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Africa: Public Health Care Must Lead
AfricaFocus Bulletin
Feb 25, 2009 (090225)
(Reposted from sources cited below)
Editor's Note
"A growing number of international donors are promoting an
expansion of private-sector health-care delivery to fulfil this
goal [of universal health care]. The private sector can play a role in health care. But ...
the evidence shows that prioritising this approach is extremely
unlikely to deliver health for poor people." - Oxfam International
This AfricaFocus Bulletin contains the executive summary of this
new report from Oxfam International, exposing the myths about the
capacity of private-sector healthcare to meet the needs for
healthcare expansion in developing countries, and providing
recommendations for expansion of freely available basic health
care. The full report is available for download at
http://www.oxfam.org/en/policy/bp125-blind-optimism
Also in this Bulletin are brief notes about two resources for
health care planning in developing countries. Intrahealth
International is publicizing new open-source software for
management of information for health workforce planning by African
ministries of health and others involved in the sector. Youssou
N'Dour and other musicians have contributed free downloads of "Wake
Up - It's Africa Calling" to help raise funds and publicize the
initiative (see http://www.intrahealth.org/open).
Also recently available and noted below is a book from the World
Bank Institute on "Establishing Private Health Care Facilities in
Developing Countries." Despite the title, this guide to the planning process for building
hospitals and clinics applies to non-profit and government projects as well as private facilities.
Another AfricaFocus Bulletin sent out today contains policy
recommendations from six health and development organizations for
U.S. global health policy, and excerpts from an opinion poll
showing strong support for government responsibility for basic
health care in 24 countries, including the United States.
For previous AfricaFocus Bulletins on health issues, visit
http://www.africafocus.org/healthexp.php
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Blind Optimism: Challenging the myths about private health care in
poor countries
http://www.oxfam.org/en/policy/bp125-blind-optimism
An Executive Summary
This executive summary is drawn from Oxfam International's Briefing
Paper No. 125, Blind Optimism: Challenging the myths about private
health care in poor countries (February 2009). It was written by
Anna Marriott with the support of many colleagues and external
advisers. The text of the full paper can be downloaded from:
http://www.oxfam.org Oxfam International is a confederation of
thirteen organizations working together in more than 100 countries
to find lasting solutions to poverty and injustice.
The realisation of the right to health for millions of people in
poor countries depends upon a massive increase in health services
to achieve universal and equitable access. A growing number of
international donors are promoting an expansion of private-sector
health-care delivery to fulfil this goal. The private sector can
play a role in health care. But this paper shows there is an urgent
need to reassess the arguments used in favour of scaling-up
private-sector provision in poor countries. The evidence shows that
prioritising this approach is extremely unlikely to deliver health
for poor people. Governments and rich country donors must
strengthen state capacities to regulate and focus on the rapid
expansion of free publicly provided health care, a proven way to
save millions of lives worldwide.
The stakes could not be higher. Every minute a woman dies in
pregnancy or childbirth for want of simple medical care; every hour
300 people die of AIDS-related illnesses; and every day 5,000
children are killed by pneumonia. The world is badly off-course to
achieve the internationally agreed health Millennium Development
Goals (MDGs). To get back on-course and achieve universal and
equitable health care for all requires a massive expansion of
health services. To fail in this endeavour will be to abandon
hundreds of millions of people to an early death and a life
blighted by sickness. The critical question is how can such a
massive scale up be achieved?
For over two decades, the World Bank advocated a solution based on
investment and growth of the private health-care sector. Decrying
the failure of public health services in poor countries, failure in
which the Bank's enforced public sector spending cuts and widescale
restructuring have played a significant role, the argument was that
the private sector could do a better job. Although in recent years
the World Bank has acknowledged the key role of the government in
health care, this is largely as a regulator and 'steward' rather
than as a provider of services.
Despite the poor performance of private sector-led solutions, there
has been a noticeable increase in efforts in recent months by a
number of donors and influential organisations, to encourage and
fund an expansion of health care by the private sector. The idea is
that those who can afford it should buy their own health care in
the private sector and governments should contract private
providers to serve those who can't. The approach is promoted not
only as a matter of 'common sense' but as essential to reverse the
lack of progress in health care and to save the lives of poor
people.
