As world leaders prepare to gather for the 66th World Health Assembly on May 20, social movements are questioning the market-friendly version of universal health coverage (UHC) it is promoting.
One organization, Jan Swasthya Abhiyan (JSA), is denouncing India’s emulation of this UHC strategy, as contained in the country’s 12th Five Year Plan, which uncritically endorses the private medical sector and focuses on health insurance schemes. In a recent paper – JSA proposes an alternative UHC model.
Public financing for whom?
In the past five years there has been an impressive roll out of government-funded insurance schemes in India that are supposed to improve the country’s public health system. In theory, treatment covered under these schemes can be provided by any accredited facility. But in practice the majority of providers are found in the largely unregulated private sector which already accounts for 80% of outpatient and 60% of in-patient care according to the National Sample Survey Organisation (NSSO), making India one of the most privatized systems in the world. India’s healthcare system is increasingly dominated by big hospitals chains (e.g. Apollo Hospitals) with an infamous track record of expensive services and unethical practices. As it is, health insurance schemes mostly channel public monies for private profit. For example, from 2007 to 2013 the state of Andhra Pradesh allocated a total Rs.47.23 billion to facilities accredited under the Arogyasri scheme, of which Rs.36.52 billion went to private facilities.
Getting it right
Health is a right, and priorities should be based on citizens’ needs. What the majority of Indians lack is comprehensive primary care, but current health insurance “packages” only insure beneficiaries for ailments that require hospitalization. They cover a very small portion of the burden of disease, excluding out-patient treatments for tuberculosis, diabetes, hypertension, heart conditions, and cancer among others. Evidence from the first such scheme in India – Arogyasri – suggests that it consumed 25% of the state’s health budget but addressed only 2% of the burden of disease.
Who inverted the pyramid?
This situation ends up distorting the very structure of the health system by starving primary care facilities to the benefit of more profitable secondary and tertiary care. In 2009-2010, direct national government expenditure on tertiary care was slightly over 20% of total health expenditure, but if one adds spending on the insurance schemes the total would be closer to 37%. In Andhra Pradesh, following the implementation of Arogyasri, the proportion of funds allocated for primary care fell by 14%.
A good health system is like a pyramid: the largest numbers should be treated at the primary level where people live and work. We need to flip the inverted pyramid that has been created and offer a new roadmap predicated on public funding and provisioning of a public system that reprioritizes primary health care, and is comprehensive, integrated and accessible to all.
The health insurance schemes in place fail to address another key issue: access to medicines. Paradoxically, India is the largest producer of drugs in the developing world and at the same time the country where the WHO estimates the greatest number can’t afford the medicines they need. Since the Patent Act was amended in 2005, domestic pharmaceutical companies can’t produce cheaper versions of new drugs, which are now sold by multinationals at prices well beyond the reach of most patients. Poor regulations also means more than 50% of the average family spending on medicines is on irrational or unnecessary drugs and diagnostic tests according to the NSSO. Clearly, the pharmaceutical sector must be reigned in, and all essential drugs should be made available, free of cost, at all public facilities.
Addressing public health gaps
The task of achieving health for all in India will not be easy. Current public health services are marked by poor access, low quality and limited choice. Besides rampant corruption, poor management results in mismatches between demand and supply of services: facilities aren’t distributed optimally; equipment and funds fall short of requirements and don’t flow efficiently. Labour shortages can be partly explained by disinvestment in medical education and flawed deployment mechanisms. Although programs such as the National Rural Health Mission have made some inroads to improve services, much remains to be done. The problem is largely one of unresponsiveness to citizens coupled with unreliable technical estimates of costs and disease burden, leading to ill-informed prioritization.
