Free and Public

‘Direct health care by government best option’ says World Bank Health Economist

People waiting to get registered at Motihari District Government Hospital, Bihar. Credit: Ranjan Rahi/Oxfam

(This article was first written in October 2010 by Anna Marriott and is reproduced here for Global Health Check)

My colleagues in Oxfam India were surprised to read the article in The Times of India this month suggesting that the World Bank - ‘the organisation that started the ball rolling by first promoting privatisation and then the public private partnership model’ - in health care, seems to have had a rethink. The article continues that the Bank now appears to be advocating direct provision of health care by the government as the best option for India, especially in the rural areas.

The Times article is based on a blog written by Rajeev Ahuja, Health Economist for the World Bank in India. Ahuja highlights continued disagreement about whether governments or the private sector should deliver publicly funded health care. He goes on to argue that it is time to put the public vs. private debate aside because….‘let’s face it, there isn’t any good alternative to public provision of health care, especially in India’s rural areas which don’t attract too many qualified private doctors’.

Ahuja continues…… ‘Likewise, public-private partnerships to deliver rural health services have only been successful where special conditions have prevailed – such as strong commitment and leadership on the part of both the public and private partners. But, since these conditions are difficult to replicate across the vast expanse of the country, this doesn’t look like a viable option, certainly not for the foreseeable future.’

The assertion by Ahuja that it is now most appropriate for the government of India to go ahead with renovating, up-grading and expanding government rural health facilities is one Oxfam and our partners in India would support. We do not believe that the public sector is currently a shining example of how to deliver decent accessible health care in India, indeed due to massive disinvestment over the last few decades the public health care system is unacceptably poor in many states. Rather, we believe that the decision to increase government resources in expanding government delivery of health care is to be applauded and used as an opportunity to dramatically improve its performance. Especially as the evidence suggests that Indian states that invest more in public health services have been more successful at reducing rural-urban inequalities.[1]

Interestingly Ahuja’s arguments reinforce those made by Dr Mead Over of the Centre for Global Development last year in relation to anti-retroviral therapy in India. Dr Over stated that for some health services, including ART, low quality treatment may actually be worse than no treatment at all.  Dr Over went on to say “public sector delivery of ART can be justified not only because it protects poor AIDS patients from catastrophic health expenditures, but also because it might differentially “crowd out” the cheapest (and therefore perhaps the worst) of the private sector AIDS treatment. If this crowding out slows or postpones the development and spread of drug resistant HIV, this is an important reason for preferring public to private sector delivery.”

Dr Over’s theory is supported by evidence from the Indian state of Kerala. Here 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.[2] The theory would also be worth testing in the state of Tamil Nadu where the public health system is now widely regarded as outperforming that in Kerala. In many other states in India, the poor quality of the public-sector health services means there is no pressure on the private sector to offer anything better. The lack of investment in public health services then has a disproportionately negative impact on poor women who in India are the main users of unqualified shopkeepers as a source of health information and drugs.[3]

Against all this it seems odd for the International Finance Corporation (the private sector investment arm of the World Bank) to argue that development of health care in India has been ‘heavily  underwritten by the private sector’, and to then use this as a foundation argument as to why further private sector growth in health care should be encouraged.[4]

In reality the proportion of existing care provided by the private sector tells us nothing about whether the ‘right to health’ is being fulfilled. 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 at all during childbirth. Indeed, 74 per cent of women who seek antenatal care in India rely on their chronically under-funded public health system.

Rajeev Ahuja’s blog provides some refreshing but measured optimism about the potential future of India’s public health system. But as the Oxfam supported campaign ‘Wada Na Todo’ rightly argue, progress of the scale needed will never be achieved until the government of India reverses it’s appalling track record of investment in health care and increases public spending on health to at least 3 per cent of national income. This from an incredibly low base of just over 1 per cent GNI.

