Who has responsibility for health in a privatised health system?

The world economy has been controlled by neoliberal economic policies and practices in the absence of an effective alternative for more than half a century. Neoliberal economics has penetrated not only how commerce and finance operate, but also the provision of almost every form of public services, including health care. As Joanna Mishtal observes in this journal issue, neoliberals have an aversion to public funding of services. That aversion has a strong hand in global health policy; the consequences are the subject of this and RHM's next journal issue in May 2011. In characterising what these papers reveal, the perspective I start with is that we live in a world where there is so much superfluous wealth being produced that no one should still have to live in poverty. Yet poverty remains endemic – in 2008, 2.6 billion people were living on less than US$2 a day¹ – and the poorest are bearing the biggest burden of ill-health.

Public sector health services are struggling in many countries and for complex and myriad reasons. With neoliberal ideology guiding public policy, we have reached a point where it is now almost assumed that governments cannot shoulder all the responsibility for public services, including for health, precisely because so many have failed to do so adequately. Yet, some countries have succeeded in steadily expanding and improving their public health care services, including for sexual and reproductive health care, and that includes both high-income and middle-income countries, ranging from Britain, France, Netherlands and all of Scandinavia, to Thailand, Brazil, Mexico, Viet Nam, and even poorer countries such as Sri Lanka. This is often not acknowledged, nor have the ways in which and reasons why these countries have succeeded been widely understood, let alone emulated.

Why have most governments in poor countries not succeeded in providing good quality health care for their populations? Two simple reasons jump off the page in the literature on expenditure on health: first, countries have failed to invest enough money in people and resources. Thus:

“WHO estimates the minimum annual cost [of meeting health needs] at US$40 per person, excluding basic survival needs. In 2001, in Abuja, Nigeria, African heads of state pledged to devote at least 15% of national budgets to the health sector. Yet, in 2007, the average per capita government health investment in Africa [was] US$34, with a mean 9.6% budget allocation (compared with US$1374 and 17.1% in the Americas). This includes 15 African countries that invest as little as US$2–10 per capita, which cannot begin to meet the population's health needs. Many low- and middle-income countries, moreover, reduce domestic health spending for every dollar they receive in foreign health assistance.” ²

Failure to invest enough, then, is the obvious answer, either because the funds do not exist or because other expenditures are given greater priority. Added to that is the reduction in what is already inadequate domestic health expenditure when external aid or loans are provided. This opens countries to two problems: first, external funders can exercise control over countries' policies and practice, and second, they will face massive deficit problems when external aid is reduced or withdrawn, which it almost invariably is. This is the situation currently facing Viet Nam as regards its family planning programme, for example, as described in this journal by Drake et al. As it has attained so-called middle-income status, Viet Nam is facing a deficit of €33 million for contraceptive supplies, as the two major donors of these supplies have withdrawn this form of aid altogether. And they are not alone with this problem.

But there is also a third reason, which is that most governments have not had a free hand in their own health policy decisions for at least several decades. Countries with low-income economies in particular have been controlled by conditionalities placed on loans and development aid and by global trade agreements that are stacked against them, in which they have been required to “open up” or “liberalise” their health systems and other public services to privatisation.

What happened in China, described in the paper here by Gao et al, is typical of what has taken place and continues to evolve in many countries, rich and poor:

“Local government, rather than the central government, became responsible for funding health care. In most places, especially the poorer areas, however, local governments have not been able to cover fixed hospital costs, and hospitals have had to charge patients to make up the difference. In 1985, central government decentralized hospital management, giving hospital directors more autonomy over personnel and finance issues. To increase income, to compensate for the inadequate investment by local government and to survive, local incentives were put in place to encourage staff to work more effectively and raise revenue. These not only made the staff work harder, but also encouraged them to over-treat and over-prescribe both high technology examinations and medications. Areas such as public health and maternal and child health (MCH) care services were neglected because they did not generate a profit.”

Privatisation in health care

The intention behind privatisation may originally have been a rational and bona fide one, and there is no denying the fact that so many governments have failed to do what they signed up for. Health indicators even 50 years ago were appalling in many parts of the developing world. The aim was, at least according to the rhetoric, to help countries improve population health. But can neoliberal health economists say they are proud of the outcomes that privatisation in health care has brought? Can they claim that neoliberal economic policies have succeeded in bringing about equitable economic and social development, well-trained health workers and well-staffed functioning services? Have they led to well-funded and well-governed health systems, let alone equity in access to good health or good quality, universally accessible, affordable, available health care?