It is necessary to recast the UHC debate and propose alternatives to strengthen the public health systemto address these problems and to build integrated, comprehensive services with strong mechanisms of accountability. Key to these changes are the following:
Over the short term, we also need to explore alternate ways of harnessing private resources for public health goals. Given the sheer size of the private sector, it is not possible to entirely ignore it while planning for equitable access to public services. It’s not a monolithic entity either; some segments such as charitable, faith-based and other not-for-profit healthcare facilities that work in less developed parts of the country can fill certain critical gaps in the public system. Under clear terms and conditions, other private providers such as general practitioners or small and medium-sized hospitals could be in-sourced to complement available public health services. Importantly, there should be no transfer of assets and resources into private hands and kickback statutes should be put in place to ensure there are no referrals with conflict of interests.
All the possible mechanisms for harnessing the private sector should be seen as supplementary (and often interim) measures, and not as a substitute for very significant scaling up and strengthening of the public system both in terms of quality and accessibility.
There is a need to reclaim public systems, to strengthen and expand them. Moving toward health for all requires major transformations in health care, but also in a wide range of social determinants of health – food security and nutrition, water supply, sanitation, working conditions, housing, environment, education and more. We need to build broad-based alliances for social change to redefine the relationship between people and their public systems.
Amit Sengupta is a Research Associate with the Municipal Services Project and Associate Global Co-ordinator with the People’s Health Movement, a global network of 18 national chapters that includes India’s Jan Swasthya Abhiyanfor which he acts as National Co-convenor.
Madeleine Bélanger Dumontier is Communications Manager for the Municipal Services Project, a global research initiative that explores alternatives to the privatization and commercialization of service provision in the electricity, health, water and sanitation sectors.
Photo: Rajeev Chaudhury
In 2009 Oxfam published “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” to help redress what we saw as an international health discourse increasingly dominated by unchallenged private sector advocates. Some of those same advocates accused Oxfam of being purposefully selective with the evidence.
The health team at Oxfam were therefore very pleased to see the recent publication of a thorough and balanced independent appraisal of peer-reviewed evidence on this topic in PloS Medicine. The study supports many (not all) of our conclusions about both the public and private sector.
In their research Basu et al. assess the comparative performance of the private and public sectors in health across a range of health system performance areas. They are clear that comparative evidence is often lacking and that distinctions between what is public and private are often difficult (for example when public facilities act more like commercial operators by charging fees). With these limitations acknowledged, the authors’ own conclusion states:
‘Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients’.
Like Oxfam, the authors of this comparative study make special note of the World Bank as an influential advocate of public-private partnerships in health, but one whose claims are often unsubstantiated by their own data. The authors raise concerns about a conflict of interest for the World Bank that may undermine the validity of their research and analysis on this topic.
Some highlights from the paper are listed below (though I recommend reading this important article in full – especially for interesting country examples):
Access and responsiveness
Accountability, transparency and regulation
Fairness and equity
Other important findings
And on the World Bank….
The evidence from this study shows that while public health systems are often weak and under-resourced they still deliver better quality of care, more equitably and with greater efficiency than the private sector. The study highlights the tendencies of private providers to serve higher socio-economic groups, have higher risk of low-quality care, create perverse incentives for unnecessary testing and treatment, and suffer from weak regulation. It also suggests there are a number of ways public health systems can do better. They must be more responsive to patients and more accountable to citizens, improve systems for distributing essential inputs like medicines, and address financial barriers to accessing care (such as formal and informal fees).
These are legitimate challenges that deserve thoughtful attention and action, but they should not be used as evidence of the superiority of private sector approaches. Instead, the policy response to these findings should be very clear: far more effort and resources must be mobilized to maximize the clear advantages of public health systems, rather than further starving them of the resources and support they need to deliver equitable and quality health care for all.
Low investment in the public health sector over the years has left India with a fractured and weak health system, unable to meet the needs of the majority of its citizens. Despite efforts in recent years to strengthen public health system – most notably through the National Rural Health Mission – India has one of the lowest levels of government investment in health in the world, with just four countries (Afghanistan, Chad, Guinea, and Myanmar) allocating a smaller share of their overall budget to health. In 2010 government expenditure on health was just 1% of GDP.
