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href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/2009/02/oxfam-this-is-not-how-to-help.php" rel="bookmark" title="Permanent Link to Oxfam — This Is Not How to Help the Poor">Oxfam — This Is Not How to Help the Poor</a></h3> <h4>By <a href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/author/april-harding/" title="Posts by April Harding">April Harding</a> </h4> <p><p><img src="https://web.archive.org/web/20090728054539im_/http://www.cgdev.org/userfiles/image/13290_image_AprilHarding.jpg" alt="April Harding" vspace="3" width="100" height="140" align="left"/>Today I had a flashback to the days when the global health community was divided into two bitterly opposed camps, the <a href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/2008/12/the_public_versus_pr.php" target="_blank">pro-public and pro-private</a>. Younger global health professionals may not recall the days when the two camps hurled invective at each other across an unbridgeable chasm that precluded any constructive discussion. It was my anecdote versus yours, underlaid by “my values” (infinitely superior) to yours (highly suspect). The folks at Oxfam, it seems, are feeling nostalgic, and their new report would take us back. The <a href="https://web.archive.org/web/20090728054539/http://www.oxfam.org.uk/resources/policy/health/bp125_blind_optimism.html" target="_new">report</a> criticizes the “Blind Optimism” of people and organizations who would work with the private health sector to improve access to health services and mortality reduction in developing countries. It kicks off with the inevitable anecdote of superior performance from a largely public system, in this case Sri Lanka. Undoubtedly old members of the pro-private camp will be tempted to toss back their own stories. But must we slide back to the old unconstructive debates? Must we revert to my anecdote versus yours? The stakes are too high to let this happen.</p> <p><span id="more-644"></span></p> <p><strong>Beyond Anecdotes</strong><br/> Fortunately, we needn’t revert to my (strategically selected) case versus yours to inform our thinking any more. Analysis in a recent <a href="https://web.archive.org/web/20090728054539/http://cep.lse.ac.uk/pubs/download/dp0751.pdf">paper</a> by Peter Boone and Zhauguo Zhan at the London School of Economics looked for any signs of superior, or not, performance in relatively public health systems. Using data from 45 countries with DHS surveys, they created an index of relative publicness vs privateness for each country based on utilization figures - and then looked to see if child mortality was lower in relatively public systems. The answer was no. But what about the poor? Do they have more access to care? Or better outcomes in relatively public systems? Again, no. But nor are the relatively private systems better. There is simply no measurable pattern. Their findings lend support to neither the pro-public nor the pro-private camp. What they do is strengthen the argument of the, thankfully growing, pragmatist camp in the middle, whose members neither bash the public sector for its unfixable nature, nor toss around inflammatory rhetoric about the private.</p> <p>If neither public nor private is better, what’s the harm in the public-sector only approaches Oxfam proposes we revert to? The harm is this: in many countries this would leave behind many poor people and those who live in rural areas who, whether we like it or not, turn to the private sector when they fall ill. Besides trying to push everyone back into their respective camps, the report dismisses arguments to engage the private sector by pointing out that much of this private sector consists of poorly trained, low-skilled providers, to which no one in their right mind would go or take their children. Yes, well, this is precisely the point.</p> <p><strong>The Informal Sector - We May Not Love It, But Many People Can’t Or Won’t Leave It</strong><br/> Oxfam points out that many of the private providers people are using are informal, unregulated and unsafe. I’ve never heard anyone argue otherwise (though Oxfam significantly overstates the proportion of care delivered by the informal sector by presenting figures from Malawi, which as the largest informal sector of the countries for which there is <a href="https://web.archive.org/web/20090728054539/http://siteresources.worldbank.org/INTAFRICA/Resources/wp93_health_service.pdf">data</a>). But, strangely, from this they conclude that we should ignore them, and focus on strengthening the public provision.</p> <p>Ignore the informal sector and you ignore the many poor and rural people who go there. I’ve never come across any research or policy papers proposing that working with drug sellers and untrained healthcare providers is the first resort. The all-too-few attempts to work with informal providers have been justified on the grounds that it is the only way to reach the poor people who go there. Poor women throughout the developing world have their babies with the help of <a href="https://web.archive.org/web/20090728054539/http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8X-4SYKKS0-1&_user=10&_coverDate=02%2F28%2F2009&_rdoc=1&_fmt=high&_orig=browse&_srch=doc-info(%23toc%235882%232009%23999109997%23857347%23FLA%23display%23Volume)&_cdi=5882&_sort=d&_docanchor=&_ct=11&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=444fcde8579291c7b21d2b66d81c13ba">untrained delivery attendants</a>; poor people in rural areas with TB turn to informal health providers; and most people with malaria turn to drugsellers (a <a href="https://web.archive.org/web/20090728054539/http://www.rollbackmalaria.org/partnership/wg/wg_management/docs/medsellersRBMmtgsubcommitteereport.pdf">review</a> of 15 interventions to improve child health and malaria-related activities of private sector medicine vendors in sub-Saharan Africa found these were used in 15-82% of recent child illnesses, with a median around 50%). What are the options?</p> <p>Oxfam implies we should get them to stop. Sweeping the challenge of getting people to change their care-seeking behavior under the rug is probably the biggest offence Oxfam makes in the report. It is not simply that evidence indicates it is very hard to improve public provider performance; it is that even when performance is measurably improved, people continue using these providers we wish didn’t exist (Arifeen et al present the largest documented shift from private to public of 9% in this <a href="https://web.archive.org/web/20090728054539/http://www.lancet.com/journals/lancet/article/PIIS0140-6736(04)17312-1/abstract">paper</a>).