Promoting the private sector: a review of developing country trends

Two questions are addressed in this article: (i) How can itbe ensured that private sector resources promote national healthgoals? and; (ii) What can be learnt from the private sectorto enhance operations in the public sector? There is a surprisingdegree of private sector activity in both the finai icing andprovision of services, despite the fact that few countries haveadopted wide-reaching privatization programmes. In some countriespressure upon government budgets for health has led to privatesector expansion - in others rapid income growth accompaniedby increased demand for health care is a causal factor. A number of problems related to private for-profit providersare evident; often quoted are supplier-induced demand and excessiveinvestment in high technology equipment, the equity implicationsof private health care, and the availability of manpower forthe public sector. Governments have tried to tackle these problemsthrough a range of innovative interventions, however littleproper evaluation of these policies has been carried out. Whilesuch problems are less likely to arise with the private, not-for-profitsector, the financial sustainability of their activities ismore worrying. There is also a need to define more clearly therelationships between governments and not-for-profit organizations. The paper considers market-oriented reforms in industrializedcountries, and their implications for the health sector in developingcountries. The measures taken in industrialized countries appearto be of limited direct applicability in developing countries,due to factors such as the sparse coverage of health facilitiesin the latter. However the principles on which the reforms arebased are relevant, in particular the need for greater transparencyin the activities of public and private sector providers andin the use of con tracting out services. Finally it is suggestedthat too much research in this area has focused on defendingone or other side of the privatization debate. Not enough workhas considered the health sector as a whole, and the complicatedinteractions between public and private sectors as providers,buyers, financ ing agents and regulators of health care services.     

国际卫生体制改革的经验与教训

引入市场机制，采取分权、分级与分类管理等政策与措施是当今国际卫生体制改革中的主流特点，由于各个国家的社会经济体制与卫生保健制度不同，这些改革政策与措施所产生的影响与效果也各具特色。因此，在深化我国卫生体制改革的进程中，借鉴国际卫生体制改革的经验与教训具有一定的现实意义。     

Evolution and new perspectives of health care financing in developing countries

Over the last twenty five years, the perspective of health care financing has dramatically changed in developing countries. In this context, it is worth reviewing the literature and the experiences in order to understand the major shifts on this topic. During the sixties, health care policies focused on fighting major epidemics. Programs were dedicated to reduce the threat to population health. Financing related to the mobilization of resources for these programs and most of them were not managed within national administrations. The success of these policies was not sustainable. After Alma Ata, primary health care became a priority but it took some years before the management of the health care district was introduced as a major topic. In the eighties, with the district policy and the Bamako Initiative, the economic approach became a major part of all health care policies. At that time, most of health care financing was related to cost recovery strategies. All the attention was then drawn on how it worked: Fee policies, distribution of revenues, efficient use of resources and so on. In the second half of the nineties, cost recovery was relegated to the back scene, health care financing policy then becoming a major front scene matter. Two major reasons may explain this change in perspective: HIV which causes a major burden on the whole health system, and fighting poverty in relation with debts reduction. In most developing countries, with high HIV prevalence, access to care is no longer possible within the framework of the ongoing heath care financing scheme. Health plays a major role in poverty reduction strategies but health care officials must take into account every aspect of public financing. New facts also have to be taken into account: Decentralization/autonomy policies, the growing role of third party payment and the rising number of qualified health care professionals. All these facts, along with a broader emphasis given to the market, introduce a need for a better management of resources through financing mechanisms. Some major reports from WHO and the World Bank are the landmarks of the evolution on how to approach health care financing: The 1993 World Bank report on investing in health, the 2000 WHO report on health in the world and the WHO report on macroeconomics and health. In this early millenium, there is a general agreement on some major aspects of health care financing such as: Lack of resources for financing health care; cost recovery as a part of any sustainable health care system; health as a public good needing some extended subsidies; protecting people from the burden of disease as a part of financing schemes; equity in relation with the public private mix at the center of many debates; financing as a key mechanism for the regulation of the whole health care system and not only as a resource mobilization; HIV in bringing up new problems clearly shows how all these matters are related. Health care financing is at the heart of ongoing questions on health care reforms. Although developing countries have low insurance coverage and weak modern medical care, they share the same questions as developed countries: How to promote technical and allocative efficiency? What place for incentives? What role for the public sector? How can market and contracting bring results? What progress through stewardship and better governance?     