[1] Sen,G., Lyer,A. and George, A. (2002) ‘Class, gender, and health equity: lessons from liberalizing India’ in Sen,G., George, A., and Ostlin, P. (eds) Engendering international health: the challenge of equity Cambridge: MIT Press
[2] Narayana,K. (2007) ‘The Role of the State in the privatisation and corporatisation of medical care in Andra Pradesh, India’ in Sen, K. (ed.) Restructuring Health Services: Changing Contexts and Comparative Perspectives, London: Zed Books
[3] Lyer,A., Sen,G., and George,A. (2007) ‘The dynamics of gender and class in access to health care: evidence from rural Karnataka, India’, International Journal of Health Services 37(3)
[4]  See Oxfam’s report ‘Blind Optimism: Challenging the myths about private health care in poor countries’ for a fuller critique of the IFC’s arguments


Success for free public health care in the epicentre of drug resistant malaria

Women cycling back to their village, Cambodia. Credit: Jim Holmes/Oxfam(This article was written in July 2010 by Anna Marriott for Oxfam and is reproduced here for Global Health Check)

Oxfam has raised significant concerns in recent years about the Affordable Medicines Facility for malaria (AMFm) because of its approach using largely unregulated shops to deliver the last effective treatment available for malaria. While the overall objective of AMFm to reduce the price of Artemisinin Combination Therapies (ACTs) is to be applauded, the sale of drugs through untrained shopkeepers, risks misdiagnosis and mistreatment. This could lead to lives lost and growing resistance. The question is whether aid money could be better spent.

In defence of the AMFm some commentators argue that it is about getting the correct treatment to the places large numbers of people already go for their medicines – local shops and market stalls. Oxfam argues that this approach miss those who lack access to medicines altogether (public or private), it also ignores that there are viable and effective alternatives to settling for this unsatisfactory and dangerous status quo.

The press release announcing the official start of the pilot phase of AMFm was released on 14 July 2010.  This came just a week after the Government of Cambodia, together with the World Health Organisation (WHO), released promising news on their efforts to tackle the alarming growth of Artemisinin resistant malaria along the Thai-Cambodia border.   What is of note is that the approach taken by the Cambodian government and the WHO directly contradicts that promoted through the AMFm. What can we learn from their early success?

Growing Artemisinin resistance in Cambodia and efforts taken to tackle

The alarming evidence of growing resistance to Artemisinin in Cambodia is by now well known across the international health community. Large-scale sale of the drug by unqualified and unregulated private providers and shopkeepers has been blamed. To tackle this urgent problem the WHO in partnership with the Government of Cambodia and Thailand have taken an evidence-based approach. Among other activities more than half a million mosquito nets have been distributed and more than 3000 village malaria workers have been trained and equipped to deliver free early diagnosis and treatment services on both sides of the border.

A lesser-known measure taken by the government of Cambodia in March 2009 was to officially ban the sale of any kind of anti-malaria treatment in the unregulated private sector within zone 1 – the area along the border where Artemisinin resistance had been identified. This measure, which goes against the underlying principles of the AMFm, is enforced by so called ‘Justice Police’ acting on behalf of the national drug regulatory authority.

Intensive and thorough blood screening across the population in seven of the most affected Cambodian villages indicate dramatic initial results. The tests found only two cases of falciparum malaria, the strain in which the Artemisinin resistance has emerged. It is of course very early days but the positive reports echo results from other countries adopting the same integrated approach using trained community health workers as an extension of the public health system, as opposed to unregulated and unqualified private providers:

Examples of success in other low-income countries

In Eritrea this same approach led to a steep decline in malaria morbidity and case fatality by 84% and 40% respectively.  In Zanzibar the introduction of free ACTs and insecticide-treated bednets resulted in a 77% decrease in malaria-associated illness and an overall decrease in deaths of children to about half within two years.   In Ethiopia and Zambia mass distribution of bednets and nationwide distribution of ACTs through the public sector reduced malaria deaths by half and 66% respectively.