This paper examines the arguments made in favour of increased
private for-profit provision of health services as a means of
scaling-up to achieve health care for all. It finds the evidence in
favour of private-sector solutions is weak. On the contrary, there
is considerable and increasing evidence that there are serious
failings inherent in private provision which make it a very risky
and costly path to take. All too often these risks are not taken
into account.
At the same time, a growing body of international research
reaffirms that despite their serious problems in many countries,
publicly financed and delivered services continue to dominate in
higher performing, more equitable health systems. No lowor
middle-income country in Asia has achieved universal or
near-universal access to health care without relying solely or
predominantly on tax-funded public delivery. Scaling-up public
provision has led to massive progress despite low incomes. A Sri
Lankan woman, for example, can expect to live almost as long as a
German woman, despite an income ten times smaller. If she gives
birth she has a 96 per cent chance of being attended by a skilled
health worker.
Examining six common arguments made in support of
private-for-profit health-care provision:
Argument 1: The private sector is already a significant provider of
services in the poorest countries, so must therefore be central to
any scaling-up strategy.
A recent report by the International Finance Corporation (IFC), the
private-sector investment arm of the World Bank, claims that over
half the health-care provision in Africa comes from the private
sector. In fact, Oxfam's analysis of the data used by the IFC finds
that nearly 40 per cent of the 'private provision' it identifies is
just small shops selling drugs of unknown quality (see photo). In
some countries such as Malawi, these shops constitute over 70 per
cent of private providers.
If the shops are removed from the data, and only the clinics
staffed by trained health workers what most would think of as
'health services' are included then the share of services in the
private sector falls dramatically, especially for poor people.
Comparable data across 15 sub-Saharan African countries reveals
that only 3 per cent of the poorest fifth of the population who
sought care when sick actually saw a private doctor.
Even if the private sector is a significant provider of some
services this does not mean it is filling the health-care gap. In
India, 82 per cent of outpatient care is provided by the private
sector. The number of first class private hospitals is rapidly
increasing. Yet this same system denies half the mothers in India
any medical assistance during childbirth. The reality is that most
people in poor countries have no health care at all. Over half of
the poorest children in Africa have no medical help when sick. To
take the failing status quo in health care, in which the private
sector, in some cases, plays a significant role, and see this as
indicative of the way that successful expansion should be organised
is illogical. It is comparable to looking at the huge rise in
private armed bodyguards in failed states and concluding that the
private sector is best placed to take over national policing. The
case for greater private provision must be made on the basis of its
merits in comparison to public provision and not simply on the
basis that, on some measures, it is currently a significant
provider in some poor countries.
Argument 2: The private sector can provide additional investment to
cash starved public health systems.
But attracting private providers to low-income risky health markets
requires significant public subsidy. In South Africa the majority
of private medical scheme members receive a higher subsidy from the
government through tax exemption than is spent per person dependent
on publicly provided health services. Private providers also
directly compete for the small number of trained health workers in
many poor countries.
Argument 3: The private sector can achieve better results at lower
costs.
In fact, private participation in health care is associated with
higher (not lower) expenditure. Lebanon has one of the most
privatised health systems in the developing world. It spends more
than twice as much as Sri Lanka on health care yet its infant and
maternal mortality rates are two and a half and three times higher
respectively. Costs increase as private providers pursue profitable
treatments rather than those dictated by medical need. Chile's
health-care system has wide-scale private-sector participation and
as a result has one of the world's highest rates of births by more
costly and often unnecessary Caesarean sections. Commercialisation
has led to a decline of less-profitable preventative health care in
China: immunisation coverage dropped by half in the five years
following reforms. Prevalance rates of tuberculosis (TB), measles,
and polio are now rising and could cost the economy millions in
lost productivity and unnecessary treatment in addition to
unnecessary suffering.
The difficulty of managing and regulating private providers also
creates inefficiencies, especially where government capacity is
weak and there are too few private providers to ensure price
competition. In Cambodia, the low number of technically acceptable
bids received in one of the largest contracting-out health-care
schemes meant that in many cases contracts were awarded without
competition and the overall size of the programme had to be reduced
by 40 per cent. Private providers were found to have lower
operating costs in only 20 per cent of contracting programmes for
which data is available. Even then the full transaction costs to
government of managing private providers are not counted: these can
divert as much as 20 per cent of spending from health budgets.
