PHA-Exch> Oxfam responds to World Bank critique of new health report 'Blind Optimism'.

[Claudio Schuftan]

From: AMarriott at oxfam.org.uk


As you may know Oxfam released a new briefing paper on 12th February 2009
entitled 'Blind Optimism: Challenging the myths about private health care
in poor countries'.

A major objective of the paper is to stimulate an evidence- rather than
ideologically-based debate on how to rapidly and sustainably expand health
care delivery in poor countries and achieve the goal of universal and
equitable access.

In the spirit of encouraging continued debate, we would like to share with
you Oxfam's response to two critiques of our paper. Firstly, our response
to the World Bank (will be circulated later) and secondly our response to
April Harding's
blog at the Centre for Global Development (see below).  We hope that
Oxfam's response to the World Bank will be published shortly on their
website.

In the future we would like to continue to share with you information and
evidence on this debate about scaling up health care delivery in poor
countries in the form of emails, approximately once a month. If you do not
want to receive these emails please let me know at any time in a reply.


For Blind Optimism , the full briefing paper, please visit :
http://www.oxfam.org.uk/get_involved/campaign/health_and_education/public_first.html




Oxfam's response to April Harding

We were sadly disappointed with your response to our paper, which we feel
is not representative of either the paper or the discussion at the
Washington seminar. We would completely agree with you that there is a need
to move beyond staunchly ideological positions to one of pragmatism. Indeed
it is through this paper that we are seeking to shift the debate away from
accusatory and emotive exchanges to rather focus on the evidence of what
policies and programmes will most effectively achieve the rapid and
sustained expansion and improvement of health care delivery so urgently
needed in so many countries.

For this reason we would like to question some of the evidence you present
and also correct some of the misrepresentations of our report and position.

‘Beyond anecdotes’
Our starting point is not a simplistic or ideological case of ‘public
good’, ‘private bad’, and we feel to suggest this is to miss the point of
the paper. Our paper draws on a variety of evidence including from health
surveys, peer-reviewed journals, World Bank and World Health Organisation
reports and particularly the Commission on the Social Determinants of
Health. It was reviewed and commented on by academics from across the
political spectrum. Rather than focus on anecdotes our decision was to
focus on the empirical evidence on what has worked to achieve universal and
equitable access in successful developing countries despite low incomes. We
found that even though high health performing countries do often have a
thriving private health care sector, the evidence shows that it is their
level of commitment to pro-poor public investment and public provision that
sets them apart from the rest. By the same token, no successful high health
performing country has chosen to rely primarily on private instead of
public provision. In their official response to our paper the World Bank
agrees with this point.  They go on to say that they feel the main factor
in these successes was good governance, but we believe that although good
governance is critical, the mix of policies used is also a major learning
point, and here rapidly scaling up public provision was central.  Our key
message is therefore quite simple - that donor agencies and governments
should be doing significantly more to learn and apply the lessons from
successful countries and what they did to scale up public provision.  This
does not preclude learning from the lessons on the evolution and governance
of the private health care sector in these same countries. Far from
‘reverting’ to an old tried and tested approach as you suggest, for many
aid donors this will mean redressing their own poor record of long-term
systematic disinvestment in government health care delivery in poor
countries.

Secondly, our advice against investing in risky and unproven approaches
that aim to expand the role of the for-profit private sector in health is
not the same as advocating a public-sector only approach, or that the
private sector should somehow be ‘stopped’, contrary to your presentation
of our arguments. In the paper Oxfam is explicit that the ‘private sector
can play a role in health’, that it ‘will continue to exist in many
different forms and involves both costs that must be eliminated and
potential benefits that need to be further understood and capitalised upon’
. Government capacity to regulate the existing private sector and ensure
its positive contribution to equity goals is prioritised as one of our core
recommendations. On the other hand, unchallenged enthusiasm for private
sector solutions is neither justified nor helpful. Based on the evidence
available there is an urgent need for more honesty about the significant
risks to efficiency and equity associated with private sector growth, and
more openness about the paucity of comprehensive evaluations of private
sector approaches and the lack of evidence that these approaches can be
scaled up. The poor quality of the data on contracting private providers as
an alternative to expanding public provision is a particular concern
especially the lack of attention to transaction costs, the level of
financial risk placed on governments and the wider impact of contracting on
the health system as a whole.

