PHA-Exchange> OXFAM response to the WB

[Claudio]

WRONG DIAGNOSIS, WRONG MEDICINE
World Bank strategy for health, nutrition and population results 2007 to 2017
Oxfam response
Summary
There is growing international recognition that health systems in poor countries need extensive strengthening if MDGs are to be met. A proliferation of disease-specific interventions by global agencies is undermined by weak health systems. Meantime such initiatives threaten to undermine the already weak systems. Decades of chronic under-funding of health systems have led to the current dire situation. A particular challenge is the massive shortage of health-workers, the low wages they receive and the poor conditions under which they work, especially in sub-Saharan Africa.  Oxfam strongly supports an increased donor focus on strengthening health systems.

The World Bank strategy for Health, Nutrition and Population, 2007 to 2017, is now being drafted. Recommendations will be presented to the Board of Directors in December 2006 and the strategy will be launched in the 2007 financial year.

The strategy envisages greater World Bank spending on strengthening health systems in low and middle- income countries. There is a new emphasis on health results rather than system inputs, with support to data and monitoring systems that can measure those results. Country teams are to be given more independence to work with recipient governments, in order to support multi-sectoral arrangements that may have a positive impact on health. The Bank will collaborate with vertical, disease-based initiatives such as the Global Fund, rather than replicating them. Governance issues feature throughout the strategy document.

Oxfam welcomes those broad outlines, but has serious concerns with a number of key assumptions in the strategy, with the omission of some important considerations, and therefore with the Bank's policy prescriptions for health system strengthening.

1. The Bank claims a unique comparative advantage in strengthening health systems. There is considerable research demonstrating the lack of success of the health reforms advocated by the Bank in the 80's and 90's. In particular the infamous Structural Adjustment Programmes (SAPs) which advocated cuts in public expenditure on health that lead to the current health system crisis in sub-Saharan Africai.  The Bank has a role to play in giving technical advice to recipient countries on how best to organise the pooling and allocation of funds for health services. However, there is nothing unique about the Bank's expertise in public health and its analytical record is weakii. It was the WHO Commission on Macroeconomics and Health which tackled the question of 'what is needed and what would it cost' to provide basic health care in low-income countries. 

2. The equation of out-of-pocket payments with ability to pay for services contradicts the Bank's own analysis on how paying for health care drives people into poverty- as stated in the same document. The introduction of user fees, under the Bank's advice, has led to serious inequity of access given that poor patients, especially women, cannot pay the cost of treatment. There is considerable research to show that by preventing people from using the services, user fees have also landed women with a huge caring burden. Yet the Bank offers paying for health care as a recipe to generate funds and ensure quality of service. 

3. The Bank's analysis is clouded by a bias towards private provision without thorough understanding of the fragmented, unregulated, and small provider nature of the private sector in developing countries. It is unclear how the Bank envisages weak public sectors being able to regulate and manage a fair, equitable and efficient system of privatisation in the context of poor ability to pay. There is serious evidence that private providers are unable to deliver equitable access to health services. Oxfam's research in South Asia shows that Sri Lanka and Kerala State in India have been able to provide comparatively far greater universal protection from health risks through publicly financed models of public provision, where services are free at the point of use. Therefore the prescription that private sector providers are the panacea to cure health system failures is erroneous. It is precisely in the countries where weak public systems prevail that contracts also fail due to weak regulatory institutions and capacities. Private contracts only provide equitable access where state revenues, capacities and institutions are sufficiently robust.

4. The strategy almost exclusively promotes a particular type of insurance -social health insurance system as a way of financing health care. However, as the document fleetingly acknowledges1, there is a need to leverage many other sources of revenue beyond income-related contributions in low-income countries. The social Health Insurance advocated by the Bank may be appropriate in some middle-income countries, as evidence from Thailand would suggest. However, there is little evidence that this approach can be used in low-income countries without creating a two-tier health system that erodes solidarity between the haves and the have-nots. In Rwanda, the Global Fund pays insurance premiums for poor people who wish to benefit from facility-based mutuelles, but these schemes have thus far only worked in small isolated localities with heavy external financial input. Evidence from the Equitap study in Asia suggests that tax-based funding systems are more effective at protecting poor people against health risks. Oxfam recommends a normative approach of financing and provision of health care that explicitly aims for universal, equitable access if the Bank is serious about health system strengthening and eradicating poverty. Therefore, the Bank must be willing to support client countries that wish to develop national revenue-based systems from tax, aid receipts and other domestic resources. 

5. The Bank continues to equate public sector systems and workers with corrupt services that are unresponsive to user demand. At the same time, the Bank promotes the idea that the private sector is inherently more accountable, less corrupt and of a higher quality. The evidence does not support this argument. Private contracts in developing and developed countries are a breeding ground for corruption. There is scant evidence that private providers are more efficient than public providers. 

6. This draft strategy also suffers from some glaring omissions. There is a total lack of gender perspective. The evidenced conclusion of private payment mechanisms is that women and children miss out on health services; women and girls miss work and education opportunities to care for sick relatives; and thousands of women die in childbirth. In a related vein, the analysis equates reproductive health with family planning. There is little emphasis on sexual and reproductive health services nor is there any clear vision on maternal health.  