Argument 4: The private sector can help raise the quality and
effectiveness of health services.
There is a lack of evidence to support claims for the superior
quality of the private health-care sector. The World Bank reports
that the private sector generally performs worse on technical
quality than the public sector. In Lesotho, only 37 per cent of
sexually transmissible infections were treated correctly by
contracted private providers compared with 57 and 96 per cent of
cases treated in 'large' and 'small' public health facilities
respectively. Poor quality in the unregulated majority private
sector puts millions of people's lives at risk every day.
Argument 5: The private sector can help reduce health inequity and
reach the poor.
In reality private provision can increase inequity of access
because it naturally favours those who can afford treatment. Data
from 44 middle-and low-income countries suggests that higher levels
of private-sector participation in primary health care are
associated with higher overall levels of exclusion of poor people
from treatment and care. Women and girls suffer most. To make a
return whilst serving the poor, the IFC recommends doctors see over
100 patients a day, or one every four minutes, while those who can
afford it can receive a much greater level of care.
Argument 6: The private sector can improve accountability.
There is no evidence that private health-care providers are any
more responsive or any less corrupt than the public sector.
Regulating private providers is exceptionally difficult even in
rich countries. Fraud in the US health-care system is estimated to
cost between $12 and $23 billion per year.
What will deliver health care for all?
The private sector provides no escape route for the problems facing
public health systems in poor countries. Instead these problems
must be tackled head on because the evidence available shows that
making public health services work is the only proven route to
achieving universal and equitable health care. Committed action by
governments in organising and providing health services was
responsible for cutting child deaths by between 40 and 70 per cent
in just ten years in Botswana, Mauritius, Sri Lanka, South Korea,
Malaysia, Barbados, Costa Rica, Cuba, and the Indian state of
Kerala. More recently countries such as Uganda and Timor- Leste
have used co-ordinated donor funding to massively expand public
provision. In Uganda, the proportion of people living within 5 km
of a clinic increased from 49 to 72 per cent in just five years. In
only three years, the Timor-Leste Government increased skilled
birth attendance from 26 to 41 per cent.
Public provision is definitely lacking or is very weak in many
countries, but the problems are not intractable. Public provision
of health care is not doomed to fail as some suggest, but making it
work requires determined political leadership, adequate investment,
evidence-based policies, and popular support. When these conditions
exist, public health systems can take advantage of economies of
scale, standardised systems for regulation and improving quality,
and most importantly, the legitimacy and capacity to redistribute
resources and reduce inequality. Policies of universal access in
Sri Lanka, Malaysia, and Hong Kong benefit the poor more than the
rich. Indian states that invest more in public health services have
been more successful at reducing rural-urban inequalities. In fact
the overall benefit of government health spending was found to have
reduced inequality in 30 studies of developing countries reviewed
by the International Monetary Fund (IMF).
Civil-society organisations (CSOs) must be considered as distinct
actors from the for-profit private sector. CSOs have a key role to
play in helping to strengthen and expand viable, accountable public
health-care services. As providers of health care, they are a
lifeline for millions in many countries, especially for some of the
most marginalised and stigmatised populations. Because they are not
seeking to make a profit, they are not subject to some of the
negative incentives of for-profit providers. But CSOs also have
limitations in capacity and scale and cannot reach all those in
need of treatment and care, including those infected with HIV, TB,
and malaria. CSOs should only ever be a complement, and not a
substitute, for the state. They work best in collaboration with the
public system, as in Uganda where the government operates in
partnership with mission hospitals. CSOs also play a critical role
in holding governments and international actors to account,
creating the political pressure to make governments act to provide
free health care for all.
Existing private providers must be integrated into public health
systems where possible, and in some contexts that role could be
partly extended. However, to look to the private sector for the
substantial expansion needed to achieve universal access would be
to ignore the significant and proven risks of this approach and the
evidence of what has worked in successful developing countries. In
particular, in most lowincome countries the high-end and expensive
formal private sector is irrelevant for the majority of citizens.
Its growth can come at a direct cost to public health systems and
undermine their capacity to deliver to those most in need.
Subsidising this sector with tax or aid dollars cannot be
justified.