‘The informal Sector – We May Not Love it, But Many People Can’t or Won’t
Leave It’
Far from ignoring the informal private sector and ‘sweeping the challenge
of getting people to change their care-seeking behaviour under the rug’ as
you suggest, the primary focus of our paper is on the poor women, children
and men across the developing world who face the unacceptable choice
between seeking care from unqualified providers or going without care
altogether. In this regard we query your argument that the poor ‘want to
go’ to informal private providers and will ‘persist in doing so’. It is
hard to conceive that when faced with a real and genuine choice between
informal unqualified providers and decent and accessible care provided free
of charge by trained professionals in the public sector poor people would
continue to use the former. In fact the empirical evidence from higher
health performing countries shows that when care is available and
accessible in the public sector the majority of poor people do choose to
use it, and it is the better-off who are more likely to go to the private
sector. We also know in cases such as Uganda, where increased investment in
government health services was combined with the removal of user fees,
utilisation rates for poor people increase dramatically. And even in those
countries with less than adequate public provision, the poor still choose
the public sector for curative care, not least pregnant mothers as our
paper demonstrates.  Public provision in these same countries has also
proven the most effective regulator of the informal sector by crowding out
the most dangerous elements and giving those providers that survive
something to compete against.

None of this means we can ignore the informal sector and contrary to your
suggestion our paper in fact calls for ‘urgent action’ to ‘minimise its
dangerous practice and improve its standards’. We cite some success of
negotiated interventions such as training and public education, although
perhaps more cautiously than you, given the highly resource-intensive
nature of these programmes, lack of evidence on impact to date as well as
the Herculean nature of the task. However, even if standards can be
improved within selected interventions the kinds of services that can be
offered safely via this sector will always be limited and market forces to
over- or under-prescribe will be a continuing threat. Monitoring and
regulating private sector providers even in advanced nations like the US is
also very complex and resource intensive.  That doesn’t mean interventions
shouldn’t be tried but they must not be perceived as a substitute to
scaling up and strengthening decent quality health care services provided
free of charge by the public sector.

The ‘unpopular-with-Oxfam Affordable Medicines Facility for Malaria (AMFm)’
Our concerns about repeating the same mistakes of the past through the AMFm
are shared by many others including the US and Canadian governments, and we
question how quick you are to dismiss them. Choloroquine, once an effective
drug, has been widely available through the private sector for decades and
under- and over-prescribing led to widespread drug resistance. The AMFm is
using the same delivery route for Artemisinin – the last effective drug
available for malaria - with minimal safeguards. We think this is a
mistake. The AMFm also ignores research by organisations such as Médecins
Sans Frontières showing how subsidisation of Artemisinin is not enough to
significantly increase access to treatment for the poor. Their direct
experience in countries across Africa has shown that it is only when
completely free care (medicines, consultations and other related costs) was
introduced that access rates dramatically increased.

You are correct to point out that AMFm will be applied to the public as
well as private sector but you should be aware that this was only agreed
after our paper went to print and only as a result of intensive lobbying
from Oxfam and many other civil society organisations involved in the
negotiations. It is also misleading to suggest attempts to improve access
to Artemisnin through the public sector have failed. Such attempts have
been hampered until recent years by a severe lack of funding. Since 1998
there has been a 25 fold increase in the resources available for malaria
and with it a significant number of public sector success stories including
a 50% reduction in in-patient malaria cases and deaths throughout Rwanda
and Ethiopia, a 33% decline in deaths in children under five in Zambia and
a 34% decline in deaths in Ghana.

In this difficult period of economic uncertainty it is more important than
ever to invest what limited resources are available in policies and
programmes that are going to make the most effective difference in ensuring
poor people have access to the health care they need. There is no question
that the private sector is an important actor, but in countries where the
poor have access to qualified health care at scale the evidence is clear
that it is the public sector that has reached them. The question we need to
be asking is how we get the public sector in other countries to do the
same. As Dr Rannan-Eliya from the Institute for Health Policy in Sri Lanka
said at our seminar at the World Bank, ‘we don’t do it by turning our
attention away from the public sector’.

Over the coming months we will be organising a series of follow up seminars
and lobby meetings in Geneva, Delhi, Brussels, Addis Ababa, London and Oslo
where we are keen to continue this debate and call for a more evidence
based approach. We look forward to continuing this conversation with you.




For April Harding's original blog see:
http://blogs.cgdev.org/globalhealth/2009/02/oxfam_this_is_not_how_.php
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://phm.phmovement.org/pipermail/phm-exchange-phmovement.org/attachments/20090310/9943c123/attachment-0001.html>