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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 10pt"><font face="Times New Roman">Human Rights Reader 206</font></span></p>
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<p class="MsoBodyText" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman"><b style="mso-bidi-font-weight: normal"><span style="FONT-SIZE: 12pt; LINE-HEIGHT: 150%">HEALTH SECTOR REFORM MEASURES: HAVE THEY WORKED?... AND WHERE DO WE GO FROM HERE?<span style="mso-spacerun: yes"> </span></span></b><span style="FONT-SIZE: 12pt; LINE-HEIGHT: 150%">(Part 2 of 2)</span></font></p>
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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">11. Let it be understood here that there is nothing inherently wrong with market-oriented reforms in health, <u>provided</u>:<span style="mso-spacerun: yes"> </span>a) They work in the direction of equity, as well as greater efficiency, b) they receive <u>no</u> government subsidies, and c) they comply with well monitored regulations set-up upfront.<span style="mso-spacerun: yes"> </span>But these prerequisites hardly exist anywhere at present --including in countries like China and Vietnam...</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">12. The bottom line is that some important, structural changes need to be enforced to get reforms in the health sector into a more sustainable track. Such a track has to lead to the outcome of assuring quality care for the prevalent health problems of the growing number of poor people worldwide.<span style="mso-spacerun: yes"> </span>Public hospital care, for example, has become unaffordable to the poor due to steep user fees and 'under the table payments'. Subsidizing such a system, instead of reforming it,<span style="mso-spacerun: yes"> </span>will only channel additional funds to the wrong (non-poor) recipients. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">13. HSRs can and have thus been used as crutches to pretend one is changing the system, when it is basically staying the course or even going backwards.<span style="mso-spacerun: yes"> </span>Historically, there is a non-accidental link between Structural Adjustment Programs, Adjustment with a Human Face and HSRs.<span style="mso-spacerun: yes"> </span>The link is actually a progression, one with a calculated internal logic, namely to apply the principles of the market economy to the health sector.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">14. The bottom line is that most current HSRs cannot address the constraints to equitable access to care faced by the poor. Not even with 'good targeting' --a concept we reject anyway since it does not address the determinants that keep people vulnerable generation after generation. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">15. Moreover, HSRs use some technical terminology with misleading imprecision (or bias).<span style="mso-spacerun: yes"> </span>Examples that come to mind are: </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">-"efficiency" (which is measured in economic terms only);</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">-"willingness to pay" (which is used in place of the much more real determinant: "ability to pay");</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">-"cost-sharing" (which is applied to regressive fee for service systems when the real issue is who is to pay more and who less or nothing).</font></p>
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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><b style="mso-bidi-font-weight: normal"><font face="Times New Roman" size="3">So, what would be more effective and sustainable?</font></b></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">16. Perhaps the best response to a part of this question is in another question: Why not ask the beneficiaries directly to respond to this question?<span style="mso-spacerun: yes"> </span>This is not an evasive response!<span style="mso-spacerun: yes"> </span>This response has the wisdom of accepting the fact that:</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">-localized viable responses will (and should) be multiple and varied; there is not one response that fits all (or even many) diverse situations; </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font size="3"><font face="Times New Roman">-our technical expertise can be put to a more effective use in a dialogue with community representatives;<span style="mso-spacerun: yes"> </span></font></font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">-communities do <u>not</u> always know best, so mistakes will be made; quickly learning from such mistakes can lead to more sustainability than applying schemes imposed from outside.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">17. Such a grassroots-centered approach calls for an unprecedented change in our priorities and in the way we operate.<span style="mso-spacerun: yes"> </span>The locus of control has to shift to beneficiaries for decisions that affect them directly on an everyday basis; and we ought to be instrumental in such a transition. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font size="3"><font face="Times New Roman">18. At the same time, equity oriented measures have to be implemented from the central level.<span style="mso-spacerun: yes"> </span>Some of the key elements of such reforms could be the following:<span style="mso-spacerun: yes"> </span></font></font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">Public rural health care services will still need to be primarily financed by governments (central and local).<span style="mso-spacerun: yes"> </span>Only up to 10-15% can be realistically expected to be raised by community contributions or rural health insurance schemes.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font size="3"><font face="Times New Roman">Financing public urban health care services in poor neighborhoods will probably also still need 50-60% government financing.<span style="mso-spacerun: yes"> </span></font></font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">Financing of health care will have to move away from regressive fee for service schemes and towards prepayment schemes where the whole population --not only the sick-- contribute.