The gap left by the public health system combined with a government policy of proactively promoting the private sector has led to the proliferation of private health providers which are unregulated, unaccountable, and out of control. From initially providing 8% of healthcare facilities in 1949, the private sector now accounts for 93% of the hospitals and 85% of doctors. The number of first class private hospitals in India has ballooned in recent years and health tourism has become big business. But such first class service comes with a high price tag and is out of reach for the vast majority of Indians. Instead, poor people become dependent on unqualified drug peddlers, fake doctors (quacks), and unlicensed shops that are largely unregulated. Up to a million unregistered providers are practicing in India today. When the private sector provides health services on behalf of the state it can make it more difficult for citizens to hold their governments to account and to seek justice.Scandals of corruption, unethical practice and human rights violations frequently break out in national newspapers.
War on women: private clinics exploiting poor women for a profit in Rajasthan, Bihar and Chhattisgarh
Under-privileged women from poor communities in India are being left with crippling debts and poor health after being incorrectly advised by private clinics to have unnecessary hysterectomies. These procedures come with huge price tags and high medical risks. In the case of Bihar, Chhattisgarh, and Rajasthan, the government and the private hospitals in some districts have violated the fundamental rights of women and girls in their failures to provide adequate healthcare.
In the last few years NGOs and citizens legal networks have attempted to investigate the practices carried out by private clinics. Local NGOs, have filed a series of Right to Information (RTI) petitions which shed light on the high number of hysterectomies being conducted.
In Dausa, a district in the rural interior of Rajasthan, thousands of women have been subjected to hysterectomies by doctors looking to make a profit at their expense. Women from the most discriminated low castes and poor economic backgrounds are being targeted because access to free government healthcare is very limited and illiteracy rates are high. In April 2012, it came to light that four private hospitals in the state’s Dausa district removed the uterus of 226 women last year and earned about Rs 14,000 (around $220) from each patient. One of the women who underwent the surgery explained, “I had a constant stomach ache and they removed by uterus, but the pain did not go. Then I went to Jaipur for treatment and it was found that I was wrongly operated upon.”
Kaushalya, a farm labourer was told she must have a hysterectomy when she visited the clinic with stomach pains. She was charged 30,000 rupees for the operation (around $540). “I went to get medication and have a check up. Because the government hospitals are far away I went to a private clinic. They didn’t check me, they didn’t give me any medication. But they gave me an injection and performed an operation. Even though I only had a tummy ache, they took my uterus out. I still have the same stomach pain I had before. I can’t work, I can’t lift heavy things. Being a poor farmer I don’t have any money, so I had to borrow money. So far I have not even been able to pay just the interest.”
Durga Prasad Saini, an advocate for a local NGO, Akhil Bhartiya Grahak Panchayat, said: “women go to doctors with some sort of abdominal pains and are then advised to undergo a hysterectomy with little diagnosis of the problem. The doctors force them to undergo surgery even though it is not necessary and scare the women in their greed for money.” The NGO filed an RTI (right to information) case to try to get to the bottom of the problem. Only 3 of the 5 clinics provided the information but the results were shocking. Nearly 70 per cent of the women investigated had had their uterus taken out – a large number of the women were under the age of 29, with the youngest being just 18 years old. Despite the fact that complaints have been made to the police and local government, no action has been taken. A special committee, which included leading gynaecologists, public health experts and government officials from Jaipur, was set up over a year ago but to date none of the affected women have been visited by committee members or had their testimonies heard.
Dr Gupta, a medical expert and head of NGO Prayas –who work with Oxfam in India, states in his report that most of the women he interviewed in Rajasthan should not have undergone a hysterectomy, and could have been cured with other treatments. Moreover, he explains that a sonography alone is insufficient to determine a need for hysterectomy, and alternative treatments should always be attempted before this invasive surgery is performed. Dr Gupta adds “Subjecting women to unethical, unreasonable and unnecessary hysterectomies or caesarean sections for financial gain is a violation of human rights and most awful form of gender based violence. The mass hysterectomies by private hospitals in Dausa are a wicked act, but such malpractices are happening in other areas as well. Prayas is initiating an intensive investigation against such unethical practices.” Similarly news stories and investigation reports in Chattisgargh and Bihar indicate that unnecessary hysterectomies are common phenomena in rural areas. Recent reports in the Indian Express exposed that many of the women who seek hysterectomies are not informed about the possible side effects, and think of a hysterectomy as an easy cure to stop menstrual problems. Prayas also found that the doctors are not obtaining informed consent for the hysterectomies.
