PHA-Exch> Oxfam’s response to World Bank criticisms of new briefing paper ‘Blind Optimism’

[Claudio Schuftan]

*Oxfam’s response to World Bank criticisms of new briefing paper ‘Blind
Optimism’*



*World Bank*

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.



*Oxfam*

*Oxfam’s Briefing Paper No. 125, “Blind Optimism” was written with many
contributions from academics across the world and was reviewed by a number
of different actors who both sympathised and disagreed with the stance we
are taking.  The evidence comes from Demographic Health Surveys; from
peer-reviewed literature; from academics in research institutes globally;
from our partner organisations; and from reports published by the World
Bank, the World Health Organisation and donor agencies. In particular it
draws heavily on the work of the WHO’s Commission on Social Determinants of
Health, which concluded that reforms driven by international agencies and
commercial actors that introduce market behaviour into public health systems
and encourage a greater role for the private sector have further undermined
the performance and ability of public health systems to redress
inequity.   Above
all the message of Oxfam’s paper is to call on the World Bank and other
donors supportive of private provision to return to the evidence and
themselves step away from ‘conclusions more reflective of dogma than
science’.  *

* *



*World Bank*

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

* *
*Oxfam*

*Oxfam welcomes the World Bank recognition that in many countries the
private sector in health may be too large, that scaling up ‘does not
necessarily mean “growth” of the private health care sector, and that ‘parts
of it [the private sector] have poor quality, inefficiency, or impose a high
payment burden that may be too large’.  This is exactly the kind of
reasonable assessment of private provision that has been lacking to date,
and that our paper calls for.   Whilst criticism of the public sector is
elaborate and detailed, our research identified no realistic assessments of
both the positives and the negatives of private provision by the World Bank
or any other major donor.  This makes a proper assessment based on evidence
difficult.  As our paper demonstrates, the reality of private care in
developing countries is that it is often either inaccessible to the poorest
due to its prohibitive costs, or is of such a poor quality as to be in many
instances dangerous to health.   *

* *

*Oxfam recognises that the World Bank does indeed contribute to public
sector health delivery through lending and non-lending (technical advice) to
governments, and that World Bank health lending is predominantly through the
public sector.  Indeed the conditions and technical advice attached to
lending to governments gives the World Bank its unrivalled position in
shaping the development policy of developing country governments in ways
that have sometimes been damaging.  The introduction of health user fees in
many instances, the systematic disinvestments in public services in favour
of economic adjustment and debt servicing, and the hugely inefficient
proliferation of vertical disease specific initiatives at the expense of
investment in primary health and health systems have resulted in part from
this influence. *

* *

*The fact that most World Bank lending goes through the public sector does
not mean that it is not used to promote private provision.  In fact, as we
outline in the paper, much of this lending and ‘non-lending’ (technical
advice) is increasingly also being used to promote an approach which seeks
to separate out the purchaser and provider roles, looking to the state
increasingly as only a regulator and steward of the health sector while
contracting out services to private providers.  In this approach, World Bank
lending to governments is used to encourage governments themselves to
contract out provision to private providers.  Our view is that this is a
risky and largely unproven way to organise health systems and public
services in developing countries, is not supported by the evidence, and can
prove a dangerous distraction from the urgent need to scale up quality
public provision.   *



* *
*World Bank*

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?


*Oxfam*

*Oxfam welcomes the recognition by the World Bank that ‘most high health-
performing developing countries have strong public sector delivery systems’.
Our starting point in developing the paper was predominantly empirical; a
survey of those countries that have been successful, and an analysis of the
policies they have chosen to pursue. *

* *

*Oxfam agrees with the World Bank that good governance and political
commitment are indeed an essential pre-requisite for delivering health care
to the entire population of any country.   Part of our work in over 100
countries around the world is supporting vocal citizen and civil society
action to demand better governance. *

* *

*However, the evidence is that good governance is not enough to fully
explain the success of high health-performing developing countries.  The
policies they have chosen to pursue in health also make a major difference.
It is reasonable to suggest that given that most of them have chosen
substantial public delivery of health services, that this method has the
best chance of working in other developing countries. This does not mean
that those countries have no private sector – they all do, and in many cases
the private sector is comparably as large as neighbouring countries without
strong public services. The difference is that those countries with strong
and sustained investment in public provision are successfully delivering
services for poor people, while those that don’t are not.  The fact that no
successful developing country has chosen to rely predominantly on private
provision instead of public provision certainly would suggest that the
burden of proof lies very much with those who are advocating this route.
*