At the same time, governments must make an effort to improve the
standards of the enormous number of informal private health-care
providers including through training and public education. But the
task is enormous, and experiences from more successful countries
suggest the most effective way to regulate is to invest in
scaling-up free public provision using competition to drive up
quality. In the Indian state of Kerala the quality of the public
hospitals, whilst far from perfect, still appears to put an
effective quality 'floor' under the health services provided by the
private sector. Any direct attempts to improve the performance of
the myriad informal providers
The available evidence should not be used to mask the scale of the
challenge facing public health systems. Nor does the evidence
suggest there can be no role for the private sector it will
continue to exist in many different forms and involves both costs
that must be eliminated or controlled and potential benefits that
need to be better understood and capitalised upon. But where the
evidence is indisputable is that to achieve universal and equitable
access to health care, the public sector must be made to work as
the majority provider. Governments and rich country donors must act
now to bring real change and prioritise the rapid scaling-up of
free public health care for all.
Recommendations
For donors
- Rapidly increase funding for the expansion of free universal
public health-care provision in low-income countries, including
through the International Health Partnership. Ensure that aid is
co-ordinated, predictable, and long-term, and where possible, is
provided as health sector or general budget support.
- Support research into successes in scaling-up public provision,
and share these lessons with governments.
- Consider the evidence and risks, instead of promoting and
diverting aid money to unproven and risky policies based on
introducing market reforms to public health systems and scaling-up
private provision of health care.
- Support developing-country governments to strengthen their
capacity to regulate existing private health-care providers.
For developing-country governments
- Resist donor pressure to implement unproven and unworkable market
reforms to public health systems and an expansion of private-sector
health-service delivery.
- Put resources and expertise into evidence-based strategies to
expand public provision of primary and secondary services,
including spending at least 15 per cent of government budgets on
health, and removing user fees.
- Ensure citizen representation and oversight in planning, budget
processes, and monitoring public health-care delivery.
- Work collaboratively with civil society to maximise access and
improve quality of public health-care provision.
- Strive to regulate private for-profit health-care providers to
ensure their positive contribution and minimise their risks to
public health.
- Exclude health care from bilateral, regional or international
trade and investment agreements, including the General Agreement on
Trade in Services negotiations in the World Trade Organisation
(WTO).
For civil society
- Act together to hold governments to account by engaging in policy
development, monitoring health spending and service delivery, and
exposing corruption.
- Resist pressure to commercialise operations and call on rich
country donors and government to strengthen universal public health
services.
- Ensure health services provided by CSOs complement and support
the expansion of public health systems, including by signing on to
the NGO Code of Conduct for Health Systems Strengthening. must
therefore always be in addition to the longer-term more sustainable
strategy to scale-up and strengthen the public health system as the
main provider.
Health Care Planning
(1) IntraHealth OPEN
http://www.intrahealth.org/open/
IntraHealth OPEN has announced the launch of the OPEN Remix
project, engaging Youssou N'Dour and other musicians to support the
use of open source technology for health care planning in Africa.
N'Dour wrote a song called "Wake Up," published it under a Creative
Commons license, and invited other artists to donate remixes back
to the OPEN Remix project. Free downloads of the songs are
available at Rhapsody, Amazon MP3, and through the IntraHealth Web
site.
IntraHealth particularly works with open-source software for
planning human resources for health. See
http://www.capacityproject.org/hris/ The HRIS software suite, for
Linux and Windows, is available for free download at:
http://www.capacityproject.org/hris/suite/
For a more detailed article on the OPEN Remix project, see
http://health.iafrica.com/features/1534143.htm
(2) Establishing Private Health Care Facilities in Developing
Countries: A Guide for Medical Entrepeneurs, by Seung-Hee Nah and
Ebbe Osifo-Dawodu, MD. World Bank Institute, 2007.
http://www.africafocus.org/books/isbn.php?0821369474
This is a nuts and bolts planning guide for medical professionals and managers
building hospitals or other medical facilities, whether profit or non-profit. It is not
an abstract discussion of policy and does not advocate
a particular mix of private/public healthcare.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
AfricaFocus Bulletin can be reached at [email protected]. Please
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or to suggest material for inclusion. For more information about
reposted material, please contact directly the original source
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