Reproductive health services in Reproductive health services in the 21the 21stst century: Is anyone century: Is anyone shortchanged?shortchanged?

TK Sundari Ravindran &Sharon Fonn

Messages and outlineMessages and outlinePrivatisation in health is a major deterrent to

progress towards the ICPD agenda SRH advocates need to engage with the larger health

system challenges to achieving universal access

Major drivers and manifestations of privatisation in health

Privatisation of SRH service delivery: analysis of illustrative examples using AAAQ lens

ALSO IN THE PAPER BUT NOT DISCUSSED IN DETAIL NOW:

Privatisation in health financing and how this affects SRH services

Example of a country trying to achieve a balance between surviving in a global economy and protecting the right to health of its citizens

Chasm between ICPD Chasm between ICPD aspirations and reality on the aspirations and reality on the groundgroundWDR 1993 “Investing in health” a

major landmarkHealth sectors of many developing

countries in crisis. Reforms introduced that would change◦Financing mechanisms – to increase

private modes of financing◦Priority setting mechanisms to change the

range of services that would be financed by the government and by others

◦Role of the state from that of financing and providing health services to that of stewardship (regulating the private sector)

Arguments for Arguments for creating/promoting ‘market’ creating/promoting ‘market’ for health carefor health careThere is already a large private sector and

this needs to be harnessed to achieve national health goals

“Market”, through competitive mechanisms is more efficient in allocating scarce resources. Government should only provide “public goods” in health.

Expanding the private sector would contribute to health equity. Those who can pay will use the private sector and public resources can be better targeted at those who cannot pay

Global forces underlying Global forces underlying increasing support for increasing support for privatisationprivatisationUnipolar world with the disintegration of the

Socialist Bloc – increasing support for the capitalist economic model

Shrinking donor aid to international organisations and financial institutions

WTO and political support for the creation for a market in services, including health services

Interest on the part of the corporate sector in the potential benefits of ‘partnerships’ in health: in terms of image, and also in terms of market creation

The current recession challenges the wisdom of marketisation – but have things changed on the ground?

Global Health InitiativesGlobal Health InitiativesMajor players in setting the Global

Health Agenda in today’s world. WHO and WB relegated to a minor role.

Known as “Global PPPs” and emerged in late 1990s and 2000s.

By 2009, > 100 GHIs for 27 health concerns. Four are most powerful: Global Fund, GAVI, PEPFAR and MAP.

Predominantly multi-stakeholder partnerships involving e.g. UN agencies, IFIs, bilateral donors, foundations, international NGOs, private for-profit entities.

GHIs and country health GHIs and country health systemssystemsHave increased development assistance

for health for the specific diseases and concerns addressed by GHIs

Reinforced and strengthened vertical programmes

GHI funding may not be in sync with national health priorities.

Increasing inequalities in terms of met needs, by type of health problem.

SRH concerns other than HIV/AIDS largely absent from GHIs.

But do we SRH to be addressed in this way?

PRIVATISATION OF PRIVATISATION OF SRH SERVICE SRH SERVICE DELIVERYDELIVERY

Contracting in and Contracting in and contracting outcontracting out

◦Of non-clinical services: canteen, laundry, ambulance etc.

◦Of some clinical services e.g. laboratory, x-ray and scanning

◦Contracting out of all primary care services to not-for-profit or for-profit entities.

◦Usually involves charging for services.

Private-provider networks Private-provider networks Janani in India; Green Star and Key

Social Marketing in Pakistan; Well Woman Modwife Clinics in the Philippines; Biruh Tesfa in Ethiopia; Market-day midwives in Kenya; MEXFAM in Mexico, IXCHEN in Nicaragua

A standard set of services under a shared brand

Subsidised products and supplies and training support; loans to improve infrastructure and equipment., marketing support.

Initiatives to make private Initiatives to make private provision of SRH services provision of SRH services financially viablefinancially viable“Midwives loan fund” in Indonesia in

1997 to give loans to midwives for setting up private practice.

2005 – “Banking on Health” project: training and technical support for private providers to run better businesses; link them with financial institutions.

More recently: “Development Credit Authority” offers partial credit guarantee to banks lending to private provider networks.

Questions to Ask about Questions to Ask about PPPsPPPsAccess

Availability

Quality

Accountability

ProspectsProspectsPotential for increasing access to

services where government unable to provide SRH services for political reasons; or to reach specific groups with whom NGOs have a good rapport.

Contracting-in clinical services or physicians helps overcome the human resource crunch.

Non-clinical services can be contracted to private sector to reduce the administrative burden on the public sector

Concerns-1Concerns-1Contracting non-clinical services has not

always been beneficial; sellers’ market Lack of experience on the part of

governments in writing and managing contracts leading to inefficiencies.

Where private physicians are contracted by the public sector, unless properly regulated, result in increase in health care costs due to unnecessary prescriptions, tests and procedures. Alternately, essential care does not get provided

Concerns-2Concerns-2Contracting within hospital settings for

diagnostic and pharmaceutical services: raise equity concerns.

Provider networks: targets those with some ability to pay and not the poorest. Therefore not an alternative to public provision.

Narrow range of SRH services : select contraceptive methods; usually only outpatient care, abortion services never included and even delivery care is the exception rather than norm.

Concerns-3Concerns-3

Quality the biggest casualty; quality of training not the best; big difference between what doctors said they do and what they actually did. Information and counselling rarely provided.

Some models have unqualified providers with a few days’ training and no back-up support providing services. Complete neglect of infection prevention procedures:◦“Contaminating disposable ‘clean’ gloves◦Touching insertion instruments◦Not swabbing vagina and cervix with

antiseptic solution before insertion of Multi Load CuT

Larger health system Larger health system implicationsimplicationsUSAID is the biggest player in efforts to

privatise SRH services. DFID and some European donors smaller players.

Donor funding being diverted from the public sector to creating a market for health.

Further accentuates resource crunch in the public sector. Those who cannot pay for health care would be worst affected – they will have to resort to the affordable “informal” SRH care ( if these are still available!)

Larger health system Larger health system implications-2implications-2Draining of human resources from the

public to the private sector, compromising quality of care in public sector facilities

Private sector not always better quality or more efficient.

Market creation efforts do not “free-up” resources that can be used for the poor. The reality is one of shrinking resources; when patient load falls, fewer resources are allocated to the public sector resulting in its steady deterioration and decline.

SRH services need to be SRH services need to be publicly financedpublicly financedPrivatisation in financing refers to

increase in out-of-pocket (OOP) payments or to various forms of insurances for paying for health care. OOP – clearly problematic.

Any insurance requires risk pooling (rich subsidies poor, healthy for sick,). To make a profit from it need to restrict to random and low probability events – this excludes for example pregnancy and contraception

Is there another way? Is there another way? Thailand – universal coverage Cambodia’s Health Equity Funds Social Health Protection Schemes

operational in many Latin American and Caribbean

Scope for improving on these models towards ICPD agenda.