</p> <p>More realistically (or should I say, pragmatically), we can try to improve the quality of treatment received when people go to these poorly qualified providers. Only recently has this been attempted. And it seems this is what has Oxfam up in arms. So what do we know about what can be done with informal healthcare providers?</p> <ul> <li>In Bangladesh, <a href="https://web.archive.org/web/20090728054539/http://www.who.int/bulletin/volumes/84/6/479.pdf">village health workers</a>, heavily used by the rural poor, were brought into the national TB control program, and achieved high rates of compliance with the recommended DOTS protocol.</li> <li>In several countries, <a href="https://web.archive.org/web/20090728054539/http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6V8X-4SYKKS0-1&_user=10&_coverDate=02%2F28%2F2009&_rdoc=1&_fmt=high&_orig=browse&_srch=doc-info(%23toc%235882%232009%23999109997%23857347%23FLA%23display%23Volume)&_cdi=5882&_sort=d&_docanchor=&_ct=11&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=444fcde8579291c7b21d2b66d81c13ba">unskilled delivery attendants</a>; heavily used by rural poor women, were trained on the use of misoprostol, and successfully applied this knowledge to reduce the very high incidence of haemorrhage and related mortality.</li> <li>What about drugsellers, the source of so much handwringing in the report? Frankly, we’ve tried little. And we know little. We know that trying to reach most of the population of malaria-endemic Africa with the right medicines has, to date, failed (the <a href="https://web.archive.org/web/20090728054539/http://www.who.int/malaria/wmr2008">WHO Malaria Report 2008</a> documents declining access to malaria medicine in most countries where it is measured). And they have failed largely because the majority of the population who come down with malaria go to the nearest drugseller for medicine, with whom malaria control programs have steadfastly avoided working (see the conclusions of the <a href="https://web.archive.org/web/20090728054539/http://www.rbm.who.int/cmc_upload/0/000/015/905/ee_toc.htm">RBM external evaluation</a>). Attempts to <a href="https://web.archive.org/web/20090728054539/http://www.malariajournal.com/content/5/1/109">constrain the use of drugsellers</a> by restricting the most effective medicine to the public sector in Tanzania led, rather predictably, to fewer people (again, especially the rural poor) getting the most effective medicine.</li> </ul> <p>There have been a few attempts to improve drug and dispensing quality via accreditation schemes, schemes which give participating drugsellers predictable access to the most effective malaria medicines (see a 2005 <a href="https://web.archive.org/web/20090728054539/http://www.rollbackmalaria.org/partnership/wg/wg_management/docs/medsellersRBMmtgsubcommitteereport.pdf">review</a> by Brieger et al.). Some improvements resulted, though nothing has been tried at scale. Which brings us to the unpopular-with-Oxfam <a href="https://web.archive.org/web/20090728054539/http://www.rbm.who.int/globalsubsidytaskforce.html">Affordable Medicines for Malaria (AMFm)</a>. The AMFm is a collaborative effort of the World Bank, the Global Fund, the UK and other donors which is attempting to get the most effective malaria medicine (ACT) to everyone by enabling subsidized drugs to flow through both the public and private drug supply chains.</p> <p>Oxfam characterizes the facility as a subsidy to be applied only to the private sector supply chain (see Box 5 in the report), when the reality is that existing subsidies to the public sector will be augmented by applying the same subsidy to the private suppliers and retailers. Misrepresentation notwithstanding, the pilots are on-going, and being heavily monitored and assessed as we write (or read). Early results, anecdotal because the malaria medicine market context varies greatly within and across countries, indicate that the upstream subsidy mechanism can “crowd out” the ineffective malaria medicines in the drugseller outlets where so many poor people get their drugs. Oxfam also implies that increasing access to effective malaria treatment through the public sector exclusively hasn’t been tried. Uh, that’s exactly what RBM has been trying to do since 1998. And it hasn’t worked.</p> <p>This Oxfam report aims for a leap backward - to the days when all efforts to help the poor were unthinkingly focused on the public providers that we like, and feel comfortable with. We know now that the poor go where they want to go, and they will persist in doing so. The choice we face is, do we acknowledge this and overcome our discomfort with these untrained people who make their living by selling their services and products or do we not? Clearly, for Oxfam, the answer is no. And, with this report, they would answer not only for their own efforts, but for everyone in the global community.</p> <p>If we listen, we are giving in to wishful thinking, and at the expense of finding ways to improve the lives of the poor.</p> </p> <br/> </div> </div>  <div class="comments"><h3 id="comments">10 Responses to “Oxfam — This Is Not How to Help the Poor”</h3></div> <ol class="commentlist"> <li class="alt" id="comment-395"> <div class="gcomment"><cite>David Bishai</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-395" title="">February 12, 2009 at 11:39 am</a> </small></div> <div class="ucomment"><p>The philosophy of harm reduction when applied to needle exchange and condom promotion is such a liberal stance and provokes reactionary smug moral superiority from the prohibitionists.</p> <p>Oxfam always struck me as pragmatic in so many other ways that I thought they would recognize and embrace a program of making private medical care safer for the poor instead of banning it.</p> </div> </li> <li id="comment-396"> <div class="gcomment"><cite>April</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-396" title="">February 12, 2009 at 4:45 pm</a> </small></div> <div class="ucomment"><p>The World Bank has posted a response to the Oxfam report too. You can find it here: <a href="https://web.archive.org/web/20090728054539/http://tinyurl.com/ch4opq" rel="nofollow">http://tinyurl.com/ch4opq</a></p> </div> </li> <li class="alt" id="comment-397"> <div class="gcomment"><cite>Dominic Montagu</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-397" title="">February 13, 2009 at 12:51 am</a> </small></div> <div class="ucomment"><p>Brilliantly argued! I’m impressed by your clarity and level-headedness. I got so frustrating reading the Oxfam report I had trouble not shouting out the errors and biases. I’m grateful you were able to get past that and highlight the more fundamental issues.