Health care in poor countries must be defended against privatisation, Oxfam says
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2737 (Published 06 July 2009) Cite this as: BMJ 2009;339:b2737
All rapid responses
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Oxfam is pushing its outdated ideas on an unimpressed world.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/Marke...
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
Increase access to health services by the poor, but don’t blame “privatisation” or export British prescriptions to developing countries
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.
Competing interests: No competing interests