In Bihar, Prayas found that several women had undergone hysterectomies at private hospitals on the same day as their initial hospital consultations. The women had only had sonographies – no additional tests were performed. As Dr. Gupta makes clear in his report, women should undergo several tests and be offered alternative treatments before a hysterectomy is performed. Many of the women interviewed in Bihar, Chhattisgarh, and Rajasthan were misled into believing that there was an emergency and that the surgery was urgent or made to believe they might get cancer if they did not comply with the doctors’ advice. In most cases the women received no paperwork regarding the surgeries, and many of the BPL (Below Poverty Line) women paid out-of-pocket for the operation. The fact-finding team also found that there is illicit recruiting in the villages, involving “middlemen” who convince women to go to private hospitals. Fraud committed by the private hospitals has also come to light, with physical examinations of former patients revealing that some of the surgeries never took place.
NGOs investigating this case have decided to go the Supreme Court to seek justice for these women and bring the unregulated and unaccountable private providers of healthcare to account.
Action for change: Implementing Universal health coverage
These cases are not ‘stand-alone’ cases of poor health care provision they are in fact symptoms of a failing and weak health care system that needs urgent rectification. Private health care providers need to be regulated and controlled and public health care provision needs to be scaled up and improved.
In line with the recommendations of a recent High Level Expert Group report, Oxfam along with its partners is calling for the government to prioritise strengthening and scaling up of government health care which is available to all citizens.
Oxfam wants immediate action to regulate private providers and cease further promotion and funding of PPPs until regulation is enforced and quality and equity performance standards are shown to have improved. Private hospitals, nursing homes and other clinical establishments must be properly standardised to improve rationality of care, regulation of fees, and to uphold patient’s rights.
Oxfam calls on international donors to support evidence-based strategies to expand government provision of health care and not promote scaling-up of private-sector health service delivery in low- and middle-income countries. The private sector’s role needs to be clearly defined and regulated and donors should work with governments to strengthen their capacity to regulate existing private health-care providers.
This story has recently featured on BBC News Online - click here for more information
Araddhya Mehtta is an Essential Services Global Campaigner for Oxfam GB
A few months ago Oxfam published a critical report on the Affordable medicines facility for malaria (AMFm), calling it a ‘dangerous distraction’ from more effective ways of providing treatment. Our problem with the scheme is that it relies on unqualified shopkeepers to diagnose and distribute drugs, rather than trained health workers. This means there’s a huge danger of people being misdiagnosed, given there are many other causes of fever, not just malaria.
Oxfam spoke to people in Ghana, to see what their experiences were. Christiana’s story highlights how harmful selling someone the wrong medicines can be.
Christiana Donyinaa is 43 and makes a living selling cosmetics. A few months ago her youngest daughter, Gloria (age 12), became ill with a fever. Christiana went to a shopkeeper and described Gloria’s symptoms and was told her daughter had malaria. The shopkeeper sold her malaria drugs.
“I gave Gloria the medicine and she felt better after a few days. The following week, schools were on vacation so she decided to visit her older sister, who lives in Accra. As soon as she got to Accra she felt sick again. Her sister took her to the hospital and she was diagnosed with typhoid fever. She was admitted to hospital for several weeks.
I got very worried because school had resumed and she was still in the hospital. The doctor said Gloria had been suffering from typhoid for a very long time, but because we didn’t take her to the hospital, we didn’t realise it early enough.
When I was told that she was sick, I was very concerned and quickly jumped on a bus to Accra. When I got there her condition was serious and I stayed with her in the hospital for more than two weeks.”
Gloria’s condition became quite serious, she found it difficult to breathe and couldn’t eat anything without being sick. Because Christiana was at her daughter’s bedside, she was unable to earn any money over those few weeks. She also spent all the money she needed to run her business on medical expenses. In the end Gloria spent several months off school recovering and has now fallen behind with her studies.