7. The role of specialised United Nations agencies is also omitted. These are the agencies that have comparative advantages in health policy development, service planning and management, standards and guidelines- setting, disease surveillance, human resources and access to medicines. The Bank does not have a comparative advantage in these areas.

The World Bank draft strategy should be rewritten in order to correct erroneous assumptions and crucial omissions:

* Out-of-pocket expenditures are not indicative of ability to pay for health services. In particular, the demand even for small payments denies women and girls their rights to health.
* Private insurance payments do not achieve the universal level of health services that guarantee the right to health in low employment economies. 
* Private contractors are not inherently more efficient at providing quality services.
* Private contractors have proven unable to provide equitable, universal services.
* There is widespread corruption in the contracting-out of health services in countries with weak state institutions and capacities.
* Public health workers are not inherently corrupt. They work under bad conditions and remedies for their petty corruption should address the core issues of salary, career and working environment incentives. Specific measures should be promoted to retain female health workers in rural areas. 
* The health rights of women and girls should be explicitly acknowledged in the strategy.
* The strategy should acknowledge the comparative advantages of UN institutions with which the Bank has to collaborate.
1. What does the new health strategy say?
1.1. The Bank has analysed external and internal challenges and opportunities that enable or hinder it to "assist global partners in their efforts to achieve the MDGs, additional country-defined HNP priority results, and to improve health system performance in low- and middle-income countries". The analysis pointed to a number of conclusions (with relevant paragraphs in square brackets):

* New development assistance architectures for health have emerged in the last decade, with proliferating agencies tackling specific diseases [25c,e].
* This has created change for the good, e.g. new vaccines under development and cheaper drugs available, but has put strains on the underlying health delivery systems [25d,e,f,h].
* The Bank's main advantage is helping client countries to strengthen 'horizontal' systems - within the health sector but also across many sectors, and with harmonised donor assistance [25d, 42].
* Vertical, disease based initiatives are better served by other agencies. The Global Fund is singled out in this regard [25c].
* Bank projects have failed to show results in the past, either because results were not being sought (only inputs were required) or were not being measured [25b].
* There is substantial out-of-pocket private financing of health care and substantial private sector provision already in LICs and MICs, but public-private complementarity is underdeveloped [25g]. 
* Strong country presence and country focus of the Bank is one of its most important comparative advantages [45].

1.2. There is a new emphasis on measurable outcomes over a long term and over many sectors. The paper identifies three main strengths that will help it to achieve results. ' These are:
 
1. Country focus through the Country Management Units - these support clients to develop and own their own plans, and will be strengthened [45-6].
2. Intersectoral approach to HNP results, in support of the fact that many factors other than health service delivery contribute to HNP results and performance. Although the paper mentions crucial sectors such as income, environment, education, water and sanitation  [47-9], it focuses on the financial sector in the rest of the paper. 
3. Health system strengthening approach to HNP results. The Bank sees its advantage here in health financing, system governance, accountability for service delivery and demand-side interventions. [52-5]. 

1.3. Based on this analysis, the draft strategy proposes new policy objectives:

* Improving sector governance' as a new objective.
* Not including  'strengthening health systems' as an objective, but rather as 'a means for Bank country assistance to achieve all [objectives]'.
* The other objectives remain from the 1997 strategy: improve HNP outcomes for the poor; protect households from impoverishing effects of illness; work with countries to ensure sustainable financing [60].

1.4. The recommendations for internal change at the Bank centre on the need to integrate HNP sector with other sectors, so that different sector, country and regional units have the skills and incentives to address all factors that affect the HNP sector, especially fiscal space and governance. [88-90]. 
       A new sector team is proposed, a 'rapid response health team' of five experts to advise on integration of health sector priorities with other strategic issues, particularly fiscal space, public sector governance, financial services and social protection [94]. 
       Finally, the Bank intends to withdraw from vertical, disease-based initiatives but will aim to coordinate with global partners to complement the Bank's comparative advantages [95-104].
2. What are Oxfam's concerns with the strategy?
Oxfam is concerned about a number of erroneous assumptions in the strategy, as well as some glaring omissions: 
2.1. The Bank is right to state that most payments for health services in low-income countries are private. So what's wrong with formalising those payments?
Paragraph 57 states that "private provision and private funding dominate health systems in LICs and in many MICs. thus, improving HNP results requires the Bank to provide sound policy advice to client countries on how to engage with private providers and how to leverage out-of-pocket expenditures so that households demand, and insurers supply, more insurance services." Translated this means 'Poor people are already paying, so lets have a system that organises that payment and makes it fairer, and seeks to spread the risk'.

The Bank recognises that out-of-pocket expenditures (OOPs) in LICs drive whole families, and even generations of families into dire poverty. The document itself states as much (para 67) and provides statistical evidence in fig. 24, annex A- although it ignores the specific impact on women and girls. The poorest people are often unable to pay and therefore do not use health services whether public or private.  When they do pay it is often by selling their assets, borrowing money, withdrawing girls from schools, and decreasing spending on essential items such as food and treatment for other sick members of the family. An episode of ill health is one of the key reasons families are driven into poverty, as the paper itself confirms. Experiments with exemptions from formal fees for poor people have failed to protect destitute households, who remain excluded from health services. Exemption systems are notoriously hard to implement, subject to widespread corruption, and often end up being 'captured' by relatively wealthier households.

