PHA-Exch> Food for an old, but still current faulty thought (2)

[Claudio Schuftan]

Human Rights Reader 206



*HEALTH SECTOR REFORM MEASURES: HAVE THEY WORKED?... AND WHERE DO WE GO FROM
HERE?  *(Part 2 of 2)



11. Let it be understood here that there is nothing inherently wrong with
market-oriented reforms in health, *provided*:  a) They work in the
direction of equity, as well as greater efficiency, b) they receive
*no*government subsidies, and c) they comply with well monitored
regulations
set-up upfront.  But these prerequisites hardly exist anywhere at present
--including in countries like China and Vietnam...

12. The bottom line is that some important, structural changes need to be
enforced to get reforms in the health sector into a more sustainable track.
Such a track has to lead to the outcome of assuring quality care for the
prevalent health problems of the growing number of poor people
worldwide.  Public
hospital care, for example, has become unaffordable to the poor due to steep
user fees and 'under the table payments'. Subsidizing such a system, instead
of reforming it,  will only channel additional funds to the wrong (non-poor)
recipients.

13. HSRs can and have thus been used as crutches to pretend one is changing
the system, when it is basically staying the course or even going backwards.
Historically, there is a non-accidental link between Structural Adjustment
Programs, Adjustment with a Human Face and HSRs.  The link is actually a
progression, one with a calculated internal logic, namely to apply the
principles of the market economy to the health sector.

14. The bottom line is that most current HSRs cannot address the constraints
to equitable access to care faced by the poor. Not even with 'good
targeting' --a concept we reject anyway since it does not address the
determinants that keep people vulnerable generation after generation.

15. Moreover, HSRs use some technical terminology with misleading
imprecision (or bias).  Examples that come to mind are:

-"efficiency" (which is measured in economic terms only);

-"willingness to pay" (which is used in place of the much more real
determinant: "ability to pay");

-"cost-sharing" (which is applied to regressive fee for service systems when
the real issue is who is to pay more and who less or nothing).



*So, what would be more effective and sustainable?*

16. Perhaps the best response to a part of this question is in another
question: Why not ask the beneficiaries directly to respond to this
question?  This is not an evasive response!  This response has the wisdom of
accepting the fact that:

-localized viable responses will (and should) be multiple and varied; there
is not one response that fits all (or even many) diverse situations;

-our technical expertise can be put to a more effective use in a dialogue
with community representatives;

-communities do *not* always know best, so mistakes will be made; quickly
learning from such mistakes can lead to more sustainability than applying
schemes imposed from outside.

17. Such a grassroots-centered approach calls for an unprecedented change in
our priorities and in the way we operate.  The locus of control has to shift
to beneficiaries for decisions that affect them directly on an everyday
basis; and we ought to be instrumental in such a transition.

18. At the same time, equity oriented measures have to be implemented from
the central level.  Some of the key elements of such reforms could be the
following:

·       Public rural health care services will still need to be primarily
financed by governments (central and local).  Only up to 10-15% can be
realistically expected to be raised by community contributions or rural
health insurance schemes.

·       Financing public urban health care services in poor neighborhoods
will probably also still need 50-60% government financing.

·       Financing of health care will have to move away from regressive fee
for service schemes and towards prepayment schemes where the whole
population --not only the sick-- contribute.

·       Direct and indirect progressive taxes must, therefore, constitute
the financial base in an efficient, equity-oriented health care
system.  Government
funds can be used directly to fund public health services or can subsidize
social health insurance schemes that will progressively cover the whole
population.

·       If communities do contribute to the financing of health care
services, they will have to have more de-facto control over how the funds
are used.

·       Governments will have to gradually reallocate resources from rich
provinces/districts to poorer ones according to a set of needs-based
indicators.

·       General tax revenues that apply more to the rich (e.g., taxes on
luxury items, spirits, tobacco, or on assets, estate and wealth) will have
to be considered more seriously as a source to bring in financial resources
from other sectors to the health sector.

·       Health staff will have to become more accountable to local
communities.

·       The use of existing resources should be rationalized and this will
mean reallocating and sometimes shedding personnel and mobilizing more
resources to outreach work outside the health stations.  In the medium term,
health staff incomes will have to be brought up to minimum standards of
living based on a system of monetary and non monetary incentives.

·       The roots of the twin trend towards self-medication and
underutilization of  PHC facilities will have to be broken in each locality
with ad-hoc measures taken with major inputs from the community itself;
existing essential drug programs have to be made to work; drug companies
(and clinical health staff...) have to be made to comply!

19. These are but a few of the central and local level options that need
being looked at more carefully again.  But this listing is not the purpose
of this review.  The idea is that the process opening the doors to a more
participatory and empowering dialogue with beneficiaries (especially
engaging women) has to come up with more of the answers and options.