“Gloria’s sickness has affected her a lot. She wants to be a Nurse in future but her illness has set her back a bit.”
Christiana believes that malaria medication should only be prescribed and distributed by trained health workers and not through shopkeepers.
“The advice I have for the government and NGOs is that the malaria drug is very good, if you have malaria. But they should not give it to the drug peddlers; they should give it only to clinics. Some of the drug peddlers have these medicines in their pockets. They sell it to you when you tell them you have a headache, they will just give you the medicines without any diagnosis. This is very dangerous the drug peddlers don’t know what illness people have.
I will advise every parent that when their child is sick they should take them to a doctor. Because if I had taken Gloria to the hospital from the onset when she was sick I don’t think both of us would have suffered as we have done.”
Oxfam is warning against any further funding for the AMFm scheme and for money to be used to invest in the training and salaries of community health workers instead, who are proven to save lives.
Sarah Dransfield is the Essential Services Press Officer at Oxfam GB
In the run up to the Georgian parliamentary elections in October 2012, two of the key policies put forward by Mr Bidzina Ivanishvili and his party Georgian Dream, were that his government would provide a basic universal health insurance and make major reforms to the health care system. There is no doubt that health care reforms that enhance access to services for the poor and improve quality are urgently needed. Years of low levels of government investment have pushed the Georgian health system to its limits – hospitals are poorly managed and health workers do not know when to expect their next pay check. However, scaling up the existing state supported insurance scheme is likely to lead to huge costs for the Georgian Government while not managing to provide health care for the poorest and most vulnerable people.
The previous Georgian government launched the Public Insurance Scheme (PIS) in 2007 to provide insurance for vulnerable groups, such as the extreme poor, through the allocation of vouchers for health services and products. This scheme was expanded in September 2012, just before the parliamentary elections, and it will eventually cover 2.1 million people (46% of the population and three times as many people as previously covered) including all under 5s and over 65s .
Government allocation to the PIS amounted to 58% of public health care expenditure in 2007 (over 88 million US dollars) but there is little transparency when it comes to how the money is spent. Meanwhile, private insurance companies have been making huge profits from the PIS – in 2010 the State Audit Service reported that some companies were making profits of up to 50% from the PIS. The previous government attempted to tackle the high profit margin of insurance companies by pressuring them to take ownership of some of the 80% of hospitals in Georgia that have been privatised. The insurance companies that now own many of Georgia’s private hospitals are often subsidiaries of the three pharmaceutical companies that dominate the market in Georgia. The near monopoly of much of the Georgian health system has led to a conflict of interest limiting a patient’s ability to choose an insurance provider, hospital or medicine.
In many cases, hospitals owned by insurance companies have been found to be poorly managed and staff have reported erratic and decreasing salaries. In October, there were protests across Georgia by health workers over salaries and the lack of clarity of the future of their hospitals. The low salaries of health professionals has contributed to the entrenchment of a culture of practitioners demanding informal payment for better quality services, leading to out-of-pocket (OOP) payments for those covered by the PIS.
The issue of high OOP payments is a major flaw in the current scheme which excludes the poorest from accessing health care. The PIS covers a select number of secondary and tertiary health services and medicines, with patients paying out-of-pocket for any treatments and services not covered. Additionally, a report by Transparency International Georgia found that low levels of awareness among beneficiaries of the PIS scheme, meant that patients were paying for health care services that should be provided for free.
As 100 days have passed since the parliamentary elections, it is time that Mr Ivanishvili makes some headway in making the needed reforms to the Georgian health system. If Georgia’s universal insurance scheme is to be effective in providing universal health care, the problems with the current health care system must be addressed to ensure that OOP payments are reduced and that services can be maintained. This must include improved monitoring and regulation of private hospitals and insurance companies to ensure that funds are spent effectively and vulnerable populations are able to access health care.
Irakli Katsitadze is the Health Policy Programme Manager for Oxfam in Georgia