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">Direct and indirect progressive taxes must, therefore, constitute the financial base in an efficient, equity-oriented health care system.<span style="mso-spacerun: yes"> </span>Government funds can be used directly to fund public health services or can subsidize social health insurance schemes that will progressively cover the whole population. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">If communities do contribute to the financing of health care services, they will have to have more de-facto control over how the funds are used.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">Governments will have to gradually reallocate resources from rich provinces/districts to poorer ones according to a set of needs-based indicators. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">General tax revenues that apply more to the rich (e.g., taxes on luxury items, spirits, tobacco, or on assets, estate and wealth) will have to be considered more seriously as a source to bring in financial resources from other sectors to the health sector.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">Health staff will have to become more accountable to local communities.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">The use of existing resources should be rationalized and this will mean reallocating and sometimes shedding personnel and mobilizing more resources to outreach work outside the health stations.<span style="mso-spacerun: yes"> </span>In the medium term, health staff incomes will have to be brought up to minimum standards of living based on a system of monetary and non monetary incentives.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; LINE-HEIGHT: 150%; mso-list: l1 level1 lfo4; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">The roots of the twin trend towards self-medication and underutilization of<span style="mso-spacerun: yes"> </span>PHC facilities will have to be broken in each locality with ad-hoc measures taken with major inputs from the community itself; existing essential drug programs have to be made to work; drug companies (and clinical health staff...) have to be made to comply!</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">19. These are but a few of the central and local level options that need being looked at more carefully again.<span style="mso-spacerun: yes"> </span>But this listing is not the purpose of this review.<span style="mso-spacerun: yes"> </span>The idea is that the process opening the doors to a more participatory and empowering dialogue with beneficiaries (especially engaging women) has to come up with more of the answers and options. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">20. One is left to wonder how many of the more sustainable Equity-Oriented Health Sector Reform (EOHSR) measures quickly reviewed here have a chance of being seriously considered and implemented in the near future...<span style="mso-spacerun: yes"> </span>The bottom line here is that we remain convinced that tinkering more with the HSRs proposed so far will not do.<span style="mso-spacerun: yes"> </span>That is the sad reality.<span style="mso-spacerun: yes"> </span>Precious time is likely to be lost only to see the problems of inequity worsen.</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">21. We think that what is really needed is a "HSR of the public health care sector", not one overwhelmingly in the direction of the private sector (we ask ourselves why the former option is flatly left out in mainstream HSR discussions and only more absolute market-oriented options are explored/proposed).<span style="mso-spacerun: yes"> </span>The so often touted non-service-mindedness of the public sector is not a given.<span style="mso-spacerun: yes"> </span>We need to fix a system that --granted-- has many flaws.<span style="mso-spacerun: yes"> </span>But it also has many strong points!<span style="mso-spacerun: yes"> </span>Only when its core is streamlined and strengthened, can one consider contracting out some ancillary services to the private sector --provided there is a fair system of competition in place. </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><font face="Times New Roman" size="3">22. This brings us back full-circle to the old "political will" issue which is not really an issue of<span style="mso-spacerun: yes"> </span>"will"<span style="mso-spacerun: yes"> </span>as such:<span style="mso-spacerun: yes"> </span>it is an issue of<span style="mso-spacerun: yes"> </span>"choice" --of political choice.<span style="mso-spacerun: yes"> </span>And being an issue of choice, for the time being --short of an awakening of civil society initiatives and movements in many places around the world at about the same time-- the responsibility to move towards Equity-Oriented Health Sector Reforms is still squarely back on the lap of the respective governments.<span style="mso-spacerun: yes"> </span>Much advocacy and lobbying on our part, as well as work to neutralize powerful internal and external forces opposing the view here presented, are still needed in order to put the last first....</font></p>
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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="IT" style="mso-ansi-language: IT"><font size="3"><font face="Times New Roman">Claudio Schuftan, Ho Chi Minh City,<span style="mso-spacerun: yes"> </span><span style="COLOR: blue"><a href="mailto:cschuftan@phmovement.org"><font color="#0000ff">cschuftan@phmovement.org</font></a></span> </font></font></span></p>
<p class="MsoBodyText2" style="MARGIN: 0in 0in 6pt; LINE-HEIGHT: normal"><span lang="DE" style="mso-ansi-language: DE"><font size="3"><font face="Times New Roman">Goran Dahlgren, Stockholm,<span style="mso-spacerun: yes"> </span><span style="COLOR: blue"><a href="mailto:dahlgren38@telia.com"><font color="#0000ff">dahlgren38@telia.com</font></a></span> </font></font></span></p>