The answer is at best equivocal. Change there has been; and certainly many improvements in many countries, though every in-depth study shows huge inequalities both between and within countries. It would be instructive to see comprehensive analyses, country by country, of the cumulative monetary cost of improvements in health and health care over the past several decades, in order to assess whether neoliberal policies have been the best possible way to go. Consider, for example, countries where vast amounts of donor money have been expended since 1980 with barely any sign of improvements, e.g. in maternal mortality ratios?

I believe it is an abuse of power by the World Bank and its partners to exercise control over international trade and national economies and impose Bank-defined health care policy on the countries they give money to. With its overweening emphasis on neoliberal health economics, the Bank has systematically sidelined the World Health Organization, which is the inter-governmental agency with a public health remit, and the World Health Assembly, the annual meeting of health ministers from all countries, which aims to develop global policy on health and agree how best to implement it, a unique institution.

At the individual level, neoliberal health policy has turned people with serious health care needs from patients into clients and consumers, under the pretence of offering them a “choice” of health care provider – instead of fulfilling their rights, most importantly their right to health. At the same time, both rich and poor, and strong and weak national health systems have been forced to become markets, which (if what is published here is any measure) seem to become increasingly fragmented the more and the longer they are privatised.

Sundari Ravindran has defined privatisation in health care as follows:

“Privatization refers not to the existence of a private sector in health, which is a universal phenomenon. It refers to deliberate interventions through policies and funding support to expand private sector provision of health care services; to introduce or expand private financing of health care (e.g. out-of-pocket expenditure, private insurance) and other market mechanisms within public sector health services; and to the gradual withdrawal of the state from taking responsibility for universal access to health care services.” (From a paper by her and Sharon Fonn, delivered at Repoliticising Sexual and Reproductive Health and Rights, Langkawi Malaysia, August 2010, to be published by RHM in 2011)

And in a paper in this journal issue, quoting from Albreht³, she explains:

“Privatisation of public sector health services may be defined as the transfer by a government of ownership and/or government functions from public to private for-profit or not-for-profit organisations. Privatisation may happen in one or more of the government's functions, including financing, service delivery, capacity-building, management and investment.”

Privatisation, then, is about governments handing over responsibility for the health of the people of their country to a whole range of different organisations and agencies, who may or may not work together, and who may or may not agree to and then implement a common plan to achieve a set of coherent, comprehensive public health goals and universal coverage. Rather, by definition, as private entities these organisations and agencies will do their best to develop their own “market segment” and serve “their clients”. Even with the best of intentions, they will not have responsibility for the health of the population as a whole. Neoliberal health policy tasks government with a stewardship role in ensuring that comprehensive programmes are instituted, but health ministries may be so weak that they are unable to play that role effectively, which is another reason why their public health systems are weak as well. This becomes even more problematic where national responsibility for health service delivery has been devolved to local government, and where systemic underfunding and lack of management expertise are often the rule rather than the exception. As I see it, this is a surefire invitation to fail.

Little has been written on these issues in relation to sexual and reproductive health services. RHM has published a number of papers where privatisation in health care has been noted, e.g. in antenatal care. Moreover, abortion services are among the most privatised services for women, legal or illegal. But those who study health systems and policies tend to avoid specific types of health services, and discuss health systems as a whole. Yet experience of what happens with sexual and reproductive health services at country and local level shows that despite a proven high burden of disease, priority attention to these services is often lacking unless they are able to bring in enough income, or better, a profit.

Papers in this journal issue – from Poland, Indonesia, China and Pakistan – indicate that privatisation is not geared to help weak public health systems become stronger, and may be exacerbating existing inequalities in the delivery of health care, so that the poorest sectors and rural populations, as well as women, may continue to be the least well served.

“The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease.” ⁴

Myths

Several myths about public vs. private health care need to be challenged. One is that public services are completely accessible for the poor because they are free, when in fact in most countries they are not free anymore, if they ever were, primarily because the public sector has not been allocated enough money to run them free of charge at the point of care. Thus, even though public health services are meant primarily to serve the poor and private services to serve the middle class and the rich, it may be that at least some public services are also too expensive for the poor to afford, particularly in a health emergency. In many countries, most services in the public sector are funded in large part by user fees (a widely implemented though now discredited and disowned World Bank policy).

