PHA-Exch> Re: Health Ministry mulls over more independence for hospitals in Vietnam

[Claudio Schuftan]

From: David Legge D.Legge at latrobe.edu.au

 "The question for progressive health activists is what our position should
be vis a vis autonomisation and corporatisation of health facilities when it
is not intended to lead to privatization (if that can be proven).
Should they go along with it as one possible measure to straighten out poor
facilities management yet stating a strong warning against final
privatization?".  [See below]

 I think, yes, but it is not easy.

 In some situations corporatisation is effectively a form of privatisation
(even without proceeding to a dividend-paying privatised entity) as when
service assets are handed over to NGOs who access donor funds or levy user
charges (and thereby relieve government of any recurrent funding
responsibilities).

 In thinking about privatisation I think that we need to include the funds
mobilisation dimension, as well as the corporate status of the facilities
and the mode of remuneration of the professionals.  One of the most
iniquitous aspects of the neoliberal prescription is the creation of
multi-tiered (multi-layered) funding arrangements: commercial insurance for
the rich; social insurance for the middle class and publicly funded
minimalist ('cost-effective' packages) for those under the 'safety
net'.  Clearly,
the purpose of this prescription is to reduce the tax burden on government
while maximising the investment opportunities for others.  This entrenches
inequity with respect to access and quality; it fragments health care
provision generally and increases the total cost burden.

Further, the multi-tiered health funding pattern is also part of adapting-to
and exacerbating widening disparities in income and wealth and of weakening
the sentiment for social solidarity and collectivism generally.

 So, I guess what I am saying is that while we should argue in the strongest
terms against privatisation we should also argue equally strongly for
universalism in health care funding.  By this I mean progressive fund raising
(taxing); inclusive funds pooling; and a common inclusive scheme for health
care funding (or 'purchasing').  These are both important criteria for
evaluating policy directions.

 We also need to think through the management dificulties which may
legitimately point towards corporatisation (conditional upon a
universalhealth provision funding arrangements as above).

 Efficiency is hard to achieve when hospitals are managed through government
management system.  Who can make choices between transferring expenditure
from staff to drugs or to equipment?  Who knows what is the most efficient
mix of inputs to achieve quality and efficiency?  Obviously there is a
related problem of staff morale in a situation where there is no good local
leadership.

 So, I guess I am back to arguing that we need to analyse the specific
circumstances in which autonomisation/corporatisation is being advanced,
both in terms of the logic in favour and the direction in which it might
lead the system.

 dl

*From:* Claudio Schuftan [mailto:schuftan at gmail.com]
*earlier to:* David Legge

See my comments on your text:

 I think we need to be a bit cautious about assuming that the same words
mean the same things in Vietnam as in Argentina.   VERY MUCH AGREE.

   It is true that the World Bank's line is about a sequence of 'reforms'
from autonomisation to corporatisation to privatisation. THIS DISTINCTION IS
CORRECT AND VERY IMPORTANT.

  It is true that corporatisation has been implemented under neoliberal
tutelage in many countries as a precoursor to privatisation.  ABSOLUTELY. IN
Vietnam IT IS CALLED 'EQUITISATION'.

  Yet it is *not* the case that the only logic for autonomisation and
corporatisation is to lay the ground work for privatisation.  EMPHASIS HERE
IS ON 'ONLY'; IT SOMETIMES OR OFTEN IS.

  There are legitimate criticisms of hospital administration. There are
substantive arguments in favour of a singular focus of management
accountability including financial and clinical accountability.  Not mortal
criticisms; not overriding arguments, but worth considering in particular
cases.  AGREE. NOT TO QUESTION 100% PUBLIC PROVISION, BUT STRAIGHTENING OUT
SERIOUS MANAGERIAL SHORTCOMINGS.

    It is very easy to overlook the contextual uniqueness of diffferent
health care systems in the face of obvious commonalities. CORRECT. MUCH MORE
RESEARCH NEEDED HERE.

   I think that it might be reasonable for those of us who are not close to
the realities in Vietnam to ask for a bit more information.  THERE IS
FACTUAL INFO, BUT NOT INFO ON LONG TERM INTENTIONS.

 QUESTION FOR PROGRESSIVE HEALTH ACTIVISTS IS WHAT OUR POSITION SHOULD BE
VIS A VIS AUTONOMISATION AND CORPORATISATION WHEN IT IS NOT INTENDED TO LEAD
TO PRIVATIZATION (IF THAT CA BE PROVEN). SHOULD WE GO ALONG WITH IT AS ONE
POSSIBLE MEASURE TO STRAIGHTEN OUT MGMT YET STATING A STRONG WARNING AGAINST
FINAL PRIVATIZATION?

 cs
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