Equity and health systems reform in Latin America

The aim of any health care system is to help improve the people's health, and to do so as efficiently as possible. In order to improve the efficiency and equity of health services provision, many countries around the world have implemented reforms, including several Latin American nations. However similar the objectives may appear, the various ways societies implement such reforms reflect different values and concepts. This article analyzes the egalitarian and neoliberal values underlying different concepts of equity in health care. The authors develop criteria to interpret selected health services funding and provision strategies in Latin American health system reforms. These criteria are then applied to health care financing and delivery policies under the reforms currently being implemented in Colombia and Costa Rica.     

Medical dominance and neoliberalisation in maternal care provision: The evidence from Canada and Australia

Since the 1970s, governments in many high-income countries have implemented a series of reforms in their health care systems to improve efficiency and effectiveness. Many of these reforms have been of a market-oriented character, involving the deregulation of key services, the creation of competitive markets, and the privatization of health and social care. Some scholars have argued that these “neoliberal” reforms have unseated the historical structural embeddedness of medicine, and in some cases even resulted in the proletarianisation of physicians. Other scholars have challenged this view, maintaining that medical hegemony continues to shape health care provision in most high-income countries. In this paper we examine how policy reforms may have altered medical dominance over maternity care in two comparatively similar countries – Canada and Australia. Our findings indicate that neoliberal reforms in these two countries have not substantially changed the historically hegemonic role medicine has played in maternity care provision. We discuss the implications of this outcome for the increased medicalisation of human reproduction.     

Venezuela's Barrio Adentro: an alternative to neoliberalism in health care.

Throughout the 1990s, all Latin American countries but Cuba implemented health care sector reforms based on a neoliberal paradigm that redefined health care less as a social right and more as a market commodity. These reforms were couched in the broader structural adjustment of Latin American welfare states as prescribed by international financial institutions since the mid-1980s. However, since 2003, Venezuela has been developing an alternative to this neoliberal trend through its health care reform program, Misión Barrio Adentro (Inside the Neighborhood). In this article, the authors review the main features of the Venezuelan health care reform, analyzing, within their broader sociopolitical and economic contexts, previous neoliberal health care reforms that mainly benefited transnational capital and domestic Latin American elites. They explain the emergence of the new health care program, Misión Barrio Adentro, examining its historical, social, and political underpinnings and the central role played by popular resistance to neoliberalism. This program not only provides a compelling model of health care reform for other low- to middle-income countries but also offers policy lessons to wealthy countries.     

Financial and organisational reforms in the health sector; implications for the financing and management of mental health care services

Since 1980 many developed countries have planned and implemented health sector reforms of different scales and ambitions. Norway has been no exception, and the main political aspirations have been to increase efficiency and improve consumer choice and responsiveness. The major financial reform was the introduction of an activity based financing based on diagnostic related groups (DRG). Other central reforms include legislative rights for patients to choose hospital of their own choice, and the handing over of the responsibility of hospital based care form the county to the state. For some of these reforms mental health care is not included. The aim of the study is to appraise with examples from different countries whether it is feasible include metal health care into the reforms and whether the reforms in general are conducive for mental health care policy goals. The problems are elaborated and discussed at the level of technically and politically feasibility and the costs involved.     

欧美等典型国家医疗保险制度改革借鉴

近年来,几个典型国家针对本国医疗保险制度存在的的问题和弊端,采取了一系列措施,进行了比较深入的改革,使本国居民在医疗保障方面得到了切实的利益。本文归纳总结了其成功的做法,期望能够对我国的医疗保险改革有所借鉴和启示。     

“Enticing case study” or “celebrated anomaly”? Policy learning from the Cuban health system

Cuba is regarded as having achieved very good health outcomes for its level of economic development. It has adopted policies and programs that focus on prevention, universal access to healthcare, a strong primary care system, the integration of health in all policies, and public participation in health. It has also established a strong and accessible system of medical education and provides substantial medical aid and support to other countries. Why then, it may be asked, has the Cuban experience not had greater influence on health policies and reforms elsewhere? This article, based on a literature review and new primary sources, analyzes various factors highlighted in the policy transfer literature to explain this. It also notes other factors that have created greater awareness of Cuban health achievements in some countries and which provide a basis for learning lessons from its policies.     

