PHM-Exch> 'Direct health care by government best option' says World Bank Health Economist

[Claudio Schuftan]

From: Anna Marriott <AMarriott at oxfam.org.uk>

As part of Oxfam’s continuing efforts to promote discussion and
evidence-based debate on health financing and delivery in poor countries I
wanted to draw your attention to a recent article quoting the World Bank’s
Health Economist in India, entitled ‘Direct health care by government best
option’.

My colleagues in Oxfam India were surprised to read the article in The
Times of India this month suggesting that the World Bank – ‘the
organisation that started the ball rolling by first promoting privatisation
and then the public private partnership model’ – in health care, seems to
have had a rethink. The article continues that the Bank now appears to be
advocating direct provision of health care by the government as the best
option for India, especially in the rural areas.
http://timesofindia.indiatimes.com/india/Direct-health-care-by-govt-best-option/articleshow/6796093.cms

The Times article is based on a blog written by Rajeev Ahuja, Health
Economist for the World Bank in India. Ahuja highlights continued
disagreement about whether governments or the private sector should deliver
publicly funded health care. He goes on to argue that it is time to put the
public vs. private debate aside because….‘let’s face it, there isn’t any
good alternative to public provision of health care, especially in India’s
rural areas which don’t attract too many qualified private doctors’.
http://blogs.worldbank.org/endpovertyinsouthasia/seize-moment-now%E2%80%99s-time-reform-rural-health-care-india

Ahuja continues…… ‘Likewise, public-private partnerships to deliver rural
health services have only been successful where special conditions have
prevailed - such as strong commitment and leadership on the part of both
the public and private partners. But, since these conditions are difficult
to replicate across the vast expanse of the country, this doesn’t look like
a viable option, certainly not for the foreseeable future.’

The assertion by Ahuja that it is now most appropriate for the government
of India to go ahead with renovating, up-grading and expanding government
rural health facilities is one Oxfam and our partners in India would
support. We do not believe that the public sector is currently a shining
example of how to deliver decent accessible health care in India, indeed
due to massive disinvestment over the last few decades the public health
care system is unacceptably poor in many states. Rather, we believe that
the decision to increase government resources in expanding government
delivery of health care is to be applauded and used as an opportunity to
dramatically improve its performance. Especially as the evidence suggests
that Indian states that invest more in public health services have been
more successful at reducing rural-urban inequalities.(1)

Interestingly Ahuja’s arguments reinforce those made by Dr Mead Over of the
Centre for Global Development last year in relation to anti-retroviral
therapy in India
http://blogs.cgdev.org/globalhealth/2009/03/public-delivery-of-aids-treatment-in-south-asia-a-timidly-heroic-assumption.php#more-694
 Dr Over stated that for some health services, including ART, low quality
treatment may actually be worse than no treatment at all.  Dr Over went 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.”

Dr Over’s theory is supported by evidence from the Indian state of Kerala.
Here the quality of the public hospitals, whilst far from perfect, still
appears to put an effective quality ‘floor’ under the health services
provided by the private sector.(2) The theory would also be worth testing
in the state of Tamil Nadu where the public health system is now widely
regarded as outperforming that in Kerala. In many other states in India,
the poor quality of the public-sector health services means there is no
pressure on the private sector to offer anything better. The lack of
investment in public health services then has a disproportionately negative
impact on poor women who in India are the main users of unqualified
shopkeepers as a source of health information and drugs.(3)

Against all this it seems odd for the International Finance Corporation
(the private sector investment arm of the World Bank) to argue that
development of health care in India has been ‘heavily underwritten by the
private sector'(4), and to then use this as a foundation argument as to why
further private sector growth in health care should be encouraged.(5).  In
reality the proportion of existing care provided by the private sector
tells us nothing about whether the ‘right to health’ is being fulfilled. In
India, 82 per cent of outpatient care is provided by the private sector.
The number of first class private hospitals is rapidly increasing. Yet this
same system denies half the mothers in India any medical assistance at all
during childbirth. Indeed, 74 per cent of women who seek antenatal care in
India rely on their chronically under-funded public health system.(6)

Rajeev Ahuja’s blog provides some refreshing but measured optimism about
the potential future of India’s public health system. But as the Oxfam
supported campaign ‘Wada Na Todo’ rightly argue, progress of the scale
needed will never be achieved until the government of India reverses it’s
appalling track record of investment in health care and increases public
spending on health to at least 3 per cent of national income. This from an
incredibly low base of just over 1 per cent GNI http://www.wadanatodo.net/


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 want to sign up
to receive
these emails or to be taken off the email list please let me know at any
time in an email to


amarriott at oxfam.org.uk



Footnotes:
(1): Sen,G., Lyer,A. and George, A. (2002) ‘Class, gender, and health
equity: lessons from liberalizing India’ in Sen,G., George, A., and Ostlin,
P. (eds) Engendering international health: the challenge of equity
Cambridge: MIT Press
(2): Narayana,K. (2007) ‘The Role of the State in the privatisation and
corporatisation of medical care in Andra Pradesh, India’ in Sen, K. (ed.)
Restructuring Health Services: Changing Contexts and Comparative
Perspectives, London: Zed Books
(3) Lyer,A., Sen,G., and George,A. (2007) ‘The dynamics of gender and class
in access to health care: evidence from rural Karnataka, India’,
International Journal of Health Services 37(3)
(4) International Finance Corporation (IFC) (2007) ‘The business of health
in Africa: partnering with the private sector to improve people’s lives’,
Washington DC: IFC,
(5)  See Oxfam’s report ‘Blind Optimism: Challenging the myths about
private health care in poor countries’ for a fuller critique of the IFC’s
arguments
http://www.oxfam.org.uk/resources/policy/health/bp125_blind_optimism.html
(6) World Bank (2004), ‘World Development Report: Making Services Work for
Poor People’, Washington DC: World Bank
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