While user fees in themselves are mostly not often very large, except in a few countries, the expense comes in when the patient is asked to buy drugs and supplies from a private pharmacy and/or diagnostic services from outside the public facility (which may not be available in the facility because the person in charge is not there, or the equipment is not functioning, or it may take a long time to get tests done and get results). What is often covered free under “universal coverage” is only the most basic services, and the patient may only have the option of going for free services to a facility considerably farther away (with no guarantee that the equipment will work or the personnel will be in post there either) or to go to a private provider or consult privately, paying a fee to the public provider (TK Sundari Ravindran, personal communication, October 2010).

To help people to offset or cover these costs, some governments have developed subsidies, e.g. payments for attending hospital for delivery, as Gao et al report from rural Shanxi Province in China. Community health insurance schemes have also been tried, but neither of these types of schemes has managed to cover either the population who need it or cover enough of the costs involved. (See, for example, the summary in the Round-Up on privatisation about Mutual Health Organisations in Benin, where it is thought that most people cannot afford to join to get such insurance.) Studies abound of what happens when there is a health emergency in a poor family, such as the need for a caesarean section, and how families may be put into debt as a result. When public health systems are starved of resources, as Mishtal points out has happened in Poland:

“The impoverishment of the health system facilitates corruption, which fuels unequal access to care. Polish physicians operate a vigorous system of informal cash payments that allow patients to skip waiting lists and get better quality care. Although informal payments were not uncommon during state socialism either, bribery has intensified so greatly since 1989 that the practice is now virtually mandatory, making many services more readily available to the wealthy than the poor.”

It seems this is a global phenomenon. Gao et al found it in hospital birthing services and, as reported in the Round Up on privatisation, in Zimbabwe, of 1,024 people living with HIV interviewed in four provinces, 73% had been asked by health workers to pay bribes to receive care, of whom 57% were trying to access drugs, 24% diagnostic services and 19% to be enrolled in HIV programmes. One third of those who were asked for bribes were unwilling or unable to pay, and 63% of them were turned away or given inadequate services.⁵

Another myth is that private sector health services provide more and better services and better treatment and care, when it seems that very often they do not, because the health professsionals in them may not be well trained or may not have sufficient resources to provide good quality care, or may not even see enough patients to maintain or develop their skills. Schiavon et al found poor quality of care, in spite of high fees, in many small clinics providing abortions privately in Mexico City, for example. They encountered the continuing (outmoded) use of D&C, poor pain management practices, unnecessary use of ultrasound and general anaesthesia, and women being made to stay overnight who should have been seen as day cases.

A third myth is that there are only two sectors in privatised health systems. In fact, there are three, especially (but not only) in developing countries:

“The private health sector… consists of both formal care in Westernized institutions and facilities (such as clinics and hospitals) and the informal lay sector, including self-medication with medicines from pharmacies, dispensaries, and street vendors; herbal or alternative medicines from traditional healers; and folk or quack treatments.” ⁶

The continuing recourse to home deliveries with a traditional birth attendant among women who say they would deliver in a facility if they could, or who reject going to a clinic or hospital because the conditions are so poor, is an important example of the failure of both the public and private formal sectors to make delivery and post-partum services, let alone emergency obstetric care, accessible and affordable in the world's poorest countries, or in the more isolated parts of countries. Much of sub-Saharan Africa and south Asia are the biggest examples of this failure.

Thus, any study of what is happening in health systems needs to include the informal sector as part of “private” care, since so many poor people depend upon it, especially for medicines. Formal private sector services may see only a small proportion of patients from the poorest populations, as formal private sector care may be completely out of reach for the great majority.⁶

One of the reasons why the informal sector is still going strong in rural areas is that most formal private sector care tends to be located in urban areas, as Sciortino et al show in Indonesia and Sundari Ravindran shows in Pakistan. People who turn to the informal private sector may often not get the treatment they need, however, and then have to seek care from one of the other sectors, as Grossman et al found with a small number of women in the USA who used over-the-counter herbs and drugs to self-induce abortions, and when they didn't work, then had to seek clinic abortions. RHM has published several papers about the extensive pathways women may travel before getting the care they need, seeking informal care first because it is cheaper but then having to pay more in the end.⁷

Are social enterprises in health a “third way”?

Is there an alternative? The charitable, or non-profit, private health sector is thought to represent a kind of “third way” in health care, being different from both the public sector at its poorest and most uncaring, and the profit-making private sector with its pursuit of high fees and rich clientele, being somewhere in the middle, needing to make money but with socially motivated goals and intentions.