</p> </div> </li> <li id="comment-398"> <div class="gcomment"><cite>David McCoy</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-398" title="">February 14, 2009 at 10:33 am</a> </small></div> <div class="ucomment"><p>Dear April,</p> <p>Unlike you, I think Oxfam should be congratulated for raising the important issue of the role of private actors (and by implication of markets and commerce) within the health care systems of poor countries. </p> <p>Most people agree that there are many problems associated with rapid growth of the private sector in poor countries: poor quality, unsafe and unregulated care, often at a cost that impoverishes many households; over-servicing and supplier-induced demand; fragmentation and duplication; inefficient allocation of resources; the undermining of Ministries of Health; widening inequalities in health care; and the association with commoditised health care. </p> <p>Oxfam’s paper notes that many of these problems have resulted from a variety of policies (often donor-driven) that have caused or allowed public sector services and government stewardship to fall into disrepair. </p> <p>Oxfam therefore responsibly calls for greater investment in the public sector and an end to policies that are aggravating the problems of health systems by encouraging private sector expansion within an unregulated context and without paying the required attention to strengthening the public sector. I would go a step further by also calling for an explicit rejection of public or philanthropic funding being used to subsidise the expansion of for-profit medical companies in Africa </p> <p>What is also clear is that data, information and evidence are profoundly deficient when it comes to forming judgements about the relative merits of private versus public actors; or about markets versus planned systems. Boone and Zahn’s paper is far from conclusive, and is contradicted by other data and analyses. </p> <p>I think you have mis-read or misunderstood the Oxfam report which does not advocate a simplistic public versus private argument. Nothing in Oxfam’s report suggests that. In fact it acknowledges that in many instances, private actors play a useful and vital role, particularly when the public sector is not available. Oxfam’s report also makes no argument for the informal sector to be neglected. What is required is greater public intervention to manage and regulate the informal sector, and for this, countries will need greater public investment. </p> <p>The debate is far more complex and subtle than you have characterised it. There are many different types of private actors; there are many different forms of private sector engagement in the health system; there are many different contexts that need to inform policy decisions. In addition, there are a many normative views (e.g. on the premium we wish to pay on equity) and health policy questions (e.g. on the balance between top-down versus bottom-up orientation of health systems) to be thrown into the mix. </p> <p>By characterising the Oxfam report as a simplistic pro-public and anti-private rant, you dismiss a useful contribution to an important subject that requires more debate. And rather ironically, you have ended up embodying the false and polarised “public versus private” debate that you have (correctly in my opinion) condemned. </p> <p>With kind regards,<br/> David McCoy</p> </div> </li> <li class="alt" id="comment-399"> <div class="gcomment"><cite>Sarah Pendleton and Winston Kibaki</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-399" title="">February 15, 2009 at 3:05 am</a> </small></div> <div class="ucomment"><p>Will someone tell Oxfam to hire more analysts and implementers instead of self-serving pundits? They are trapped in an ideological time capsule.</p> <p>The Oxfam report is pathetic, shoddy and based on dubious inferences. It ignores the reality in most poor countries, where large proportions of the population, rich or poor, use the private sector. The report is also dishonest; nowhere does Oxfam acknowledge the failure of public sector services. Finally, Oxfam has taken to a pathetic height its holier-than-thou pretenses. </p> <p>Who elected Oxfam to speak on behalf of the developing world’s population? One of the tragedies of global health is the way some northern NGOs have appointed themselves as representatives of the developing world. You will see them on all-expenses-paid trips at international conferences where they rehash the same meaningless mantra. They do no real work and add no substance to discussions, but fill up the room and waste everyone’s time. Their arrogance is off-puting, and so is their vehemence. They assume that the mere designation of a northern NGO confers wisdom and infallibility.</p> <p>Why is Oxfam afraid of ideas that can be tried? Does it feel threatened that its ideological bubble is losing air? Is it afraid of losing donor support to approaches that may prove more useful than its tired and failed ideology?</p> <p>Here is our message to Oxfam. Please stay in Oxford. You represent nobody but yourselves, and nothing but self-interest. You have zero credibility in science and, if your paper is any indication, you have no useful idea.</p> </div> </li> <li id="comment-400"> <div class="gcomment"><cite>moses kumambala</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-400" title="">February 15, 2009 at 5:54 am</a> </small></div> <div class="ucomment"><p>I think it is high time that your brand of ‘pragmatism’ is challenged and I applaud Oxfam for a strong report that builds on substantial evidence. For too long private sector advocates like you have masqueraded behind pseudo- pragmatism when you have only one agenda. Where are the experts in the public sector and public sector provision on the CGD staff? It seems looking at your resume that you have spent your whole career working either at the World Bank or now CGD looking at ways to get the private sector further involved in healthcare, hardly great credentials for a self-proclaimed defender of objectivity!