Scaling up to achieve health care for all

Anna Marriott1 June, 2010

Oxfam Papers:

Health Insurance in low-income countries. Where is the evidence that it works (Joint Paper: 2008)

Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries (Oxfam 2009)

Your Money or Your Life: Will Leaders Act Now to Save Lives and Make Health Care Free in Poor Countries? (Joint Paper, Over 60 Organisations 2009)

Health Financing

Don’t work:

Private health insurance Private for-profit micro health insurance Community based health insuranceHave potential but no evidence for poor countries:

Social health insurance (mandatory tax subsidization, per capita >$2000)

Has worked at all income levels:

Tax based funding – free/nominal payments at point of delivery

Blind Optimism Challenging the myths about private

health care in poor countries

Six arguments for private provision

currently majority provider in many countries and should therefore be at the heart of scaling-up;

can take strain off public health services;

is more efficient;

is more effective and of better quality;

can reach the poorest;

can improve accountability through competition

Argument one

Because the private sector is already significant, it will be key in scaling up

‘A poor woman in Africa today is as likely to take her sick child to a private hospital or clinic as to a public facility.’ IFC: The Business of Health in Africa, 2007

Malawi: Private health-care providers for poorest fifth of population

Private health facility11%

Private pharmacy

0%

Private doctor1%

Traditional healer15%

Shop73%

Based on data from the Malawi Demographic and Health Survey (2000)

What about those who have no access?

India: Private sector provides 82% of outpatient care (IFC)

But 50% of women have no medical assistance whatsoever during childbirth

Proportion says nothing about fulfillment of right to health

Argument two

Private sector is more efficient and can help reduce costs

Lebanon and Sri Lanka

Privatized Lebanon spends twice as much per capita as public Sri Lanka

Yet infant mortality is 2.5 times higher And maternal mortality is 3 times higher

Argument Three

Private sector can improve quality of care and accountability to patients

Argument Four

Private sector can help reach the poor

Private Care in China and Vietnam

Substantial increase in rural people reporting illness but not using health services

Increase in unattended home deliveries Delay of care, particularly for women and

girls Chinese reforms now being reversed

The public alternative

Public failure?

Many domestic factors contribute to poor performance

– Political will– Technical capacity– Corruption

Also role of donors– SAP legacy– Tiny proportion of aid to budget support– Side effects of vertical initiatives

Advantages of public provision

Economies of scale Easier to regulate quality Redistributive capacity (to reach poorest) Public ethos of service And longer-term:

– Builds government legitimacy

Public success stories

Old ones:– Kerala– Sri Lanka– Botswana– Caribbean &

Pacific islands– Cuba

More recent ones:– Timor Leste– Eritrea

Where’s the difference? In public or private provision?

Bangladesh

0

10

20

30

40

50

Q1 Q2 Q3 Q4 Q5

Public Private

India

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4 Q5

Sri Lanka

0

10

20

30

40

50

Q1 Q2 Q3 Q4 Q5

Malaysia

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4 Q5

Indonesia

0

10

20

30

40

50

60

Q1 Q2 Q3 Q4 Q5

Hong Kong

0

10

20

30

40

50

Q1 Q2 Q3 Q4 Q5

Coverage with skilled birth attendance in poorest quintile by type of provider, according to overall level of skilled birth attendance (%)

All countries with DHS surveys analyzed by WB PHN

4

13

23

65

02 3 4

0

10

20

30

40

50

60

70

<10% 10-19.9% 20-39.9% 40-100%

Per

cen

tag

e o

f b

irth

s (%

)

Births attended by public providers (%) Births attended by private providers (%)

Download “Blind Optimism” at:

www.oxfam.org

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