From cooperation to competition in national health systems--and back?: impact on professional ethics and quality of care

Ethical behaviour in health workers is the jewel in the crown of health services. Health system policies need to nurture a professional service ethic. The primary health care policy envisioned a national health system led by the public sector and based on a philosophy of cooperation. A common theme of 'health sector reform' in OECD countries, introduced in the context of neoliberalism, has been the use of 'managed competition' to increase efficiency. Some countries that flirted with health system competition have returned to cooperation. Market relationships tend to be oppositional and to stimulate self-seeking behaviour. Health system relationships should encourage patient and community centred behaviour. The World Bank and bilateral donors have exported health sector reform theories from the north to the south, involving privatization and marketization policies. This is despite the lack of evidence on their desirability or feasibility of implementing them. Private health care has increased in many developing countries, more as a result of economic crisis and liberalization than specific health sector reforms. Much of this private practice is unlicensed and unregulated, and informal privatization has had a damaging effect on health worker ethics. The lead policy should be reconstruction of the public health system, involving decentralization, democratization and improved management. Commonsense contracting of an existing private sector is different from a policy of proactive privatization and marketization. Underlying the two approaches is whether health care should be viewed as a human right best served by socialized provision or a private good requiring governments only to correct market failures and ensure basic care for the poor. It is a matter of politics, not economics.     

美国卫生服务循证决策及其对中国的启示

文章分析研究了二十一世纪以来美国卫生服务循证决策。十年来,美国卫生服务调查数据分析显示,其疾病格局发生改转,美国卫生服务体系的工作重点已由急性损伤和传染病的救治,逐渐转变为慢性病和传染病的救治和预防、保健。及时调整、准确定位卫生服务体系的功能,制定了有针对性的医疗卫生政策。中国作为发展中国家,现已进入老龄化社会,原来的疾病和健康问题依然存在,同时也出现了美国等发达国家面临的健康问题。美国所遇到的挑战及其所采取的对策,以及发展趋势,为当前在中国开展卫生服务政策研究提供了启示。     

The role of strategic health planning processes in the development of health care reform policies: a comparative study of Eritrea, Mozambique and Zimbabwe

This paper reports on comparative analysis of health planning and its relationship with health care reform in three countries, Eritrea, Mozambique and Zimbabwe. The research examined strategic planning in each country focusing in particular on its role in developing health sector reforms. The paper analyses the processes for strategic planning, the values that underpin the planning systems, and issues related to resources for planning processes. The resultant content of strategic plans is assessed and not seen to have driven the development of reforms; whilst each country had adopted strategic planning systems, in all three countries a more complex interplay of forces, including influences outside both the health sector and the country, had been critical forces behind the sectoral changes experienced over the previous decade. The key roles of different actors in developing the plans and reforms are also assessed. The paper concludes that a number of different conceptions of strategic planning exist and will depend on the particular context within which the health system is placed. Whilst similarities were discovered between strategic planning systems in the three countries, there are also key differences in terms of formality, timeframes, structures and degrees of inclusiveness. No clear leadership role for strategic planning in terms of health sector reforms was discovered. Planning appears in the three countries to be more operational than strategic.     

Health care reform: informing difficult choices

During the last decade, policy makers in a large number of countries have attempted various reforms of their health care systems. Health care reform has been described as a 'global epidemic' (Klein, 1993). All health care reforms consist of very complex policy choices, some of which are examined in this article. After an introductory exploration of ideological issues, the objectives of health care reformers are considered. Three major policy objectives of health care reform are examined: cost containment; efficiency; and, equity. Three types of reform which have been advocated are also considered: public planning; market regulation; and provider-advocated reforms such as a 'basic package' with copayments and alternative means of finance. Finally, appropriate features of efficient health care reform are suggested, addressing explicit policy goals.     