</p> </div> </li> <li class="alt" id="comment-401"> <div class="gcomment"><cite><a href="https://web.archive.org/web/20090728054539/http://www.oxfam.org/en/campaigns/health-education/primary-healthcare-services" rel="external nofollow" class="url">Anna Marriott</a></cite> Says: <br/> <small class="commentmetadata"><a href="#comment-401" title="">February 27, 2009 at 2:59 pm</a> </small></div> <div class="ucomment"><p>Dear April</p> <p>We were sadly disappointed with your response to our paper(1), which we feel is not representative of either the paper or the discussion at the Washington seminar. We would completely agree with you that there is a need to move beyond staunchly ideological positions to one of pragmatism. Indeed it is through this paper that we are seeking to shift the debate away from accusatory and emotive exchanges to rather focus on the evidence of what policies and programmes will most effectively achieve the rapid and sustained expansion and improvement of health care delivery so urgently needed in so many countries. </p> <p>For this reason we would like to question some of the evidence you present and also correct some of the misrepresentations of our report and position. </p> <p><strong>Beyond Anecdotes</strong><br/> Our starting point is not a simplistic or ideological case of “public good, private bad”, and we feel to suggest this is to miss the point of the paper. Our paper draws on a variety of evidence including from health surveys, peer-reviewed journals, World Bank and World Health Organisation reports and particularly the Commission on the Social Determinants of Health(2). It was reviewed and commented on by academics from across the political spectrum. Rather than focus on anecdotes our decision was to focus on the empirical evidence on what has worked to achieve universal and equitable access in successful developing countries despite low incomes. We found that even though high health performing countries do often have a thriving private health care sector, the evidence shows that it is their level of commitment to pro-poor public investment and public provision that sets them apart from the rest. By the same token, no successful high health performing country has chosen to rely primarily on private instead of public provision. In their official response to our paper the World Bank agrees with this point. They go on to say that they feel the main factor in these successes was good governance, but we believe that although good governance is critical, the mix of policies used is also a major learning point, and here rapidly scaling up public provision was central. Our key message is therefore quite simple - that donor agencies and governments should be doing significantly more to learn and apply the lessons from successful countries and what they did to scale up public provision. This does not preclude learning from the lessons on the evolution and governance of the private health care sector in these same countries. Far from “reverting” to an old tried and tested approach as you suggest, for many aid donors this will mean redressing their own poor record of long-term systematic disinvestment in government health care delivery in poor countries. </p> <p>Secondly, our advice against investing in risky and unproven approaches that aim to expand the role of the for-profit private sector in health is not the same as advocating a public-sector only approach, or that the private sector should somehow be “stopped”, contrary to your presentation of our arguments. In the paper Oxfam is explicit that the “private sector can play a role in health”, that it “will continue to exist in many different forms and involves both costs that must be eliminated and potential benefits that need to be further understood and capitalised upon”. Government capacity to regulate the existing private sector and ensure its positive contribution to equity goals is prioritised as one of our core recommendations. On the other hand, unchallenged enthusiasm for private sector solutions is neither justified nor helpful. Based on the evidence available there is an urgent need for more honesty about the significant risks to efficiency and equity associated with private sector growth, and more openness about the paucity of comprehensive evaluations of private sector approaches and the lack of evidence that these approaches can be scaled up. The poor quality of the data on contracting private providers as an alternative to expanding public provision is a particular concern especially the lack of attention to transaction costs, the level of financial risk placed on governments and the wider impact of contracting on the health system as a whole. </p> <p><strong>The Informal Sector - We May Not Love it, But Many People Can’t or Won’t Leave It</strong><br/> Far from ignoring the informal private sector and “sweeping the challenge of getting people to change their care-seeking behaviour under the rug” as you suggest, the primary focus of our paper is on the poor women, children and men across the developing world who face the unacceptable choice between seeking care from unqualified providers or going without care altogether. In this regard we query your argument that the poor “want to go” to informal private providers and will “persist in doing so”. It is hard to conceive that when faced with a real and genuine choice between informal unqualified providers and decent and accessible care provided free of charge by trained professionals in the public sector poor people would continue to use the former. In fact the empirical evidence from higher health performing countries shows that when care is available and accessible in the public sector the majority of poor people do choose to use it, and it is the better-off who are more likely to go to the private sector. We also know in cases such as Uganda(3), where increased investment in government health services was combined with the removal of user fees, utilisation rates for poor people increase dramatically. And even in those countries with less than adequate public provision, the poor still choose the public sector for curative care, not least pregnant mothers as our paper demonstrates. Public provision in these same countries has also proven the most effective regulator of the informal sector by crowding out the most dangerous elements and giving those providers that survive something to compete against. </p> <p>None of this means we can ignore the informal sector and contrary to your suggestion our paper in fact calls for “urgent action” to “minimise its dangerous practice and improve its standards”. We cite some success of negotiated interventions such as training and public education, although perhaps more cautiously than you, given the highly resource-intensive nature of these programmes, lack of evidence on impact to date as well as the Herculean nature of the task. However, even if standards can be improved within selected interventions the kinds of services that can be offered safely via this sector will always be limited and market forces to over-or under-prescribe will be a continuing threat. Monitoring and regulating private sector providers even in advanced nations like the US is also very complex and resource intensive. That doesn’t mean interventions shouldn’t be tried but they must not be perceived as a substitute to scaling up and strengthening decent quality health care services provided free of charge by the public sector. </p> <p><strong>The Unpopular-with-Oxfam Affordable Medicines Facility for Malaria (AMFm)</strong><br/> Our concerns about repeating the same mistakes of the past through the AMFm are shared by many others including the US and Canadian governments, and we question how quick you are to dismiss them. Choloroquine, once an effective drug, has been widely available through the private sector for decades and under- and over-prescribing led to widespread drug resistance. The AMFm is using the same delivery route for Artemisinin, the last effective drug available for malaria - with minimal safeguards. We think this is a mistake. The AMFm also ignores research by organisations such as Medecins Sans Frontieres(4) showing how subsidisation of Artemisinin is not enough to significantly increase access to treatment for the poor. Their direct experience in countries across Africa has shown that it is only when completely free care (medicines, consultations and other related costs) was introduced that access rates dramatically increased.