20. One is left to wonder how many of the more sustainable Equity-Oriented
Health Sector Reform (EOHSR) measures quickly reviewed here have a chance of
being seriously considered and implemented in the near future...   The
bottom line here is that we remain convinced that tinkering more with the
HSRs proposed so far will not do.  That is the sad reality.  Precious time
is likely to be lost only to see the problems of inequity worsen.

21. We think that what is really needed is a "HSR of the public health care
sector", not one overwhelmingly in the direction of the private sector (we
ask ourselves why the former option is flatly left out in mainstream HSR
discussions and only more absolute market-oriented options are
explored/proposed).  The so often touted non-service-mindedness of the
public sector is not a given.  We need to fix a system that --granted-- has
many flaws.  But it also has many strong points!  Only when its core is
streamlined and strengthened, can one consider contracting out some
ancillary services to the private sector --provided there is a fair system
of competition in place.

22. This brings us back full-circle to the old "political will" issue which
is not really an issue of  "will"  as such:  it is an issue of  "choice"
--of political choice.  And being an issue of choice, for the time being
--short of an awakening of civil society initiatives and movements in many
places around the world at about the same time-- the responsibility to move
towards Equity-Oriented Health Sector Reforms is still squarely back on the
lap of the respective governments.  Much advocacy and lobbying on our part,
as well as work to neutralize powerful internal and external forces opposing
the view here presented, are still needed in order to put the last first....



Claudio Schuftan, Ho Chi Minh City,    cschuftan at phmovement.org

Goran Dahlgren, Stockholm,                dahlgren38 at telia.com



*Postscript:*

Some of you may not fully agree with the alternatives we propose:

·       You may be of the opinion that proposing a bottom-up approach puts
too much faith in attaining the many structural changes needed.  Further,
you may think that when management of services is turned over to the local
people, they do not become any more efficient or effective. *{We, on the
other hand, still do find evidence that when management of services is
(really) turned over to the people, the added accountability and
transparency does make them more efficient/effective than what they are now
(may not be perfect, but better). Of course, this turning over of control
has to be matched by government support of such a move including the
reallocation of resources to back the new, truly decentralized structure}.*

·       You may contend the problem is not the structure; the root problem,
you think, is pervasive apathy and corruption at all levels of the public
service --from village to the top. Some of you may have become hardened to
believe that people tend to act only when there is some compelling reason
for it. And today, in many countries, there is absolutely no compelling
reason for anybody to take their public responsibility seriously. In fact,
you may think it is against their own self-interest to fulfill their public
responsibility. *{We do agree that people tend to act when there is some
compelling reason for it; we remain convinced though that one has to and can
create such compelling reason for people to take their public responsibility
seriously using the right mix of (monetary and non-monetary) incentives and
a shift towards local control. Devolving real powers to local populations,
so that public servants are de-facto accountable to them, is therefore also
crucial for this}.*

·       Unfortunately, many of our colleagues have also come to believe that
predominantly tax financed healthcare is a myth. (Citizens often end up
paying twice, they say: first for the consultation at the public clinic and
then again at the private practice of the public-clinic physician. This may
be the reason for an increasing number of people going to the private sector
services directly). *{Against this, we contend that there is absolutely no
evidence (but a lot of faith) that private providers and hospitals do a
better job for low income groups or locate in areas of need rather than of
potential profit… (only public hospitals serve disadvantaged groups or
areas!). Let us face it squarely, as regards the private alternative, even
if we could perfect all the 'market distortions' that hinder private
services, the result would still be grossly inequitable and totally
unworkable to care for the poor as we posited in the body of this Reader}.*

·       Proponents of the HSRs we here criticized *are* interested in
finding a workable solution to the major problems here exposed, granted. *{But
they define the current realities with what we think is a bias and an
a-priori skepticism against the public sector.  That is the unhealthy
attitude we think needs to be broken. The public sector in health still has
the central moral, political, human rights and de-facto responsibility to be
the guarantor of equitable health services being accessible to all its
citizens; nobody can or will do it for the state.  Within this context,
neither the public financing of private providers (contracting out of
clinical and/or preventive services) nor the private financing (running) of
public health facilities (as for example currently in some places in China)
serves the interests of  poor people equitably. The profit motive stands in
the way}.*

   - Finally, you may say that dogmas are just dogmas; and what we need are
   solutions.

*{Yes. But it is HSRs, as currently applied, that seem to be more driven by
dogmas than by evidence.  From our perspective, and not claiming
exclusivity, solutions start with a vision that leads to a mission…and
visions of an enhanced role for public sector solutions, as we have here
proposed, are not dogmas; they are viable and in the best interest of those
we purport to serve}.*


*Important note:* This article was written in 1998! It is astonishing how
the issues brought up here are as current today as they were then….Would we
have written it today, we would have added the human rights perspective.
With what you have read in these Readers, you can perhaps add such a
perspective…Anybody inclined to contribute?
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