It is therefore erroneous to claim that the scale of OOPs shown in fig. 2 is a given fact and can be harnessed into pre-payment systems and pooled across populations.  Many people pay for health care because they have no choice: user fees introduced under the auspices of the WB are a key factor in this lack of choice. 

Based on the mounting evidence of a negative relationship between OOPs and equity, the Bank must commit to abolishing user fees.
2.2. What is wrong with social insurance systems?
Social health insurance is one way of financing services but it is not the only way or necessarily the best way in most developing countries.  It relies on the existence of a large formal sector, where health insurance can be taken from wages, and where people can afford it. In many LICs the formal sector is tiny: it accounts for just 5% of the employed population. The vast majority are simply too poor to pay for healthcare, especially in sub-Saharan Africa. Income-related insurance schemes have so far created two-tier health systems that further erode national solidarity and undermine the long-term pursuit of universal and equitable health systems.

In Germany and France the system of social insurance based on people's employment took over 100 years to establish universal coverage. When insurance is not available to all then it becomes affordable for a few, as is the case in the US where 18,000iii people die every year because they do not have health insurance. Successful developing countries have for the most part relied on paying for health services from general taxation, natural resource revenue and aid receipts. Sri Lanka, Botswana, Cuba and Malaysia are cases in point. More recently Uganda, which removed user fees for health in 2001, saw an immediate 50 to 100 percent increase in attendance at clinics and a 105 percent increase in immunisation ratesiv.  This removal of fees was accompanied by massive investment in expanding health services to reach poor people in rural areas. The success of such public sector examples is not mentioned in the new strategy. 

The Bank must stop promoting social health insurance as the only way to finance health systems in low-income countries. Countries must be free to choose to pursue public investment in public services.
2.3. What is wrong with contracting out the provision of health care?
This strategy ignores the evidence that contracting out has not been the method used in the vast majority of countries that have successfully expanded health care for all.  Research cited in Oxfam's report, In the Public Interest, shows that public financing of national services based on large-scale government provision has had a far greater impact on providing services to poor people. The history of health service development in Europe shows that universal coverage (still not available in the USA) has been achieved only through government financing and organisation with highly sophisticated national government institutions regulating and providing services. The same has happened in developing countries such as Sri Lanka, where political values and commitment were crucial in developing services that slashed maternal mortality rates over a very short period.  In developing countries that have succeeded in expanding healthcare, government has virtually always been the largest provider of simple and applicable health services for all. 

This does not mean contracting out does not have its place, or that private providers are not important. But evidence shows that market-oriented reforms consolidate power "with central decision makers and privately interested service delivery organisations" rather than transferring power to service users, which is the Bank's stated interest in promoting such reformsv.

The strategy is wrong to equate contracting out services with less corruption and greater accountability. Box 1 on page 27 is a further example of erroneous argument in this document. Oxfam does not accept the statement that 'contracting out services and overseeing performance' leads to 'accountability tightening'. There is hardly any evidence to support this. On the contrary, there is plenty of evidence to suggest that contracts account for a large proportion of unaccountable fraud, even in industrial countries with sophisticated accountability systems in place. The 2006 Transparency International report on health services and corruption clearly identifies contracting out as a major source of health care fraud. In developing countries with extremely weak systems of regulation, contracting services out to the private sector is extremely likely to lead to opportunities for fraud, bribery and corruption.  

There are no grounds for the a priori assumption that contracting out services and charging fees will automatically lead to greater accountability, or that public provision and free services are automatically more prone to corruption. 

The Bank should review its assumptions and base its policy on evidence. In particular it should review the erroneous equation of contracting out with decreased corruption and increased accountability. The Bank should question the wisdom of contracting out health services and should emphasise the need to build and improve government provision of services in poor countries.
2.4. Why does gender matter?
The burden of diseases and caring for the sick falls disproportionately on women and girls. Girls can be pulled out of school in order to look after a sick relative and/or to save money to pay for treatment. Women have less access to resources, so they are less able to make independent decisions on payment for health services. When fees are charged, women miss out on seeking medical care. After introducing fees for health care in Nigeria, research in Zaria district found that the number of babies delivered in hospital halved, and the number of mothers dying in childbirth doubled. Every day, 1,400 women die needlessly in pregnancy or childbirth. Only countries like Sri Lanka that have ensured access to maternal services in rural areas have been able to address this unjust situation - very few Sri Lankan women live more than 1.4km from a health clinic, and 96 percent of births are now attended by a qualified professional. But overall, women in developing countries have a 1 in 60 chance of dying from pregnancy-related causes. Compare that to 1 in 2,800 in developed countries.

The Bank must fully integrate gender considerations into this 10- year strategy. The health of women has an impact on the health and productivity of the entire household and vice-versa. 

End
3rd November 2006


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