Vertical or holistic decentralization of the health sector? Experiences from Zambia and Uganda

Many countries in Africa have embarked on health sector reforms. The design of the reforms differs considerably. A key feature of the reforms is decentralization, of which Uganda and Zambia are implementing two different models. This paper analyses the two models of health sector reform, and their implications for ultimate development goals. In Uganda, the whole government has been decentralized, with a wide range of powers and resources transferred to the districts. The health care system is part of the political set up of the country. In Zambia, only the health sector has been decentralized. Power and resources for health care have been divested to new parallel organizations. While useful lessons can be drawn from the managerial and administrative experience in the two countries, not least concerning donor coordination, it seems that neither form of decentralization has so far led to a clear and appreciable improvement of health services and, ultimately, to a clear focus on development goals, such as poverty alleviation. The conditions for this to happen are discussed in this paper.     

The role of non-governmental organizations and the private sector in the provision of health care in developing countries

A major component of total hzalth care in many developing countries is that provided by organizations outside the state sector. Analysis of the relationships between the state and non-state sectors and explicit government policies towards the non-state sector have, however, often been neglected. Within many developing countries, there is heterogeneity rather than homogeneity within the non-state sector, making the task of developing consistent and workable policies difficult. In order for such policies to be developed, a clear understanding of the characteristics and roles of the various non-governmental and private health care providers is needed. This, in turn, requires the development of analytical tools and evaluative criteria. This article outlines and discusses issues requiring consideration in the formulation of policies, and sets a preliminary agenda for research action.     

Reflections on curative health care in Nicaragua.

Improved health care in Nicaragua is a major priority of the Sandinista revolution; it has been pursued by major reforms of the national health care system, something few developing countries have attempted. In addition to its internationally recognized advances in public health, considerable progress has been made in health care delivery by expanding curative medical services through training more personnel and building more facilities to fulfill a commitment to free universal health coverage. The very uneven quality of medical care is the leading problem facing curative medicine now. Underlying factors include the difficulty of adequately training the greatly increased number of new physicians. Misdiagnosis and mismanagement continue to be major problems. The curative medical system is not well coordinated with the preventive sector. Recent innovations include initiation of a "medicina integral" residency, similar to family practice. Despite its inadequacies and the handicaps of war and poverty, the Nicaraguan curative medical system has made important progress.     

A framework for assessing health systems from the public's perspective: the ALPS approach.

There is hardly a country in the world where the health system is not undergoing major changes. Low- and middle-income countries are particularly hard hit by enforced reforms and commercialization. The overwhelming focus of assessment of these reforms has been on the supply side: effects on governments and providers. Yet the raison d'être of health services is to serve people when in need, and most systems have the equity objective of ensuring the widest possible access to essential services for the whole population, and poor people in particular. The Affordability Ladder Program (ALPS) is a tool for analyzing health systems from the public's perspective--the so-called "demand side," which the authors prefer to consider in terms of "need" for care. ALPS is concerned with how social inequities in health care are experienced by people in different sections of society. By taking a step-by-step approach to examining the many aspects of a health care system from a household/patient perspective, one can more accurately pinpoint where and why a country's health system is working and where it is breaking down, and identify the sticking points that need to be addressed by reconsidering present policies and initiating new ones to promote efficient, equitable health care systems.     

Planning health care in South Africa--is there a role for traditional healers?

Developing health policies for the 'post-apartheid' era has become an urgent task of the early 1990s in South Africa. A neglected policy issue thus far has been the question of whether traditional healers have a role to play in future health care, and if so what this should be. Rather than developing positions on these questions, this paper sets out the main debates which need the consideration of health care planners. Arguments for and against traditional healers in health care are presented, and alternatives which could be chosen are outlined. Options adopted by countries on South Africa's borders, Zimbabwe, Mozambique and Swaziland are briefly considered.