There is a growing subset of private health organizations that are being called “social enterprises”, described by Bhattacharyya et al as having “developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models”.⁴ These social enterprises see themselves as innovators and as:

“…organizations who develop simpler and cheaper services that enable the participation of new sets of consumers previously excluded from conventional markets [and]… which aim to develop models of pattern-breaking social change that can scale up easily, which can include novel financial strategies.” ⁴

However, when Bhattacharyya et al set out to study the best of these organisations, what they found was that:

“Despite being well-known, information on the social impact of these organizations was variable, with more data on availability and affordability and less on quality of care.” ⁴

One of the social enterprises they describe is Greenstar Social Marketing Pakistan, which Sundari Ravindran also examines in her paper in this journal issue in far greater depth, whose achievements are patchier than first meets the eye.

Bhattacharyya et al also use the Population and Community Development Association (PDA) in Thailand as an example of a social enterprise, which has indeed successfully used innovative means to address subjects that used to be taboo, such as contraception and HIV awareness and have “achieved unprecedented success in garnering positive public attention”. They describe the PDA's success as follows:

“Their social marketing initiatives include “Condom Nights” and “Miss Anti-AIDS Beauty Pageants” in the red light districts of Bangkok. PDA has also established training and peer education programs that focus on behavior change in the country's schools, prisons, sex industry and the public in general. Their condom distribution network penetrates one-third of Thailand. Their family planning effort contributed to the decrease in the population growth rate in Thailand from 3.3% in the 1970s to 0.6% in 2005. The organization developed a national AIDS education program in partnership with government, contributing to Thailand's 90% reduction in new HIV infections in 2004.” ⁴

According to PDA's own website, most recently, they have “aggressively approached the problem of rural poverty by empowering the poor through the Village Development Partnership, which established a community-owned Village Development Bank for the purpose of microcredit… [PDA has] 800 staff members and is working with over 12,000 volunteers. PDA has 18 regional development centers and branch offices located across 15 provinces in rural Thailand. It also manages operation of the Lamplaimat-Pattana Primary and Secondary Schools, which is revolutionary, private education for the poor. PDA has pioneered sustainable grassroots endeavors, marked by extensive villager involvement not only as beneficiaries, but also as partners, planners, managers, and leaders. PDA's programs are based on the belief that local people are best suited to be an equal partner in shaping and sustaining their own development.” ⁸This is hardly a description of an organisation involved in privatising of health care, however. It is certainly true that the innovative kinds of work that NGOs such as PDA do less often begin as government-led initiatives, but rather arise most often from the NGO sector, or at least from the NGO sector as it existed in the past. Today, however, small, innovative national or local NGOs are threatened with extinction. They are being replaced by a new generation of NGOs which, in spite of being non-profit-making, behave like businesses and in the current privatised health care climate seek to capture as a big a share of the “market” as they can, plowing the sometimes considerable fees they charge (which may still be less than private for-profit fees) back into their own services so as to expand and make them grow. These large, often first-world controlled new-style NGOs are carving out territory in a growing list of developing countries thanks to donor funding. They are acting same way as for-profit health companies in many places, increasingly in competition with each other, and are a central motor in the privatisation of health systems.

Sciortino et al offer a sobering example from Indonesia of how the charitable aims of a non-governmental health care provider can be undermined by the need to compete in a rapidly privatising health system. This is their analysis of the changes in the services of Muhammadiyah, a large Islamic charitable health service provider:

“In order to survive and thrive amidst private and public competitors, Muhammadiyah's primary care units, mostly consisting of maternal and child health centres and maternity clinics, when not closed altogether, have been directed toward providing curative hospital services, and more expensive and sometimes unnecessary treatment. A shift in the patient population away from the poor has also occurred, as market pressures transform this charitable enterprise into a commercial one, prejudicing reproductive health care and reducing access for those most in need.”

PDA, in contrast, did not develop as part of systematic attempts to privatise family planning or HIV prevention activities. Its aim, from the start, was to support the government's public health policies. Indeed, Thailand is one of the few countries outside the developed world where the public health sector has succeeded in achieving near-universal health care coverage since 2002, financed through taxation based on income level,⁹ in a health system that is far more equitable than most. Britain's National Health Service too has been financed through taxation since it was set up at the end of World War II, when the country was on its knees financially due to the war. The burden of disease uncovered after it began to provide free care is barely remembered, but puts dealing with today's health problems in a different perspective. Knowing this, we should reject claims that a national health service is neither affordable nor feasible, when it is above all a matter of making it a national priority and putting in the human and other resources needed to make it succeed.

National demonstration in support of public services, London, May 2010

Can and should privatisation be reversed?

