11. Let it be understood here that there is nothing inherently wrong with market-oriented reforms in health, provided: a) They work in the direction of equity, as well as greater efficiency, b) they receive no government subsidies, and c) they comply with well monitored regulations set-up upfront. But these prerequisites hardly exist anywhere at present –including in countries like China and Vietnam…
12. The bottom line is that some important, structural changes need to be enforced to get reforms in the health sector into a more sustainable track. Such a track has to lead to the outcome of assuring quality care for the prevalent health problems of the growing number of poor people worldwide. Public hospital care, for example, has become unaffordable to the poor due to steep user fees and ‘under the table payments’. Subsidizing such a system, instead of reforming it, will only channel additional funds to the wrong (non-poor) recipients.
13. HSRs can and have thus been used as crutches to pretend one is changing the system, when it is basically staying the course or even going backwards. Historically, there is a non-accidental link between Structural Adjustment Programs, Adjustment with a Human Face and HSRs. The link is actually a progression, one with a calculated internal logic, namely to apply the principles of the market economy to the health sector.
14. The bottom line is that most current HSRs cannot address the constraints to equitable access to care faced by the poor. Not even with ‘good targeting’ –a concept we reject anyway since it does not address the determinants that keep people vulnerable generation after generation.
15. Moreover, HSRs use some technical terminology with misleading imprecision (or bias). Examples that come to mind are:
-‘efficiency’ (which is measured in economic terms only);
-‘willingness to pay’ (which is used in place of the much more real determinant: ‘ability to pay’);
-‘cost-sharing’ (which is applied to regressive fee for service systems when the real issue is who is to pay more and who less or nothing).
So, what would be more effective and sustainable?
16. Perhaps the best response to a part of this question is in another question: Why not ask the beneficiaries directly to respond to this question? This is not an evasive response! This response has the wisdom of accepting the fact that:
-localized viable responses will (and should) be multiple and varied; there is not one response that fits all (or even many) diverse situations;
-our technical expertise can be put to a more effective use in a dialogue with community representatives;
-communities do not always know best, so mistakes will be made; quickly learning from such mistakes can lead to more sustainability than applying schemes imposed from outside.
17. Such a grassroots-centered approach calls for an unprecedented change in our priorities and in the way we operate. The locus of control has to shift to beneficiaries for decisions that affect them directly on an everyday basis; and we ought to be instrumental in such a transition.
18. At the same time, equity oriented measures have to be implemented from the central level. Some of the key elements of such reforms could be the following:
Public rural health care services will still need to be primarily financed by governments (central and local). Only up to 10-15% can be realistically expected to be raised by community contributions or rural health insurance schemes.
Financing public urban health care services in poor neighborhoods will probably also still need 50-60% government financing.
Financing of health care will have to move away from regressive fee for service schemes and towards prepayment schemes where the whole population –not only the sick– contribute.
Direct and indirect progressive taxes must, therefore, constitute the financial base in an efficient, equity-oriented health care system. Government funds can be used directly to fund public health services or can subsidize social health insurance schemes that will progressively cover the whole population.
If communities do contribute to the financing of health care services, they will have to have more de-facto control over how the funds are used.
Governments will have to gradually reallocate resources from rich provinces/districts to poorer ones according to a set of needs-based indicators.
General tax revenues that apply more to the rich (e.g., taxes on luxury items, spirits, tobacco, or on assets, estate and wealth) will have to be considered more seriously as a source to bring in financial resources from other sectors to the health sector.
Health staff will have to become more accountable to local communities.
The use of existing resources should be rationalized and this will mean reallocating and sometimes shedding personnel and mobilizing more resources to outreach work outside the health stations. In the medium term, health staff incomes will have to be brought up to minimum standards of living based on a system of monetary and non monetary incentives.
The roots of the twin trend towards self-medication and underutilization of PHC facilities will have to be broken in each locality with ad-hoc measures taken with major inputs from the community itself; existing essential drug programs have to be made to work; drug companies (and clinical health staff…) have to be made to comply!
19. These are but a few of the central and local level options that need being looked at more carefully again. But this listing is not the purpose of this review. The idea is that the process opening the doors to a more participatory and empowering dialogue with beneficiaries (especially engaging women) has to come up with more of the answers and options.
20. One is left to wonder how many of the more sustainable Equity-Oriented Health Sector Reform (EOHSR) measures quickly reviewed here have a chance of being seriously considered and implemented in the near future… The bottom line here is that we remain convinced that tinkering more with the HSRs proposed so far will not do. That is the sad reality. Precious time is likely to be lost only to see the problems of inequity worsen.
21. We think that what is really needed is a “HSR of the public health care sector”, not one overwhelmingly in the direction of the private sector (we ask ourselves why the former option is flatly left out in mainstream HSR discussions and only more absolute market-oriented options are explored/proposed). The so often touted non-service-mindedness of the public sector is not a given. We need to fix a system that –granted– has many flaws. But it also has many strong points! Only when its core is streamlined and strengthened, can one consider contracting out some ancillary services to the private sector –provided there is a fair system of competition in place.
22. This brings us back full-circle to the old ‘political will’ issue which is not really an issue of “will” as such: it is an issue of “choice” –of political choice. And being an issue of choice, for the time being –short of an awakening of civil society initiatives and movements in many places around the world at about the same time– the responsibility to move towards Equity-Oriented Health Sector Reforms is still squarely back on the lap of the respective governments. Much advocacy and lobbying on our part, as well as work to neutralize powerful internal and external forces opposing the view here presented, are still needed in order to put the last first….
Claudio Schuftan, Ho Chi Minh City, cschuftan@phmovement.org
Goran Dahlgren, Stockholm, dahlgren38@telia.com