PHM-Exch> From Nyala, Darfur.

[Claudio Schuftan]

>From massimo serventi <ser20 at hotmail.it>

*Private healthcare in poor countries*

Private healthcare began entering developing countries in the 1990s, when
healthcare systems of
many poor countries were “convinced” to reduce public expenditure and to
introduce forms of
payments for the users of healthcare services (user fees).

*Foreword*

In Nyala (Darfur), where I am working, Private Healthcare (PH) is very
popular. Nearly all
physicians work privately as well as in the public sector. Within the city
public hospital there is a
private facility that provides a service of medical advice, a sophisticated
laboratory and an X-ray
facility with CAT scan service. It is owned by the previous governor of
South-Darfur and the same
specialists of the state hospital work there.

The “in-Sudan-you-pay-for-everything” trend concerns services that should
come free.
Pregnant women often pay for their Pregnancy Health Card and iron/folic acid
capsules. The baby
is nearly always delivered at home (80%), where the well-off have a trained
midwife or the less
well-off have a TBA. A referral to the central hospital will cost €30, plus
the cost of infusions
and/or medicines. Children (under five) pay 30 cents per visit, the
prescribed drugs must then be
purchased. Only vaccinations are free of charge.

*Research*

For the documentation of this article I searched the Internet under ‘private
health care in poor/
developing countries’. You can find everything, those who write in favour of
it [1,2,3] and those
who write against it [4], while others analyse the current situation and
refrain from any specific
judgment [5].

Some conclusions appear to be fairly shared :

1. PH is clearly expanding in the world. In 2005, 60% of the funds spent on
health care in
Africa was spent on PH. In China, 5 years after the reforms that opened to
PH, vaccination
dropped by 50% and diseases such as TB, measles and polio began to spread
again. There
are also marked inequalities: in Paraguay, 5% of physicians work in the
private sector, while
in Korea 86%. Costa Rica has the lowest percentage of private beds, while
the highest is in
Korea. Lebanon, whose private coverage is one of the highest in the world,
spends more
than twice as much as Sri Lanka on health care but achieves worse results in
terms of
child and maternal mortality. Chile has a largely private healthcare service
and one of the
highest rates of births by Caesarean section in the world.

2. Achieving a clear separation between public and private is not easy:
there is a lot of
intertwining between the two sectors and definite data cannot be achieved.
Every year,
WHO publishes data on physicians, nurses, paramedics, hospitals and beds in
State-owned
services, but no figures refer to private services. Many physicians around
the world work in
both the public and private sector. In general, Latin America has the
highest percentage of
exclusively private physicians, Africa the lowest.

3. The expansion of PH, of its influence on public healthcare and its
implications on people’s
health does not seem to attract the interest of observers and policy makers.

4. It appears that PH proliferates in proportion to the economic growth of a
country. This
applies more to the number of private physicians than to the number of
private beds
(there are more public beds). The level of urbanization has a positive
correlation with the
expansion of private healthcare, also due to employed people in cities
having some forms
of healthcare insurance. The same applies to the level of education and life
expectancy: in
those societies where these values are higher, private healthcare is more
used. And also,
countries with low child mortality use private services more. As to
physicians, where there
is better public healthcare there are fewer private physicians, while the
same correlation
does not hold true in terms of the number of beds.

5. PH is very much present in outpatient clinics and less in hospital beds,
which means that
there are many private outpatients services while hospitals are more likely
to be public. This
is particularly true of Africa.

6. Private Healthcare began propagating in developing countries in the
1990s, when the World
Bank and other international organizations stated that the healthcare
systems of very many
poor countries were a failure, and they were ‘convinced’ to reduce
healthcare expenditure
(especially by means of draconian cuts of hired staff) and to introduce
forms of payments
for the users of healthcare services (user-fees).
In 2007, the World Bank, together with the Bill&Melinda Gates Foundation and
McKinsey^Co
produced a report “The Business of Health in Africa: Partnering with the
Private Sector to Improve
People’s Lives” and announced a plan of investments and loans (1 billion
USD) to finance the
growth of the private sector in Sub-Saharan African Countries [1].

Arguments in favour were as follows:

•

private medicine is already very much developed: excluding it is
unconceivable so it must
be regulated and involved in the provision of healthcare services

•

investments in the ‘private sector’ would bring money also to the poor
public coffers

•

the private sector offers better results at lower costs: it is less
corrupted.

Against these statements it is worth noting Anna Marriott’s from Oxfam[4],
who (the only voice
against it) countered one by one all points favouring the propagation of the
private medicine. Her
conclusions are: “The private sector will continue to exist and offer
potential benefits that must be
capitalized. But there is no doubt that in order to ensure fair and
universal access to healthcare
treatments, the public sector must play a primary role. The public sector
must be supported
and given the opportunity to function well: this is the most effective
approach to reduce PM
proliferation and influence”.

Personal remarks.
Paediatrician with 28 years work experience in 4 African countries
(Tanzania, Uganda,
Mozambique and Sudan) and 2 Asian countries (Sri Lanka and Afghanistan).

1. PH is very much present in outpatient services, where children are the
most numerous
patients accounting for more than 50% of visits. The paediatrician is
therefore
more ‘interested’ by this aspect.

