Privatisation in reproductive health services in Pakistan: three case studies

Abstract

Abstract

Privatisation in Pakistan's health sector was part of the Structural Adjustment Programme that started in 1998 following the country's acute foreign exchange crisis. This paper examines three examples of privatisation which have taken place in service delivery, management and capacity-building functions in the health sector: 1) large-scale contracting out of publicly-funded health services to private, not-for-profit organisations; 2) social marketing/franchising networks providing reproductive health services; and 3) a public-private partnership involving a consortium of private players and the government of Pakistan. It assesses the extent to which these initiatives have contributed to promoting equitable access to good quality, comprehensive reproductive health services. The paper concludes that these forms of privatisation in Pakistan's health sector have at best made available a limited range of fragmented reproductive health services, often of sub-optimal quality, to a fraction of the population, with poor returns in terms of health and survival, especially for women. This analysis has exposed a deep-rooted malaise within the health system as an important contributor to this situation. Sustained investment in health system strengthening is called for, where resources from both public and private sectors are channelled towards achieving health equity, under the stewardship of the state and with active participation by and accountability to members of civil society.

Résumé

La privatisation du secteur de la santé pakistanais s'inscrivait dans le programme d'ajustement structurel lancé en 1998 après la crise aigüe de liquidités du pays. Cet article examine trois exemples de la privatisation qui a touché les fonctions de prestation de services, gestion et renforcement des capacités dans le secteur de la santé : 1) sous-traitance de la prestation de services financés par les fonds publics à des organisations à but non lucratif ; 2) réseaux de franchise sociale assurant des services de santé génésique ; et 3) partenariat public-privé réunissant un consortium d'acteurs privés et le Gouvernement pakistanais. Il évalue dans quelle mesure ces initiatives ont contribué à promouvoir un accès équitable à des services de santé génésique complets et de qualité. L'article conclut que ces formes de privatisation ont, au mieux, assuré la disponibilité d'une gamme limitée de services de santé génésique fragmentés, souvent de qualité sous-optimale, à une fraction de la population, avec de médiocres avantages pour la santé et la survie, en particulier des femmes. L'analyse met en lumière un malaise profondément enraciné dans le système de santé qui a contribué sensiblement à cette situation. Des investissements suivis sont requis en faveur du système de santé où les ressources des secteurs public et privé doivent être canalisées en vue de garantir l'équité dans la santé, sous l'administration générale de l'État et avec la participation active et le contrôle des membres de la société civile.

Resumen

La privatización en el sector salud de Pakistán fue parte del Programa de Ajuste Estructural iniciado en 1998 tras la aguda crisis de divisas. En este artículo se examinan tres ejemplos de privatización que han ocurrido en las funciones de prestación de servicios, administración y desarrollo de capacidad en el sector salud: 1) la contratación en gran escala de organizaciones sin fines de lucro para la prestación de servicios financiados públicamente; 2) la prestación de servicios de salud reproductiva por parte de redes de franquicias sociales; y 3) la alianza de los sectores público y privado, que consiste en un consorcio de actores particulares y el gobierno de Pakistán. Se examina hasta qué grado estas iniciativas han contribuido a promover acceso equitativo a servicios integrales y de buena calidad de salud reproductiva. Se concluye que estas formas de privatización en el sector salud de Pakistán, como mucho, han hecho disponibles una limitada gama de servicios de salud reproductiva fragmentados, a menudo de calidad subóptima, a una fracción de la población, con pocas recompensas en salud y supervivencia, especialmente para las mujeres. Este análisis expuso un malestar profundamente arraigado en el sistema de salud como un importante contribuidor a esta situación. Es imperativo continuar fortaleciendo el sistema de salud y canalizar los recursos de los sectores público y privado hacia lograr equidad en salud, bajo la administración del Estado y con la participación y responsabilidad de los integrantes de la sociedad civil.

Key Words:

• reproductive health policy and programmes
• privatisation
• social franchising
• public-private partnerships
• Pakistan

Acknowledgements

This paper is a shorter, modified and updated version of a report entitled “Privatisation in health services and implications for sexual and reproductive health services: a case study of Pakistan”, prepared for and with funding from ARROW (Asia-Pacific Research and Resource Centre for Women), Kuala Lumpur, Malaysia, as part of its ICPD+15 monitoring project. Some parts of this paper have also appeared in an article entitled “Privatisation in SRHR: glimpses from some countries in South and South-East Asia. Arrows for Change 2009;2&3:4–6.

Notes

* “Capacity to benefit” refers to the extent to which health services benefit a population group. Populations with relatively good health are expected to have a more limited “capacity to benefit” as compared with those who are in poorer health. Capacity to benefit may also vary in two population groups with the same “level” of health when one population's health problems are more amenable to health service interventions than the other's.³

* Figures for the proportion of health expenditure by government are based on the revised WHO estimates in World Health Statistics 2010.⁵

* The Punjab Rural Support Programme appears to be a quasi-government body rather than a civil society organisation. It was registered in 1997 with a start-up endowment fund provided by the Punjab government. Three of its 12 board members are from government and the majority of its personnel, including the Chief Executive Officer, are officials seconded from government departments.¹⁶ (p.33)

* In addition to the four provinces with 105 districts, there are four federally administered territories, of which the Federally Administered Tribal Areas is one; it is divided into seven tribal agencies and six smaller frontier regions.

* According to the project's annual report for 2008–09, 1,150 students were enrolled during the three years 2006–08 in the course for community midwives.²⁴ However, in the evaluation report, only 174 community midwives were reported to have completed the course by mid-2009. The reasons for this huge discrepancy are not clear.