* *

* *

*Oxfam is clear that many developing countries have not managed to deliver
the success of the few that have.  However, where we differ from the World
Bank is that we do not feel that this means that there is some inherent or
intractable weakness in public provision in these countries that means the
private route is preferable.  The evidence does not show that the public
route has failed, ‘despite decades of investment’, leaving no choice but to
pursue private provision instead.   Instead the public sector in many poor
countries has been decimated by years of under-investment and sapping of
government revenues through debt servicing and low levels of very poor
quality aid.  This was compounded by pressure to adopt now largely
discredited policies such as the imposition of user fees (fees that remain
in place in the majority of poor countries).  *

* *

*None of this is to suggest that working with the public sector is not
without many problems in developing countries, or that these services are
not in a terrible state in many instances.  Neither do we suggest anywhere
in our paper that donors and governments should ‘focus exclusively on public
delivery’  - this is an inaccurate representation.  But as the increasing
number of successful sector-wide approaches and initiatives such as the
International Health Partnership show, it is possible in a wide variety of
developing countries to get behind one government plan to expand access to
health, and that the opportunities for scaling up quality free public
provision are greater now than they have been for many years. It is for this
reason we have released this paper now, to encourage donors to support the
policies that have the best chance of working for a successful scaling up of
health care in developing countries. *


*World Bank*

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.

* *
*Oxfam* Oxfam is clear that non-profit or civil society providers are a
lifeline for millions of people and are not subject to many of the market
failures that disadvantage for-profit providers. But we also recognise that
performance, capacity and cost-effectiveness vary across civil society
organisations. In some countries the rapid growth of NGOs providing services
has undermined the co-ordination of the health care system and has left some
regions without any services at all. Non-profit organisations can still
compete with the government for already limited numbers of health workers.
That is why we are encouraging non-profit health care providers to sign up
to the NGO Code of Conduct for Health Systems Strengthening to ensure their
services do not undermine but support government health care provision.
Existing non-profit provision where appropriate should be integrated into
the national health system to ensure co-ordination and avoid duplication.   We
do not agree with the World Bank that the evidence on contracting out
provision to private providers is of a high quality. In fact we have very
serious concerns about the quality and reliability of the data, especially
in countries such as Cambodia and Bangladesh, and the way some World Bank
advisors have used this data to promote contracting elsewhere. There are no
fair comparisons we have found where donor agencies and government dedicate
the same level of expertise and resources to strengthen public provision as
compared to contracted private provision. Existing World Bank research has
also avoided calculating the significant transaction costs associated with
contracting. There is a need for more transparency in the analysis.
Furthermore, any attempts to simply apply the findings of contracting with
non-profit providers to promote contracting with very differently motivated
and resourced for-profit providers is a serious mistake.   The World Bank’s
focus on contracting is to the detriment of exploring other ways in which
not-for-profit organisations can support and expand health care provision.
In Timor-Leste for example, NGOs played a critical but temporary role in
rehabilitating the public health system and working in partnership with the
government to build its capacity to manage and deliver services itself. The
World Bank played a leading role in co-ordinating donors in support of this
successful approach, and it would be great if this could be disseminated
more widely.





*World Bank*

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.


*Oxfam*

*Oxfam welcomes the fact that the World Bank recognises that ‘evidence on
quality in general and evidence that properly compares public and private
sector providers is particularly lacking’.  It is for this reason that we
researched and wrote this paper, and hope that it will contribute to the
process of addressing this research deficit and enable a much more evidence
based debate.  *

* *

*The World Bank itself has contributed to this research gap.  Research by
the World Bank into the failures of the public sector, for example into its
capture by the middle classes, or absenteeism of nurses and doctors, has
been elaborate and detailed.  At the same time documentation or analysis by
the World Bank or any other donor of public sector success stories and of
private sector failings is sorely lacking, as are comparative studies.  Until
we see this evidence deficit addressed, we believe that a truly ‘pragmatic’
approach is not possible, and any pretence to pragmatism is unfairly biased
against public provision.  Given finite resources, the risk of pursuing the
wrong policies in this evidence vacuum is deeply concerning.  We look
forward to the World Bank working with others to address this research
deficit rapidly in the coming period, so that the debate can be more
evidence based.   *


*World Bank*

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).


