PHA-Exch> Private sector role in health care: the debate continues....

[Claudio Schuftan]

From: AMarriott at oxfam.org.uk AMarriott at oxfam.org.uk

I am very pleased to say that the debate instigated by the launch of
Oxfam's new paper 'Blind Optimism' on the role of the private sector in
delivering health care in poor countries continues to heat up.

The debate continues within the Centre for Global Development - you may
recall April Harding's critique of Oxfam's paper
http://blogs.cgdev.org/globalhealth/2009/02/oxfam-this-is-not-how-to-help.php
. More recently Dr Mead Over, a senior economist at the CGD, published a
paper on anti-retroviral therapy in India. In his own blog about the paper
Dr Over states that for some health services low quality treatment may
actually be worse than no treatment at all. This is when low quality care
not only provides fewer benefits for the patient, but also generates
substantial negative effects for the entire population, such as the
development of resistant strains of infectious diseases including
tuberculosis, malaria and HIV/AIDS.

Dr Over goes on to say “public sector delivery of ART can be justified not
only because it protects poor AIDS patients from catastrophic health
expenditures, but also because it might differentially “crowd out” the
cheapest (and therefore perhaps the worst) of the private sector AIDS
treatment. If this crowding out slows or postpones the development and
spread of drug resistant HIV, this is an important reason for preferring
public to private sector delivery.”
http://blogs.cgdev.org/globalhealth/2009/03/public-delivery-of-aids-treatment-in-south-asia-a-timidly-heroic-assumption.php#more-694

Also in reference to the private health care sector in India, I would like
to draw your attention to a new short video produced by Oxfam – ‘Queues,
Quacks and Chaos – The Reality of Indian Health Care’.
http://blogs.oxfam.org/video/20090223-queues-quacks-and-chaos-reality-health-care-india

Finally, since our last email, the British Medical Journal has published a
critical piece by Dominic Montague, Richard Feachem and colleagues.  This
inaccurately represented Oxfam’s position, saying that we are calling for
donors to cease all work with the private sector.  It also questioned our
evidence of what the private sector looks like in Africa by accusing us of
purposively distorting data. Oxfam has posted its response on the BMJ
website which is copied below.*
http://www.bmj.com/cgi/eletters/338/feb16_2/b667

We would like to continue to share information and evidence on this debate
about scaling up health care delivery in poor countries with you.  We
intend to send an email approximately once a month. If you do not want to
receive these emails please let me know at any time in an email to
amarriott at oxfam.org.uk

Kind regards
Anna Marriott
Oxfam GB



*Critique of Oxfam paper inaccurate, unconstructive and ideologically
biased
Barbara Stocking, Chief Executive, Oxfam GB
British Medical Journal, 7 April 2009
http://www.bmj.com/cgi/eletters/338/feb16_2/b667



A primary objective of our new paper Blind Optimism is to encourage and

advance an evidence-based debate on the appropriate role of the private

sector in health care delivery in poor countries. Not only does your

response detract from this important debate by misrepresenting the paper,

you incorrectly accuse Oxfam of purposively distorting the data to support

our arguments.


Firstly, we do advise against investing in risky and unproven private

-sector approaches to expand health care in poor countries. You are wrong

to suggest that this is the same as advocating that all engagement with the

private sector should cease. 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 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 in health care, 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.


Secondly, you also claim that Oxfam uses data from DHS surveys to imply

when poor countries have a large private sector this causes greater overall

exclusion from health care. This is not true. We do say there is a

correlation but we do not claim causality. In fact we state clearly in the

paper that: "…Although this correlation does not clarify whether high

levels of private participation cause exclusion, it at least suggests that

the private sector does not in general reduce it…"


Your final point questions our analysis of what the private sector looks

like for poor people in Africa, which finds that 36% of private provision

is just small shops selling drugs of unknown quality. You claim that we

deliberately exclude countries that don’t support our position. Instead we

compared only those countries where survey data was directly comparable(1).

Your calculation includes countries with differing data categories, for

example countries that do not include a category for private doctor. By

doing this you are not comparing like with like and this distorts your

findings. You also appear naively optimistic with your suggestion that

seeking care from a private facility always means seeing a “doctor or

better”. Even if we assume, as you do, that every private facility in

sub-Saharan Africa has a qualified doctor or better, using the comparable

data the total proportion of the poorest quintile that seek private care

that get to see a private doctor is still only 29%, not 37% as you suggest.

More importantly, you also avoid addressing the most pressing issue we

highlight; that over half of the poorest children in Africa do not receive

any health care at all – public or private. The real question is how we are

going to reach them, and here the evidence for promoting private sector

expansion is very thin indeed.


We do agree with you that the private sector in health often proliferates

in the absence of a well functioning and accessible public health system.

This can be compared to the way private bodyguards expand in a failed

state. Does this mean we abandon the public health system or does it mean

we need to reverse decades of under-investment and focus on making the

public sector work better? Governments have historically intervened to

provide health services precisely because the market fails to deliver

decent health care for everyone. In more successful countries government

provision of decent health care free of charge has played a direct role in

crowding out the worst elements of private sector provision. A recent paper

by Dr Mead Over from the Centre for Global Development on anti-retroviral

therapy in India(1) argues that we should take this government role

seriously. The author states that "public sector delivery of ART can be

justified not only because it protects poor AIDS patients from catastrophic

health expenditures, but also because it might differentially 'crowd out'

the cheapest (and therefore perhaps the worst) of the private sector AIDS

treatment"(2).


Whilst we appreciate there are many different points of view in this debate

your critique of Oxfam’s paper is unfounded and inaccurate and your tone

unfairly and unhelpfully dismissive. We would urge you to take more time to

look at the evidence of what works for the poorest people and enter into a

more constructive debate.


(1) Mead Over. 2009. "AIDS Treatment in South Asia: Equity and Efficiency

Arguments for Shouldering the Fiscal Burden When Prevalence Rates Are Low."

Working Paper 161. Washington, D.C.: Center for Global Development.

http://www.cgdev.org/content/publications/detail/1421119/


(2) http://blogs.cgdev.org/globalhealth/2009/03/public-delivery-of-
aids-treatment-in-south-asia-a-timidly-heroic-assumption.php
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