</p> <p>You are correct to point out that AMFm will be applied to the public as well as private sector but you should be aware that this was only agreed after our paper went to print and only as a result of intensive lobbying from Oxfam and many other civil society organisations involved in the negotiations. It is also misleading to suggest attempts to improve access to Artemisnin through the public sector have failed. Such attempts have been hampered until recent years by a severe lack of funding. Since 1998 there has been a 25 fold increase in the resources available for malaria and with it a significant number of public sector success stories(5) including a 50% reduction in in-patient malaria cases and deaths throughout Rwanda and Ethiopia, a 33% decline in deaths in children under five in Zambia and a 34% decline in deaths in Ghana. </p> <p>In this difficult period of economic uncertainty it is more important than ever to invest what limited resources are available in policies and programmes that are going to make the most effective difference in ensuring poor people have access to the health care they need. There is no question that the private sector is an important actor, but in countries where the poor have access to qualified health care at scale the evidence is clear that it is the public sector that has reached them. The question we need to be asking is how we get the public sector in other countries to do the same. As Dr Rannan-Eliya from the Institute for Health Policy(6) in Sri Lanka said at our seminar at the World Bank, “we don’t do it by turning our attention away from the public sector”. </p> <p>Over the coming months we will be organising a series of follow up seminars and lobby meetings in Geneva, Delhi, Brussels, Addis Ababa, London and Oslo where we are keen to continue this debate and call for a more evidence based approach. We look forward to continuing this conversation with you.</p> <p>(1) <a href="https://web.archive.org/web/20090728054539/http://www.oxfam.org/policy/bp125-blind-optimism" rel="nofollow">http://www.oxfam.org/policy/bp125-blind-optimism</a><br/> (2) <a href="https://web.archive.org/web/20090728054539/http://www.who.int/social_determinants/en/" rel="nofollow">http://www.who.int/social_determinants/en/</a><br/> (3) <a href="https://web.archive.org/web/20090728054539/http://www.savethechildren.org.uk/en/docs/Freeing_up_Healthcare.pdf" rel="nofollow">http://www.savethechildren.org.uk/en/docs/Freeing_up_Healthcare.pdf</a><br/> (4) <a href="https://web.archive.org/web/20090728054539/http://www.doctorswithoutborders.org/publications/reports/2008/MSF-Malaria-Full-Prescription-Sep2008.pdf" rel="nofollow">http://www.doctorswithoutborders.org/publications/reports/2008/MSF-Malaria-Full-Prescription-Sep2008.pdf</a><br/> (5) <a href="https://web.archive.org/web/20090728054539/http://www.who.int/malaria/docs/ReportGFImpactMalaria.pdf" rel="nofollow">http://www.who.int/malaria/docs/ReportGFImpactMalaria.pdf</a><br/> (6) <a href="https://web.archive.org/web/20090728054539/http://www.ihp.lk/" rel="nofollow">http://www.ihp.lk</a></p> <p>Kind regards<br/> Anna Marriott</p> </div> </li> <li id="comment-402"> <div class="gcomment"><cite>April</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-402" title="">March 6, 2009 at 12:52 pm</a> </small></div> <div class="ucomment"><p>I appreciate Anna’s post - in the interest of having an open discussion. </p> <p>The post, and the report underscore a goal we share - making decisions about health policy and programs based on good information. </p> <p>While the report has helpfully stimulated debate, I don’t feel it contributed as much as it could have to basing discussions on unbiased information. I refrained in my post from sorting through the more important misrepresentations in the report, though there are quite a few. </p> <p>Dominic Montagu from UCSF has just posted on this at BMJ.com. The post includes, for example, selective presentation of country statistics to overstate the proportion of private sector utilization that is medicine sellers rather than private clinics and doctors. </p> <p>“Oxfam cites its own ‘analysis of data from DHS in 15 sub-Saharan Africa countries with comparable data categories for private providers.’ It shows that only 3% of all patients visiting the private sector go to doctors and that 40% of private provision in Africa is ‘just small shops selling drugs of unknown quality.’ </p> <p>The post continues:<br/> “But the authors mislead through being selective. Their source of data includes 21 countries, but they select 15 that support their thesis. The more complete information shows that shops represent 29% of the source of care and that among the poorest quintile 11% (not 3% as Oxfam reported from a sub-section of data) of patients were seen by a doctor. Then an additional 24% were treated in a ‘private facility,’ which, as Oxfam must have known, means a multi-provider facility where there is a doctor plus other providers. So 37% of patients were seen by a doctor or better. Oxfam has distorted the data tenfold”.</p> <p>I commend the rest of the blog entry, and indeed the other entries, to our readers.