PHA-Exch> Private sector role in health care: the debate continues....(2)

[Claudio Schuftan]

From: Ben Bellows bbellows at berkeley.edu

In the interests of finding common ground, on April 17th, Dr. Montagu and
colleagues responded in the BMJ to Oxfam's April 7 BMJ letter, which was a
response to Montagu and colleagues original critique (March 5) of Oxfam's
February report "Blind Optimism".

The link to the letters in the British Medical Journal is posted here:

http://www.bmj.com/cgi/eletters/338/feb16_2/b667#top

And copied below is Montagu and colleagues April 17th response to Oxfam's
April 7th letter, which was forwarded yesterday to this listserv.



"Agreements and disagreements with Oxfam"
Dominic Montagu, Richard Feachem, Neelam Sekhri Feachem, Tracey Perez
Koehlmoos, Heather Kinlaw, Richard Smith
British Medical Journal, 17 April 2009
http://www.bmj.com/cgi/eletters/338/feb16_2/b667#212353

We responded vigorously to the Oxfam report because we believe that it owes
too much to ideology and too little to evidence. We make our criticisms in
the hope that Oxfam will not prematurely adopt an extreme position regarding
public or private health services, but join in an objective search for
critical evidence on all systems of financing and delivery of health care.

The point made by Oxfam's chief executive concerning failed states and the
proliferation of private security firms is indicative of the ideological
predisposition that impedes an open debate regarding healthcare delivery in
developing countries. It is universally agreed that the provision of law and
order is a fundamental responsibility of the State and must be largely
provided by agencies of the State. The view that this may also be true of
health care is not accepted outside of the UK, and is increasingly being
challenged within the UK.

We agree with Oxfam regarding the proliferation of the private sector in the
absence of a well functioning and accessible public healthcare system. We
would add, however, that the private sector also proliferates in the
presence of well functioning and accessible public health care services.
This is demonstrated in most European countries, across Latin America, in
Thailand, South Korea, Vietnam, and many other countries at various income
levels.

Two of us are Britons, and it is our experience outside of Britain that has
made us realize the peculiarity of British organisations in being so
skeptical of the private sector. Elsewhere, the important role of the
private sector in health systems, in countries both with and without well
functioning state health programs, is widely acknowledged.

Public versus private provision is not a binary choice facing governments,
donors, patients, and global policy makers. We believe that the goal should
be the best alignment of public and private capabilities and strengths, to
achieve public policy objectives.

Regarding the specific issues of data analysis and interpretation that are
pointed out in our first letter, clearly we are analyzing the data
differently. We are pleased to note, however, that both we and Oxfam are in
agreement that there is no causal link between the size of the private
sector and access to health services.

We fully agree with Oxfam that attention and action is needed to provide
care to the more than fifty percent of children in developing countries who
receive no medical care at all when ill. We know that in both the poorest
and wealthiest quintiles, three quarters of children who receive health care
get it from the private sector. The difference is that 55% of the wealthier
children received care when sick, but only 33% of the poorer children. ,

To us, this inequity in access must be addressed by supporting all providers
- public and private - who can bring quality care to poor children.
Unfortunately the evidence, sketchy though it is, suggests that there is no
delivery system, public or private, that is doing this now. It is
disappointing to note that across the developing world, despite billions of
dollars of public subsidies and fully salaried government doctors backed up
by armies of nurses, clinical officers, technicians, and bureaucrats, public
systems have not outperformed a rag-tag bunch of private operators with no
subsidy or support from governments and donors. Public delivery must be
assessed through the same critical lens as private delivery, and the best
approaches pursued in each country according to context.

We do not suggest that private provision is inherently preferable to other
delivery models, or that private provision should be expanded. We recommend
that both public and private sectors should work together to achieve public
policy goals, harnessing the unique capabilities of each.

Significant rates of private provision are the reality in all developing
countries today, and calling for a statist revolution in health care, rather
than calling for improvements in the status quo, is not justified by
evidence. Despite being superficially attractive, people get hurt in pursuit
of extreme or ideological positions. Ignoring private care will not improve
the performance of the public sector or provide better access to good
quality services for the poor. Seeking to improve care by private providers
and better align private activity with public policy goals may not be sexy,
but it is right and responsible.

As our ends are the same we feel that debate and engagement on these issues
serves us all well. We join Oxfam in its call for more and better
information on the effectiveness of a range of health delivery models -
public, private and mixed - and for investment in those approaches that are
most effective at improving access to high quality services for those most
in need.
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