*Oxfam*

*The issue of equity of access is addressed in our paper at length, and also
extensively by the IMF and in the recent report on the Social Determinants
of Health.  The IMF is clear that even in situations where the middle
classes capture more of the benefits of health provision, the fact that they
pay more taxes means that the overall impact on society in most instances is
still to increase equity.   In the majority of developing countries public
health care still has to be paid for and user fees are still in place; it is
no real surprise then that the better-off capture more of the services
available.  This is why Oxfam, along with many others is calling for the
World Bank to help eliminate user fees in all developing countries.*

* *

*Oxfam’s paper does not suggest that there should be no attempt to make
private provision work better for the poor.  In Malawi for example, we
support the negotiation of agreements between governments and mission
hospitals to make their services free. We support pragmatic approaches that
build on equitable foundations. We also think that regulating and organising
the multiplicity of private providers is in many instances a Herculean task
that even developed country governments struggle with.  *

* *

*At the same time the rapid expansion of public provision is not even being
discussed in most country contexts. This is despite empirical cross-country
evidence from Asia that equity in health care access is determined by what
the government does or doesn’t finance and deliver, whilst the role of the
private sector has negligible impact. We need to urgently redress the
balance of emphasis if we are going to successfully scale up, and that is
the main message of this paper. *


*World Bank*

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?

* *
*Oxfam*

*Our paper does not shy away from the many difficulties and problems with
public provision in many developing countries. However, there is already a
substantial and detailed body of evidence detailing public sector failings,
but almost no assessment of the public sector successes that we identify in
our paper, or what can be learned from them.  At the same time there is
virtually no research undertaken by the World Bank or others looking at the
failings of private provision, or a realistic assessment of the ability of
governments to regulate or control private providers. In our paper we have
tried to redress this balance, by looking in more detail at the available
evidence in favour of private provision. *
*Regarding the AMFm (the proposed scheme to subsidise private provision of
Malaria drugs), we are particularly worried about repeating the mistakes of
the past, where over and under-prescriptions of Chloroquine led to
widespread drug resistance.  Already resistance to Arteminsinin has been
found in Cambodia.  Given this is, as you rightly point out, ‘the last
effective drug we have against Malaria’, risking its distribution by
unqualified shop-keepers with minimal safeguards we feel is a mistake.  The
AMFm also ignores research by organisations such as **Médecins *Sans
Frontières showing how subsidisation of Artimisinin 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.* *



*This does not mean the private sector should have no role in the provision
of this medicine, particularly the faith sector and not-for-profits, in the
same way the public and private sectors are working closely together to
enable access to ART for those with HIV.  However, once again we feel the
option of strengthening  public sector channels of delivery, including the
use of community health workers and mobile clinics is being neglected in the
rush to pursue private sector strategies, in this instance as a result of
research that is weak. *

* *


*World Bank*

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.


*Oxfam*

*Oxfam remains concerned that the World Bank retains such an upbeat
assessment of the informal private sector, especially in contrast to its
damning assessments of public provision.  The informal private sector, is
too often a shop-keeper, selling out-of-date drugs or an otherwise
unqualified individual.   Too many informal private providers are a danger
to public health in too many instances and cause untold misery to millions
with false diagnosis and mistreatment every day. *

* *

*This does not mean that regulating or working with these providers is
impossible, but there is no doubt that it is an enormous task, and should be
realistically weighed up with the costs of expanded public provision, and
the competitive pressure this will put on private providers to improve their
standards, as has been the case in countries such as Sri Lanka.  Improving
the standards of the informal private sector will also  necessarily involve
limiting services to only those that can be delivered safely by unqualified
practitioners. Informal sector interventions therefore cannot substitute for
building and expanding comprehensive primary health care provision backed by
an effective referral system for more complex treatment and care. This is
critical if we are to reverse the appalling progress made to date on
reducing maternal morality rates. *


*World Bank*

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.


*Oxfam*

*Oxfam would agree with the World Bank that there is indeed an unprecedented
consensus amongst partners in global health about the need to scale up
services fast to meet the MDGs.  We would also agree that there is consensus
on a number of policy areas, for example the need to invest in health
systems and rationalise the hugely inefficient and Byzantine proliferation
of vertical health initiatives.  However, there are also very fundamental
differences of opinion as to what policies will work best to rapidly scale
up health in developing countries, both in terms of financing and in terms
of provision.  Private financing and private provision have not been
scrutinised or researched nearly enough to warrant the level of support they
receive. *



*With countries as diverse as the US and China planning significant scaling
up of public financing and provision in health, and a fundamental
recognition globally of the failure of the market in delivering equity,
there is a need for the World Bank to move with the times.  Given finite
resources and a worsening economic picture we cannot afford to waste a
single dollar pursuing policies that are risky and largely unproven.  Instead
we need advice and support on policies that have a track record of success
at reaching poor people with systems that work for all.*
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