2. PH is not ‘neutral’: in other words, it is better if it is available
since more care does not
hurt anyone. In fact, since it is connected to profit, an outpatient clinic
for children must
prescribe more to justify to the mother the cost of the service and to
receive money from
the sale of drugs and laboratory exams (which are often sold in the same
outpatient
clinic). This applies also to the ‘religious’ outpatient clinics that only
request a minimum
payment (because they can often get medicines free of charge) but which must
always
prescribe a drug. In any case, the mother had to pay for a ‘disease’ that
perhaps might have
been ‘treated’ by means of simple, cheap remedies such as rehydrating salts
(diarrhoea),
drops of water in the nose (rhinitis), Paracetamol syrup (viral fevers, the
most frequent)
or simple food recommendations. Prescribing and selling expensive drugs
(antibiotics) to
children that do not need them is like depriving their mothers of money they
could spend on
food, and this is even worse in those places where the most frequent cause
of death is child
malnutrition.

3. Profit making, and also ‘missionary-for charity’, PH drains healthcare
staff from the
reservoir of the State Healthcare Service (HS), that is , it deprives the
health service of
valid people, often taking them away from country areas which are poorly
served. This
development also affects staff hired by international NGOs: WHO recently
drafted a code
of behaviour with the aim of regulating this issue and reduce the drainage
of healthcare staff
from State-owned facilities [6].

4. The goals regarding healthcare (MDGs) can be achieved without the action
of PH. Child
mortality has and is being decreased by actions that do not pertain strictly
to healthcare and
treatment (vaccinations, public hygiene, water, nutrition, healthcare
education). Mortality
among babies and the benefits of safe pregnancy and delivery and the early
identification of
the first signs of sepsis in the newborn, certainly do not get any help from
the private sector.
Private facilities for safe deliveries are almost always in the cities and
they serve the richer
classes in the population. Pregnancy monitoring, family planning, prevention
of sexual
diseases including AIDS, TB treatment and control, distribution of treated
mosquito nets
are all actions that pertain to the public domain. True, malaria treatment
and prevention also
gain benefit from drugs and mosquito nets sold on streets.

5. Private pharmacies appeared years ago in the cities, and now they are
expanding into
the outskirts: they are a safe source of income. They must be subject to
government
rules but in fact they work in full ‘autonomy’ and ‘deregulation’. Given
their constantly
increasing number, we can be certain that there are no pharmacists behind
the counter. They
are filled with all sorts of drugs (whose quality is uncertain and rarely
ascertained) and OTC
products. In Afghanistan, the outpatient clinic has a pharmacy attached:
first they prescribe
the medicines and then they sell them. OTC products are of all sorts, from
herbal teas to
carbonated waters for babies with colic to ‘tonics and appetite stimulators’
for children (very
popular in India). The world production of useful drugs for poor countries
has not yielded
any positive results so far [7]. Here in Nyala, in the very many private
pharmacies, products
to lose weight (!), sachets of seaweed salt and pills, multivitamins and
‘tonics’ are displayed
prominently (and therefore used). These ‘drugs carry along with them’ other
‘luxury’
products, for example formula milks which in Afghanistan are easily
prescribed at the first
sign of a problem with breast feeding. UNICEF initiatives: ‘exclusive breast
feeding for 6
months’ and ‘breast feeding for 2 years’ lose their meaning in cities where
formula milks
are sold and any type of OTC drugs ‘useful’ for the child’s health.

6. Non profit hospitals are the most popular form of private sector in
Africa. The mission
expressed by these hospitals is peculiar: offer services to poor people that
they do not
get from public facilities. In fact many of them have become private clinics
where every
service is paid, including paediatric visits and deliveries. One example is
the Aga Khan
hospitals. Many others have gone from initial support from Europe that would
have allowed
them to keep fees fairly low, to a gradual fund reduction. To survive, many
centres have
been obliged to raise their fees, make patients pay all sorts of services
and finally select
patients on the basis of their income. Attempts to pay overheads by means of
good quality
specialist clinics failed: in reality it is sufficient that the specialist
(usually a European)
returns home for the specialist clinic to be closed down.

*Conclusions*

PH exists and is expanding, in the wake of global liberalism that permeates
the whole world,
including poor countries. The World Bank that triggered this process years
ago is now
reconsidering it [8]. PH has almost no influence in achieving the MDGs and
PHC values [9]. I
believe it cannot be regulated and/or involved in a process of global and
fair healthcare; the aim of
achieving profit results in an implicit conflict of interests: more health
for people (today) means less
money (tomorrow). Hence the absolute lack of any type of prevention
supported by PM. Children
and pregnant women, who are the most vulnerable population groups, are also
the least ‘treated’ by
PH. Or rather, …. children are treated, but badly, without respecting WHO
guidelines, with drug
abuse and misuse. Types of healthcare insurance are in their early stages
and only relate to very
narrow bands of the population who are already privileged. Farmers, who
account for 70-80% of
Africa’s population, certainly do not have healthcare insurance. Methods of
contracting out, that is,
assigning PHC services, or service packages to local NGOs, are interesting:
in Afghanistan I saw
them function well, though my experience was limited.

Massimo Serventi, paediatrician.

Ser20 at hotmail.it


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