of health sectors where different kinds of health markets operate across these boundaries. For example, many government employees provide services or drugs for a charge (legal or illegal), and many work part-time in private facilities. In most cases, formal user charges are much smaller than informal payments. In some countries, many informally trained providers exist as a direct consequence of earlier government programmes to train paramedics and community health workers. These providers have become market agents, often as a consequence of the failure of governments to support, supervise and remunerate health staff appropriately. These markets in health care were not produced by a deliberate policy of privatisation, but by a whole range of political economy factors. Understanding the role and functions of health markets in these settings is not the same as talking about, still less advocating, privatisation. Providers in these kinds of settings have complex legal and political relationships with each other and with the state (2). One consequence is that the challenges in aligning incentives with health system objectives and influencing the quality and safety of services are often as great in the “public” sector. Simple dichotomies between “public” and “private” sectors and between “social” and “commercial” motivations and incentives bear little resemblance to this complex reality. Solutions to the very real problems of equity, access and quality which ignore these complex and local realities will continue to fail. The history of health system development in the best performing OECD countries tell of complex interactions between “public” and “private” sectors that were involved in the move towards universal coverage. Their health systems continue to be characterized by plurality. For example, general practitioners are “private” contractors in the UK, and most doctors paid from Canada’s universal public health insurance schemes are private practitioners. OECD countries exemplify a wide range of settlements, institutional arrangements and financing mechanisms that evolved as highly specific and customized solutions. Their common denominator is a sustainable commitment to principles of solidarity that were underwritten by states, providers and the public. There will similarly be many roads to universal access in the low and middle income countries involving different institutional arrangements and ways of managing health markets. And there will be contexts where markets and market driven innovation in health sector supply and delivery chains will help accelerate the goal of universal coverage and improve access for disadvantaged populations. Advocacy for rapid scaling up of external financing for health through either public or private sectors is often overly optimistic and tied to implicit or explicit ideological positions. Such positions may benefit from simplicity and popular appeal, but they tend to downplay the huge non-technical challenges that scaling up faces. These include the often intractable governance problems in the public sector, and the absence of regulatory oversight in the private sector. The creation of effective and equitable health systems is difficult. The history in many countries of the creation and subsequent decay of government-run health systems suggests that we ought to acknowledge that the challenges require more sophisticated and concerted efforts. Rather than blaming “privatisation” and pushing “one size fits all” solutions, what is needed is increased and targeted funding to support promising innovation and learning that is grounded in local realities. Effective solutions for increasing access to health care to the poor are likely to require more, rather than less inclusive approaches that engage private, non-profit, and public stakeholders, and provide voice to disadvantaged populations in their design, implementation, and oversight (3). Systemic monitoring & evaluation and disclosure should not only provide the evidence needed to gain confidence in the emerging health system arrangements, but should facilitate continued adaptation and accountability that is needed in all health systems. References: 1. Marriott A, 2009, “Blind Optimism: Challenging the myths about private health care in poor countries”, Oxfam Briefing Paper. 2. Bloom G, Standing H, (2008) “Future health systems: Why future? Why now?” Special Issue of Social Science and Medicine. Volume 66, Issue 10, Pages 2067-2075 3. Peters DH, El-Saharty S, Siadat B, Janovsky K, Vujicic M. 2009. Improving Health Services Delivery in Developing Countries: From Evidence to Action. Washington: The World Bank. Competing interests: The authors are researchers working on health systems development in low income countries. Some of their work is funded by the UK Department for International Development, including the Future Health Systems Research Programme Consortium. The views expressed are those of the authors. |
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