<br/> <a href="https://web.archive.org/web/20090728054539/http://www.bmj.com/cgi/eletters/338/feb16_2/b667" rel="nofollow">http://www.bmj.com/cgi/eletters/338/feb16_2/b667</a></p> </div> </li> <li class="alt" id="comment-513"> <div class="gcomment"><cite><a href="https://web.archive.org/web/20090728054539/http://www.oxfam.org.uk/" rel="external nofollow" class="url">Anna Marriott</a></cite> Says: <br/> <small class="commentmetadata"><a href="#comment-513" title="">April 7, 2009 at 9:43 am</a> </small></div> <div class="ucomment"><p>Thank you for pointing out Dominic Montagu’s contribution in the BMJ. Oxfam has made the following submission to the BMJ in response. </p> <p>Critique of Oxfam paper inaccurate, unconstructive and ideologically biased:</p> <p>A primary objective of our new paper Blind Optimism is to encourage and advance an evidence-based debate on the appropriate role of the private sector in health care delivery in poor countries. Not only does your response detract from this important debate by misrepresenting the paper, you incorrectly accuse Oxfam of purposively distorting the data to support our arguments. </p> <p>Firstly, we do advise against investing in risky and unproven private-sector approaches to expand health care in poor countries. You are wrong to suggest that this is the same as advocating that all engagement with the private sector should cease. In the paper Oxfam is explicit that the ‘private sector can play a role in health’, that it ‘will continue to exist in many different forms and involves both costs that must be eliminated and potential benefits that need to be further understood and capitalised upon’. Government capacity to regulate the existing private sector and ensure its positive contribution to equity is prioritised as one of our core recommendations. On the other hand, unchallenged enthusiasm for private sector solutions is neither justified nor helpful. Based on the evidence available there is an urgent need for more honesty about the significant risks to efficiency and equity associated with private sector growth, and more openness about the paucity of comprehensive evaluations of private sector approaches and the lack of evidence that these approaches can be scaled up. </p> <p>Secondly, you also claim that Oxfam uses data from DHS surveys to imply when poor countries have a large private sector this causes greater overall exclusion from health care. This is not true. We do say there is a correlation but we do not claim causality. In fact we state clearly in the paper that: \…Although this correlation does not clarify whether high levels of private participation cause exclusion, it at least suggests that the private sector does not in general reduce it…\</p> <p>Your final point questions our analysis of what the private sector looks like for poor people in Africa, which finds that 36% of private provision is just small shops selling drugs of unknown quality. You claim that we deliberately exclude countries that don’t support our position. Instead we compared only those countries where survey data was directly comparable. Your calculation includes countries with differing data categories, for example countries that do not include a category for private doctor. By doing this you are not comparing like with like and this distorts your findings. You also appear naively optimistic with your suggestion that seeking care from a private facility always means seeing a “doctor or better”. Even if we assume, as you do, that every private facility in sub-Saharan Africa has a qualified doctor or better, using the comparable data the total proportion of the poorest quintile that seek private care that get to see a private doctor is still only 29%, not 37% as you suggest. More importantly, you also avoid addressing the most pressing issue we highlight; that over half of the poorest children in Africa do not receive any health care at all – public or private. The real question is how we are going to reach them, and here the evidence for promoting private sector expansion is very thin indeed. </p> <p>We do agree with you that the private sector in health often proliferates in the absence of a well functioning and accessible public health system. This can be compared to the way private bodyguards expand in a failed state. Does this mean we abandon the public health system or does it mean we need to reverse decades of under-investment and focus on making the public sector work better? Governments have historically intervened to provide health services precisely because the market fails to deliver decent health care for everyone. In more successful countries government provision of decent health care free of charge has played a direct role in crowding out the worst elements of private sector provision. A recent paper (1) by Dr Mead Over from the Centre for Global Development on anti-retroviral therapy in India argues that we should take this government role seriously. The author states that ‘public sector delivery of ART can be justified not only because it protects poor AIDS patients from catastrophic health expenditures, but also because it might differentially “crowd out” the cheapest (and therefore perhaps the worst) of the private sector AIDS treatment’ (2). </p> <p>Whilst we appreciate there are many different points of view in this debate your critique of Oxfam’s paper is unfounded and inaccurate and your tone unfairly and unhelpfully dismissive. We would urge you to take more time to look at the evidence of what works for the poorest people and enter into a more constructive debate. </p> <p>(1) Mead Over. 2009. \AIDS Treatment in South Asia: Equity and Efficiency Arguments for Shouldering the Fiscal Burden When Prevalence Rates Are Low.\ Working Paper 161. Washington, D.C.: Center for Global Development. <a href="https://web.archive.org/web/20090728054539/http://www.cgdev.org/content/publications/detail/1421119/" rel="nofollow">http://www.cgdev.org/content/publications/detail/1421119/</a><br/> (2) <a href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/2009/03/public-delivery-of-aids-treatment-in-south-asia-a-timidly-heroic-assumption.php" rel="nofollow">http://blogs.cgdev.org/globalhealth/2009/03/public-delivery-of-aids-treatment-in-south-asia-a-timidly-heroic-assumption.php</a></p> </div> </li> <li id="comment-669"> <div class="gcomment"><cite>Jeff Barnes</cite> Says: <br/> <small class="commentmetadata"><a href="#comment-669" title="">May 6, 2009 at 6:02 pm</a> </small></div> <div class="ucomment"><p>Oxfam’s Briefing Paper, “Blind Optimism” has generated a lot of interest in private sector approaches to health. They raise legitimate issues, but ultimately their understanding of private sector approaches to health is based on a number of misconceptions and is out of step with current thinking of WHO and other institutions that rightly recognize private providers as integral to the overall health system. I don’t think it is productive to engage in anecdote or regression wars to make general statements about the private sector. The evidence is too thin and the private sector too diverse to say something this broad.