Health care in poor countries must be defended against privatisation, Oxfam says

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.