Unless governments become capable of the stewardship role they are being tasked with, and unless the public sector is funded sufficiently to meet the needs of everyone who is unable to access private services of any kind, whether charitable or for-profit, the informal sector will continue to pick up the pieces, and privatisation will fail to lead to the right to health. It is a rare study that reports successful regulation of the private sector by government, and I suspect it is even rarer for the private health sector to commit itself to helping the public health sector become stronger instead of trying to take its place. The private sector in health will not choose to wither away. It must be rejected and ejected. I believe privatisation in health care, like user fees, will be seen in the not too distant future as another failed neoliberal policy, and public health systems to be an inappropriate area for the principles governing trade and private enterprise of any kind to assume control. Halfdan Mahler's call for “Health for All” is neither an outdated nor impossible concept and should remain the goal of the entire international community. The only way to achieve that goal is through adequately funded, good quality, universal public health services, paid for from income tax and the public purse, and not at the point of care.

None of the papers on privatisation published here has analysed the entire national health sector of the countries they report on, nor evaluated the situation of all sexual and reproductive health services within that comprehensive picture. However, RHM has now published journal issues on health sector reforms (2002), integration of services (2003), human resources (2006), task shifting (2009), commercialisation as it relates to cosmetic surgery (2010), and now in this and the next issue, privatisation. Taken together, these papers have opened an important window on issues of equity in health care, and provide a coherent picture of what is going right and wrong with sexual and reproductive health services in today's health systems, and what is needed. Given what they show about the problems of weak public health systems and the deep flaws in and inequities created by privatised services, it is clear that more comprehensive research on appropriate models for universal access is an urgent priority. RHM encourages researchers to undertake such studies and would be happy to consider them for publication not only next May but in the years beyond. Meanwhile, global and national-level action is needed to challenge the hegemony of neoliberal health policies and to reject privatisation in national health systems.

Joint Action and Learning Initiative on National and Global Responsibilities for Health

A newly formed Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) is calling for a global health treaty that would, for the first time, express a shared vision for realising the human right to the highest attainable standard of health and enabling all people to have their essential health needs met. Reproductive Health Matters will be supporting this initiative and encouraging others around the world to do the same.¹⁰

Theme: national abortion laws and policies and access to services

There are seven papers this time on the subject of national abortion laws and policies. I am pleased to be able to publish an in-depth analysis by Reed Boland of second trimester abortion laws globally, which is the most comprehensive and up-to-date source of information on this subject to date, and a paper by Shah and Åhman with global estimates for 2008 on unsafe abortions.

The others, from Brazil, Colombia, USA and the cities of Hong Kong and Mexico City, address women's lack of access to services due to unwilling providers in spite of law reform, e.g. in Colombia, and barriers created by regulations and high fees, as Suet Lin Hung shows in Hong Kong, that make it impossible for adolescent girls from marginalised backgrounds to access public abortion services intended to serve them.

It is important to note that although these papers are not primarily about privatisation as such, they all speak to the subject in one form or another.

Theme: violence against women

This journal issue also includes three papers arising from research on the subject of the prevalence and consequences of violence during pregnancy. Bacchus et al report on an evaluation of a domestic violence intervention in the maternity and sexual health services of a UK hospital. Stöckl et al report on a large household survey in Tanzania on physical violence by a partner during pregnancy. And Devries et al report on an analysis of prevalence data from 19 countries on intimate partner violence during pregnancy. These data give great pause. Devries et al suggest that violence during pregnancy is more common than several recognised maternal health conditions for which it is current practice to screen during antenatal care. Bacchus et al offer a well-tested model for initiating screening for violence in two types of health care clinics where women get ongoing attention, though the authors warn that such screening programmes are complex, fluid and difficult to get right. Support must be ongoing and professional, so that women can be helped and unintended harm is avoided, e.g. making sure that health workers maintain strict confidentiality.

Mawaheb El-Mouelhy et al report on a study of issues of sexuality in relation to female genital mutilation in Egypt, in which they find that on matters of sexual pleasure, although men and women understand this concept differently, sexual problems – including lack of pleasure in sex and sexual dissatisfaction – for whatever reasons, were widespread among the women and men they interviewed.

Last but not least

Lisa Hallgarten reviews an excellent new resource prepared by colleagues from six NGOs entitled: It's All One Curriculum: Guidelines and Activities for a Unified Approach to Sexuality, Gender, HIV, and Human Rights Education.

Acknowledgements

Many thanks to TK Sundari Ravindran, Pascale Allotey and Eric Friedman for editorial comments.