</p> <p>Oxfam rightly objects to strategies that have as their primary objective increasing the private share of the provision of health care. However, they mistakenly describe the trend to promote expansion of private sector strategies with a trend to shift service delivery to the private sector. The objective is not to shift health care delivery to the private sector per se, although this may be a peripheral result of some PPP’s. Shifting to the private sector should only be done in so far as it helps to achieve efficiency, effectiveness or equity in delivery of health care. As a practitioner of PPP’s with Abt Associates, the basic principles we follow are :</p> <p>• Health programs should take account of consumer preferences and practices in deciding what aspects of the health system to strengthen and<br/> • Health programs should make the best possible use of all available resources in order to improve efficient use of public resources.</p> <p>Many of the countries we work in have very large and poorly regulated private health sectors that serve a large segment of the population. This represents both a challenge and an opportunity. The challenge is to integrate the private sector into the health system and ensure they meet quality standards. The opportunity is to leverage the infrastructure and human resources in the private sector and take advantage of the additional reach to the Nigerian people that they can provide. </p> <p>Oxfam also raises some legitimate concerns about the quality of health care in the private sector. However, the main conclusion they draw (that donors should only focus on strengthening the public sector) does not follow from these points. Oxfam’s solution seems to be to ignore the private health sector and just focus on publicly financed and publicly delivered health care. This solution ignores the issue of where public financing will come from and whether the public sector has the capacity to serve the entire population. It assumes that the state can be a responsible monopoly provider of health care. In countries where the state has demonstrated little accountability to its citizens, relying exclusively on the government is arguably as risky as relying exclusively on the private sector. Oxfam assumes that only if major improvements are made to the public sector, consumers will naturally cease to obtain care in the private sector. This is excessively optimistic on two counts. First, there is a long history of donor investments in supply inputs to the Nigerian public sector that have not resulted in improved performance, equity or outcomes. Secondly, even in health systems where the public sector performs relatively well, many consumers persist in seeking services in the private sector.</p> <p>I have no illusions that the private sector automatically provides better, more efficient or more accessible care. Sometimes it does; sometimes it doesn’t. When the private sector quality is below standard, positive efforts through training, accreditation and incentives can be used to improve it. Where private providers’ is so far below standard that a significant risk to consumers’ health is involved, then the public sector’s role as regulator needs to be engaged and strengthened.</p> <p>One of the common misconceptions of private sector strategies is that they ignore government. Strengthening the government’s role as steward of the private sector is key to many of the private sector strategies that we promote. Many of the examples of poor private sector practices occur because the government has left policy gaps or is not enforcing good policies and regulations. When donors invest in support of public sector provision of care, they rarely invest in strengthening the government’s regulatory capacity. Governments and their donors would be wise to strengthen both the service delivery capacity of the public sector as well as its regulatory and stewardship capacity.<br/> One might argue that strengthening the regulatory and stewardship roles of government should be the first thing health systems programs do. After all, only government can regulate health care; the non-profit and commercial sectors can provide it. Focusing exclusively on the government’s role in delivering services without paying attention to its role as regulator leaves a major gap in ensuring public health. </p> <p>Oxfam points out that the private sector often does not adequately serve the poor. This may be true, but this is because little work has been done to increase consumers’ ability to pay for services through demand-side health financing strategies such as vouchers and health insurance. Where consumers have financing mechanisms that allow them to choose providers, they will often seek services in the private sector. When these strategies are also combined with effective health education programs, consumers will direct resources to providers that provide the best services in either the public or private sector.</p> <p>Oxfam reminds us that the private sector is not an “escape route” to dealing with issues in the public sector. I know of no practitioners of public private partnerships that would think of making such a claim. Engaging, leveraging and improving the private sector are just complementary strategies to other health systems strengthening strategies that obviously must include providing support to government delivery of health care. But one must not exclude working with the private sector, any more than one would consider excluding working with consumers through health education to promote prevention and appropriate care-seeking behavior. </p> <p>Providers in the private sector treat citizens of the same country that the public sector does. If government has a responsibility to ensure the health of all of its citizens, then a government must work with the private sector. Stove piped approaches which ignore the private sector are ultimately counter productive and miss easy opportunities. Donor supported training can be made more accessible to private providers at minimal incremental cost. Allowing private providers to access subsidized vaccines or TB drugs improves the private sector services while leveraging the private sector’s infrastructure and expanding coverage. </p> <p>Oxfam makes much of the fact that a large segment of the private sector includes loosely regulated drug sellers. This is certainly true in a country like Nigeria where patent medicine vendors (PMV’s) are the first stop for care for roughly 70% of Nigerians. It is also true that many of the PMV’s engage in risky practices and exceed their scope of practice. The solution is not, however, to ignore them or forbid people from using PMV’s. PMV’s require better regulations and greater integration into the health system, not exclusion. One NGO, Society for Family Health has worked extensively with PMV’s and shown that with training and monitoring, PMV’s