In all cases it has been demonstrated that rapid and effective scale up to reach large numbers of patients is possible through the public sector. In Ethiopia for example, over 30,000 health extension workers were trained and deployed within just four years.  This evidence directly challenges the argument of many private sector advocates that public sector expansion takes too long and the private sector is automatically a faster, and at least interim, alternative.

AMFm goes against WHO advice on malaria treatment

The WHO revised official guidelines for the treatment of malaria now recommends a parasitological confirmation of diagnosis in all patients suspected of having malaria before treating.  This guidance aims to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure, and in turn delay development and spread of drug resistance. The latter issue is of particular importance given that Artemisinin is the last remaining effective drug for malaria.

Recent evidence from a number of countries, including many of those cited above, has demonstrated the effective use of rapid diagnostic tests (RDTs) at community level to confirm malaria status before treatment. In Uganda research has demonstrated that parents trust community health workers if educated to a minimum level to test and diagnose their children. Surveys conducted in Uganda at low-level health care facilities where RDTs were deployed found their use led to a 2-fold reduction in anti-malarial drug prescription. The authors of the study concluded that ‘RDT use is feasible at low-level health facilities and can lead to better targeting of treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management.’

Unfortunately the AMFm’s approach to subsidise treatment, including for sale through unregulated private providers goes against the WHO guidance. While grantees could include the purchase and distribution of diagnostic tests as part of their proposals this is not a requirement. Furthermore, untrained and unregulated private shopkeepers are not in a position to utilise rapid diagnostic tests on behalf of their clients. Even if they were, it is highly questionable that they would utilise them correctly if this meant losing a potential sale.

The AMFm is still going ahead without evidence to support the approach it will take. This is why Dr. Bernard Nahlen, the deputy co-ordinator of the US President’s Malaria Initiative, described the AFMm as the biggest faith-based initiative in the world of malaria’.

And for Cambodia…..?

Cambodia is one of the pilot countries for the AMFm. The AMFm hopes that subsidised Artemisinin Combination Therapies (ACTs) will crowd out the less effective Artemisinin monotherapy from the market and reduce the spread of resistance. In the light of evidence from the ‘epicentre of drug-resistant malaria in the world’ on the Thai-Cambodia border, along with the increasing body of evidence from other low-income countries, it seems sensible to suggest that rather than use aid to subsidise the sale of ACTs through the unregulated private sector, the Cambodian government would do better by expanding the successful approach of extending the reach of free services through the public sector and community health workers. The question remains whether the staunch defenders of the AMFm will be brave enough to change tack.


Privatising health care in China: a failed experiment

(This article was written in September 2009 by Anna Marriott for Oxfam and is reproduced here for Global Health Check)

Oxfam’s report Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries, included evidence on the devastating impacts of introducing market based health care reforms in China. Since Blind Optimism was published China’s government has made significant announcements acknowledging the failure of this approach and laying out their plans for a significant and urgent expansion of publicly funded and publicly provided health care. In the midst of the debate about US health care reform the investment in public provision by the other members of the G20 is very interesting.

From 1952 to 1982 the Chinese government-owned, funded, and operated health-care system achieved enormous improvements in health and health care. Infant mortality fell from 200 to 34 per 1,000 live births, and life expectancy almost doubled. Since the 1980s, cuts in government health spending and wide-scale privatisation have had devastatingly inequitable consequences for people’s lives. Services that were once free are now charged for by profit-driven hospitals. Insurance to cover costs has been introduced but 80 per cent of the rural poor are not covered. The numbers and quality of health-care facilities and personnel in rural areas are inadequate resulting in huge disparities in health outcomes. Infant mortality is now 3 times higher in rural than urban areas. Illness is now the leading cause of impoverishment in rural areas.

In 2007 a government-endorsed report concluded that the success of China’s health system during the planned economy period was based on the dominant role played by the government.[1] Market-based reform has led to a decline in both the fairness of medical services and the efficiency of investment in the health sector.

