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
PUBLIC FIRST