can be responsible providers of ACT drugs that are so desperately needed. </p> <p>Oxfam proposes to exempt civil society organizations from the private sector solely because they are free from the evils of the profit motive. CSO may not have a profit-driven model, but they, too have to cover their costs and they respond to incentives created by their benefactors, be they faith-based organizations or international donors. These may be socially beneficial, but as we have seen with the advent of specialized vertical health programs, CSO’s can also disrupt the health system and create an additional burden to public sector. Their dependency on irregular donor funding can also lead to spotty and unpredictable service delivery. Moreover, there is evidence that quality in the CSO sector can also be lacking. CSO’s have a lot to offer public health, but, like the private commercial providers, they have their weaknesses and they must be held to the same standards for quality and accountability as other players in the health system.</p> <p>Ultimately, all approaches to health care involve costs. The public, private for profit and civil society providers use different models to cover those costs. None of the models are perfect. In the public sector taxation-based model, the gap between the separation of clients from source of revenue means that providers are often unresponsive to clients. Allocating and mobilizing resources to where they are most needed in the public sector is also a slow and difficult process. The for-profit model has advantages in both these areas. Providers are more responsive to clients needs because sustaining their business depends on satisfying their clients. The proximity of providers to clients also means that resources can be quickly allocated where they will provide the most benefit. The downside to the profit model, of course, is that providers are tempted to encourage overutilization or inappropriate therapies in order to generate profit. This downside has to be managed through public health education, regulatory enforcement and strengthening of a professional code of ethics among providers. Oxfam would rightly argue that the downsides to the public sector model can also be mitigated through empowering of citizens and improving accountability within the civil service. I would agree. The overall point, however, is that no single approach is automatically better and that stakeholders who seek to improve the health system must be aware of the advantages and disadvantages of each model.</p> <p>Finally, Oxfam discourages donors from supporting “unproven and risky” strategies that involve working with the private sector. Is provider training an unproven intervention simply because it involves working with the private sector? Is tendering and contracting an unproven mechanism for mobilizing services simply because the contractor is a private health professional? Is social health insurance a risky intervention simply because the insurance beneficiary can choose between a public and private provider? I agree that much remains to be learned about the best way to strengthen the public sector’s capacity to engage the private health sector. Indeed, much research is needed to understand where the private sector works, what their strengths and weaknesses are, and what contributions they are best placed to offer public health. However, the core building blocks of public private partnerships have been used effectively in the health sector and other development sectors for years. Oxfam would do well to offer more practical ideas on how to solve the issues they raise on the private health sector rather than simply concluding that everyone should avoid the private health sector and pretend they don’t exist.</p> </div> </li> </ol> <br/> <div align="left"><a href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/2009/02/redefining-good-business.php"><< Previous</a></div> <div align="right"><a href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/2009/02/climbing-a-mountain-of-data-in.php">Next >></a></div> <br/> <div class="comments"><h3>Leave a Reply</h3></div> <form action="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/wp-comments-post.php" method="post" id="commentform"> <p><input type="text" name="author" id="author" value="" size="22" tabindex="1"/> <label for="author"><small>Name (required)</small></label></p> <p><input type="text" name="email" id="email" value="" size="22" tabindex="2"/> <label for="email"><small>Mail (will not be published) (required)</small></label></p> <p><input type="text" name="url" id="url" value="" size="22" tabindex="3"/> <label for="url"><small>Website</small></label></p>  <p><textarea name="comment" id="comment" cols="60%" rows="10" tabindex="4"></textarea></p> <p><input name="submit" type="submit" id="submit" tabindex="5" value="Submit Comment"/> <input type="hidden" name="comment_post_ID" value="644"/> </p> <script type="text/javascript"> var RecaptchaOptions = { theme : 'white', lang : 'en' , tabindex : 3 }; </script><script type="text/javascript" src="https://web.archive.org/web/20090728054539js_/http://api.recaptcha.net/challenge?k=6LfzdwUAAAAAAOUHBPuigpQhA7deScWPg7HC9wc9"></script> <noscript> <iframe src="https://web.archive.org/web/20090728054539if_/http://api.recaptcha.net/noscript?k=6LfzdwUAAAAAAOUHBPuigpQhA7deScWPg7HC9wc9" height="300" width="500" frameborder="0"></iframe><br/> <textarea name="recaptcha_challenge_field" rows="3" cols="40"></textarea> <input type="hidden" name="recaptcha_response_field" value="manual_challenge"/> </noscript> <div id="recaptcha-submit-btn-area"></div> <script type="text/javascript"> var sub = document.getElementById('submit'); sub.parentNode.removeChild(sub); document.getElementById('recaptcha-submit-btn-area').appendChild (sub); document.getElementById('submit').tabIndex = 6; if ( typeof _recaptcha_wordpress_savedcomment != 'undefined') { document.getElementById('comment').value = _recaptcha_wordpress_savedcomment; } document.getElementById('recaptcha_table').style.direction = 'ltr'; </script> <noscript> <style type="text/css">#submit {display:none;}</style> <input name="submit" type="submit" id="submit-alt" tabindex="6" value="Submit Comment"/> </noscript> </form> <div class="navigation"><p></p></div>  </div> <div id="right"> <ul> <li id="text-377439231" class="widget widget_text"> <div class="textwidget"><p><a href="https://web.archive.org/web/20090728054539/http://blogs.cgdev.org/globalhealth/"><strong>Global Health Policy</strong></a> is a group blog discussing the issues facing the donor community on everything from HIV/AIDS financing to pharmaceutical R&D to broader health systems concerns. 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