I have been re-reading some of the Health Sector Reform (HSR) and health and poverty literature. I have been amazed by the ambiguity, lack of clarity and of a sense of direction, and even some misconceptions I have found in an otherwise serious literature. This is not the time to call names or to point fingers, but let me give you a generic potpourri (or a smorgasbord) of what I found:

  1. The most pervasive problem with some of the articles is that they say a lot of the right things one could be in agreement with, but they fail to put it all together to build a new needed vision (and much less a mission) for the future. They would say things like: “what is needed are plausible strategies”, but fail to come up with such. Or, as another says: “Our discussion has perhaps been frustratingly inconclusive. In our view, this is inevitable, given the complexity of the issues and the current state of knowledge about them. We can only estimate potential benefits”. Alternatively, I have seen authors use an ‘options’ approach which is a sanitized way to give advice by saying things like: ‘governments have a choice of doing A, B or C’. But the respective author rarely sticks her/his neck out strongly in favor of one or two alternatives that point to a clear direction.
  2. Further, the literature too often portrays governments as not having the political will to do such and such, without making it clear that that (laissez faire) in itself IS the manifestation of a will, ergo a political choice (i.e., not to exercise a will…).
  3. I am also disturbed by the abuse of the ‘cost-effectiveness’ paradigm in the writingsas a stiff, sacrosanct principle overriding good old social concerns in health.
  4. What bothers me further is the acceptance, as a fait accompli, that the existence of an already in-place ‘mixed public-private health sector’ system supposedly is an impediment for decisive government action to straighten out the system as a whole, especially with a view to securing care for the poor who are consistently and universally being left out in this ‘mix’.
  5. Some of the literature I ran into also implies the DALY approach can be modified to steer actions in the direction of the needs of the poor (which some authors purport to be experts in when, as one of them says “it is important to understand these changes from the perspective of poor households”). I’m not so sure the DALYs are a fruitful analytical tool for the poor to put their hopes in; equity issues just take the back seat in its approach.
  6. When it comes to what functions governments MUST perform, people make lists. I feel these often to be biased. In some of the papers reviewed, these lists more and more often –almost as a given– take the position of the market approach to the delivery of health care, namely ‘Let government do what the private sector cannot’. I am afraid this is not a proven recipe either, as long as the profit motive remains the driving force of the latter.
  7. Nowhere I read are community based insurance schemes presented as an important potential co-payer of health services. I say co-payer, because governments (central and local) DO HAVE to live up to their Human Rights obligation to provide care for the poor. Because, and let me stick out my neck here, I AM – together with others – talking about governments having to increase their health budgets in a renewed greater, long-term commitment to Health for All! Of course we are also talking about other things that need being done, but this issue of a renewed struggle to increase government spending in health is key in our vision for the near future. Governments around the world have indeed neglected their duty to meet the needs of the public.
  8. In most of what I have re-read, I do think there are prescriptions that could have been put forward more forcefully. Not truths, but prescriptions to better address the challenges we face. Without having an argument with a lot of what is said as individual statements, I would have loved to see more authors give some more direction even at the risk of attracting criticism. That is exactly what the times are calling for.

The second generic comment I would like to make is that much of the literature also critiques some of the more equitable approaches proposed elsewhere for a more ‘poor-friendly’ HSR. Many authors do not fully agree with the alternatives proposed:

  1. Many are convinced that proposing a bottom-up approach puts too much faith in attaining the many structural changes needed. Further, many are of the opinion that when management of services is turned over to the local people, they do not become any more efficient or effective.

– On the other hand, I, together with many others, still do find evidence that when the management of services is (really) turned over to the people, the added accountability and transparency DOES make them more efficient/effective than what they are now; not perfect, but better. Of course, this turning over of control has to be matched by government support of such a move including it reallocating resources to back the new truly decentralized structure. For sustainability purposes, any viable alternative will have to pass through this turning over of responsibilities, whatever other remedies are instituted. Even diehards would agree with some variant of this today.

  1. Other authors contend the problem is not the structure; the root problem, they think, is pervasive apathy and corruption at all levels of the public service –from the village to the top. Some of them may have become hardened through some personal experience to believe that people tend to act only when there is some compelling reason for it. And today, in many countries, there is absolutely no compelling reason for anybody to take their public responsibility seriously. In fact, these authors think it is against the public servants’ own self-interest to fulfill their public responsibility.

– Many of the proponents of equitable approaches do agree that people tend to act when there is some compelling reason for it; I remain convinced though that one has to and can create such compelling reasons for people to take their public responsibility more seriously using the right mix of (monetary and non-monetary) incentives, local support supervision and local accountability to beneficiaries. Devolving real powers to local populations, so that public servants are de-facto accountable to them, is feasible and is crucial for this.

  1. Unfortunately, many of our colleagues have also come to believe that predominantly tax financed health care is a myth. (‘Citizens often end up paying twice’, they say, ‘first for the consultation at the public clinic and then again at the private practice of the public-clinic physician; this is probably the reason for an increasing number of people going to the private sector services directly’).

– Against this, the many ‘other’ of us contend that there is absolutely no evidence (but a lot of faith) that private hospitals do a better job for low income groups or that they will locate in areas of need rather than of potential profit (when the evidence shows that only public hospitals serve disadvantaged groups or areas). Let’s face it squarely, as regards the private alternative, even if we could perfect all the ‘market distortions’ that hinder private services, the result would still be grossly inequitable and totally unworkable to care for the poor.

  1. Proponents of HSRs of any kind ARE genuinely interested in finding a workable solution to the major problems exposed by this humble ombudsman –granted.

– But what I found is that too many define the current realities with what I think is a bias and an a-priori skepticism against the public sector. That is the unhealthy attitude many of us think needs to be broken. The PUBLIC SECTOR IN HEALTH still has the central moral and de-facto responsibility to be the guarantor of equitable health services being made available to all its citizens; nobody can or will do it for the state. Within this context, neither the public financing of private providers (contracting out of clinical and/or preventive services) nor the private financing (running) of public health facilities (as for example currently in China) serves the interests of the poor equitably. The profit motive stands in the way.

  1. Finally, you may say that dogmas are just dogmas; and what we need are solutions.

– Yes. But it is HSRs, as currently applied, that seem to be more driven by dogmas than by evidence. From my ombudsman’s perspective, and not claiming exclusivity, solutions have to start with a vision that leads to a mission…and visions of an enhanced role for public sector driven solutions as here proposed are not dogmas; they are viable and in the best interest of those we purport to serve.


I thank Goran Dahlgren for his contribution to this text.

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