There is also a clear link to be made between high rates of household saving and high out-of-pocket payments.  This is thought by many to have contributed to relatively low levels of domestic spending and demand in China, which in turn has helped to fuel global macroeconomic imbalances.  So what is good for the health of the Chinese is good for the economic health of the global economy, further underlining that public investment and public provision of health care is essential to underpin more equitable and sustainable growth.

Significant Chinese investment planned in scaling up public provision
In April of 2009 the government unveiled reforms that had been much anticipated and intensely debated. Whilst much of the coverage of these plans has focused on reform of healthcare financing there has been less coverage of the huge expansion in public provision of services that is also being planned.

The plan for the first time in China defines basic health care as a ‘public service’ for all citizens with the government committed to spending $124 billion over a three-year period to 2011 to massively expand publicly provided care. Details of the massive expansion include:

  • at least one clinic to be established in every village before 2011 to improve health care at grass roots level. Township hospitals and clinics will be expanded over 2009 and a further 2,000 hospitals to be constructed at county level so that each county will have a hospital that meets national standards by 2011
  • to build or renovate 3,700 community clinics and 11,000 health service centres in urban areas. While the central government will also build 2,400 health service centres in underdeveloped urban areas
  • train 1.37 million village doctors and 160,000 community doctors and extend systems of obligation and incentives for medical staff to serve in rural areas
  • set up an essential medicine system including 307 different medicines to curb the rise in drug prices and quell public unrest at the poor accessibility.

This would represent a huge expansion of public provision of health care by any standards, and should be studied carefully over the coming years.

[1] Cited in Huong, D., Phuong, N. et al.,(2007) ‘Rural health care in Vietnam and China: conflict between market reforms and social need’, International Journal of Health Services 37(3)


Introducing Blind Optimism

(this article was written by Anna Marriott in February 2009 following the launch of Oxfam Briefing Paper No. 125 Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries)

In the last two years Oxfam has noticed a trend of growing interest internationally in the potential of the private sector to improve access to health care in low-income countries. A number of influential donors and advocates frequently make claims for the benefit of the private sector suggesting it can help raise quality, is more efficient and can be more accountable.  In fact there is very little empirical evidence to support these claims. At the same time the potential risks of a greater role for the private sector in health care delivery are largely ignored. Oxfam is deeply concerned that this failure to examine the evidence of what works in providing health services could lead to many wasted opportunities to scale up health in poor countries.

Blind Optimism explores in depth the evidence available against a number of often-unexplored and unchallenged assumptions made in favour of private sector health care provision. It also looks to those developing countries that have achieved significant successes in scaling up towards universal and equitable access to health care and the policies they have pursued. It concludes that publicly delivered services, although far from perfect and often in need of substantial reform and support, are at the heart of health services in poor countries with higher performing, more equitable health systems.

Developing country governments and rich country donors have a responsibility to invest in policies that work to achieve health care for all. In launching this new paper Oxfam is calling for a halt to unproven and risky policies that promote an expansion of the private sector and threaten to undermine government capacity to deliver to those most in need. At the same time governments must prioritise the rapid scaling-up of free public provision of health services – the only proven route to achieve health care for all.

At the same time, we want to be clear that Oxfam does recognise the contribution the private sector does and must play in reducing poverty and inequality. Oxfam has for example, recently worked with a number of major corporations to discuss the role that they may have in accelerating progress towards the Millennium Development Goals. However – in the specific area of the provision of basic public services like health – the evidence outlined in this paper bears out our position of deep scepticism regarding private sector solutions.

Responses to Blind Optimism

Read The Center for Global Development’s blog on Blind Optimism by April Harding

Read Oxfam’s response to April Harding’s criticisms

Read The World Bank’s blog on Blind Optimism

Read Oxfam’s response to The World Bank

Read Duncan Green’s From Poverty to Power blog on Blind Optimism


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