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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 150%"><b style="mso-bidi-font-weight: normal"><font size="3"><font face="Times New Roman">Postscript:</font></font></b></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font face="Times New Roman" size="3">Some of you may not fully agree with the alternatives we propose:</font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; mso-list: l2 level1 lfo2; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font face="Times New Roman" size="3">You may be of the opinion that proposing a bottom-up approach puts too much faith in attaining the many structural changes needed.<span style="mso-spacerun: yes"> </span>Further, you may think that when management of services is turned over to the local people, they do not become any more efficient or effective. <i style="mso-bidi-font-style: normal">{We, on the other hand, still do find evidence that when management of services is (really) turned over to the people, the added accountability and transparency <u>does</u> make them more efficient/effective than what they are now (may not be perfect, but better). Of course, this turning over of control has to be matched by government support of such a move including the reallocation of resources to back the new, truly decentralized structure}.</i> </font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font size="3"><font face="Times New Roman">You may contend the problem is not the structure; the root problem, you think, is pervasive apathy and corruption at all levels of the public service --from village to the top. Some of you may have become hardened to believe that people tend to act only when there is some compelling reason for it. And today, in many countries, there is absolutely no compelling reason for anybody to take their public responsibility seriously. In fact, you may think it is against their own self-interest to fulfill their public responsibility. <i style="mso-bidi-font-style: normal">{We do agree that people tend to act when there is some compelling reason for it; we remain convinced though that one has to and can create such compelling reason for people to take their public responsibility seriously using the right mix of (monetary and non-monetary) incentives and a shift towards local control. Devolving real powers to local populations, so that public servants are de-facto accountable to them, is therefore also crucial for this}.</i></font></font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font size="3"><font face="Times New Roman">Unfortunately, many of our colleagues have also come to believe that predominantly tax financed healthcare is a myth. (Citizens often end up paying twice, they say: first for the consultation at the public clinic and then again at the private practice of the public-clinic physician. This may be the reason for an increasing number of people going to the private sector services directly). <i style="mso-bidi-font-style: normal">{Against this, we contend that there is absolutely no evidence (but a lot of faith) that private providers and hospitals do a better job for low income groups or locate in areas of need rather than of potential profit… (only public hospitals serve disadvantaged groups or areas!). Let us face it squarely, as regards the private alternative, even if we could perfect all the 'market distortions' that hinder private services, the result would still be grossly inequitable and totally unworkable to care for the poor as we posited in the body of this Reader}.</i></font></font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .25in"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore"><font size="3">·</font><span style="FONT: 7pt 'Times New Roman'"> </span></span></span><font size="3"><font face="Times New Roman">Proponents of the HSRs we here criticized <u>are</u> interested in finding a workable solution to the major problems here exposed, granted. <i style="mso-bidi-font-style: normal">{But they define the current realities with what we think is a bias and an a-priori skepticism against the public sector.<span style="mso-spacerun: yes"> </span>That is the unhealthy attitude we think needs to be broken. The public sector in health still has the central moral, political, human rights and de-facto responsibility to be the guarantor of equitable health services being accessible to all its citizens; nobody can or will do it for the state.<span style="mso-spacerun: yes"> </span>Within this context, neither the public financing of private providers (contracting out of clinical and/or preventive services) nor the private financing (running) of public health facilities (as for example currently in some places in China) serves the interests of <span style="mso-spacerun: yes"> </span>poor people equitably. The profit motive stands in the way}.</i></font></font></p>
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<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; mso-list: l3 level1 lfo3; tab-stops: list .5in"><font face="Times New Roman" size="3">Finally, you may say that dogmas are just dogmas; and what we need are solutions. </font></li>
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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt 0.25in"><i style="mso-bidi-font-style: normal"><font size="3"><font face="Times New Roman">{Yes. But it is HSRs, as currently applied, that seem to be more driven by dogmas than by evidence.<span style="mso-spacerun: yes"> </span>From our perspective, and not claiming exclusivity, solutions start with a vision that leads to a mission…and visions of an enhanced role for public sector solutions, as we have here proposed, are not dogmas; they are viable <u>and</u> in the best interest of those we purport to serve}.</font></font></i></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font face="Times New Roman" size="3"> </font></p><b style="mso-bidi-font-weight: normal"><span style="FONT-SIZE: 14pt; FONT-FAMILY: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman'; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA">Important note:</span></b><span style="FONT-SIZE: 14pt; FONT-FAMILY: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman'; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA"> This article was written in 1998! It is astonishing how the issues brought up here are as current today as they were then….Would we have written it today, we would have added the human rights perspective. With what you have read in these Readers, you can perhaps add such a perspective…Anybody inclined to contribute?</span><span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Times New Roman'; mso-fareast-font-family: 'Times New Roman'; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA"><br style="mso-special-character: line-break">
<br style="mso-special-character: line-break"></span>