Oxfam’s Briefing Paper No. 125 “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries” argues that “international donors are promoting an expansion of private-sector health care delivery” to meet global health goals and sharply criticizes the conceptual and practical arguments for working more with the private sector. Oxfam argues that “the evidence is indisputable… that to achieve universal and equitable access to decent health care … the public sector must be made to work as the main provider. There is no short cut and no other way.” In several important respects, this paper misrepresents the evidence on private health care in poor countries and the work of donors, including the World Bank, and draws conclusions more reflective of dogma than science. The following are some key points of disagreement. 1. Oxfam states (p.2) “For over two decades the World Bank advocated a solution based on investment and growth of the private health-care sector.” World Bank lending and non-lending work in the health sector is overwhelmingly focused on strengthening public sector health delivery. Lending is almost entirely to governments. The World Bank has repeatedly argued that, given the large presence of non-state actors in health, more could and should be done to leverage their potential contributions. This does not necessarily mean “growth” of the private health-care sector. Indeed in many countries the private sector in health may be too large, or parts of it that have poor quality, inefficiency, or impose a high payment burden may be too large. Improving the private sector can have a variety of different elements. 2. Oxfam states (p.2) “…publicly financed and delivered services continue to dominate in higher performing, more equitable health systems. No low- or 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.” We agree that most high health-performing developing countries have strong public sector delivery systems. However, we know of none that rely “solely” on tax-funded public delivery and are not sure what “predominantly” means. But we question the implied causality and the conclusions. Does tax-funded public delivery cause a country to become high performing, or are those countries with better governance able to make public sector health care delivery systems work (as well as other systems)? We believe the latter is the correct conclusion and note that the number of developing countries able to do so is small and that there are far more examples of developing countries where public systems still do not give satisfactory results despite decades of investment in such systems, often strongly supported by the World Bank and other donors. What then is the guidance for donors and countries with poor governance in the public sector? Should they focus exclusively on tax-funded public delivery and hope for the best? Or should they seek more pragmatic approaches that build on what is available and what works in both the government and non-government sector to expand access and quality? Clearly we feel the latter is the right strategy. It is also worth noting as well that very few high performing developed countries rely solely or even primarily on government delivered services. (In the U.K. for example, GPs are not civil servants but private contractors to the NHS and hospitals are mainly non-profit trusts. Other rich countries have a wide mix of government and private roles in service delivery.) Why then be so dogmatic in prescribing only this approach for developing countries? 3. Oxfam’s arguments about the not-for-profit private sector (“civil society providers”) are inconsistent and confused. Oxfam praises CSOs for “not being motivated by profit” and for being “a lifeline for many.” Yet Oxfam criticizes evidence from recent impact evaluations that CSOs sometimes provide better access and quality at lower cost than government services. This growing body of evidence that governments can effectively contract out services to improve results is largely dismissed and we believe Oxfam ignores high quality evidence to reach this conclusion. According to Oxfam “CSOs must only ever be a complement to and not an alternative to, public health systems.” We are unsure what Oxfam means by this. If it means that public and private (including non-profit) provision should co-exist in systems – we agree. But if it means that CSOs can only provide services as an adjunct to in-place public sector delivery capacity, we disagree. Experience shows that CSOs have enabled governments to finance alternative strategies of service delivery where governments themselves may be unable to deliver services. Most of the relatively modest financing from the World Bank for working with private providers has been of this type (not primarily support the private for profit sector as Oxfam implies) – assisting governments to contract out service delivery to accelerate health gains when government provision has not been able to meet the needs – and we anticipate doing more of this. Governments often recognize the advantages of this approach of using non-government providers as an alternative vehicle of health care delivery. 4. Oxfam emphasizes a polemic approach to the insufficient and highly mixed evidence about the performance of both the public and private sectors, emphasizing only mainly negative findings about the private sector. We feel that overall the evidence is inadequate for such strong generalizations. Evidence on quality in general and evidence that properly compares public and private sector providers is particularly lacking. Rather than sterile and inadequate debates about which system is better, we prefer a more pragmatic approach especially in countries with weak public sector systems. We need to gain more understanding not only of how different strategies for service delivery perform but of why they perform the way they do and the relative benefits and costs of different strategies for increasing effective coverage with priority services. If working with the private sector will improve outcomes more than dogmatic strategies to expand poorly performing public sector delivery, we think it merits support. 5. Oxfam argues that the public sector is the key to equity in access to health care. However there is very mixed evidence about the equity performance of the public and private sectors. Recent work by the World Bank in its “Reaching the Poor” program, including extensive analysis of the Demographic and Health Surveys, shows a large disparity between the poor and the better-off in coverage with priority services including from public sources. For a number of priority health problems – treatment of children’s acute infections for example, private providers may deliver a larger share than public in reaching the poor. Public sector services may be captured by the non-poor and private providers may be the main source of service to the poor where public systems fail. This does not mean there are not significant problems with private provision. We feel it is useful to think in terms of both access and quality and ask whether creating new access (say to public provision) is necessarily or always better than improving quality of existing access (say to non-government provision). 6. Oxfam raises some difficult questions about the role of the private formal and informal sector providers and specifically criticizes the recently established AMFm. As in other places in the paper, Oxfam holds to the idealistic notion of free, universal, and good quality public provision and capable government regulation as the remedy to the problems of pluralistic health care delivery and lack of quality control in the non-government sector. Unfortunately, the evidence to assure us about the feasibility of this remedy in many countries is not there. Despite free public provision, people, including the poor, in many settings use a mix of government and non-government health care providers. Specifically with regard to artemisinin, our last effective drug against malaria, should we wager its efficacy solely on the hope that public systems will be effective and preferred in many difficult settings? Or should we seek a range of strategies to try to sustain effectiveness? 7. The informal private health care providers pose some particularly difficult problems. They are widespread, easily accessible, and popular. They are often of very poor quality. We think they have a role to play, but more evidence is needed on how to help governments work with them to improve access, quality, and coverage. 8. Oxfam states (p. 27) “The World Bank and IMF, as well as some rich country donors have, through their aid and policy prescriptions, significantly hampered the ability of government to provide health for all” and that “ …failed policies, were a significant cause of government failure to deliver in recent decades.” We are at a moment of increasing and unprecedented consensus amongst partners in global health about how to accelerate health gains towards achieving the MDGs. We doubt that the Oxfam paper, with its weak analysis, is a helpful contribution. |
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