Who are the “blind optimists”? A comment on the Oxfam report

Hilary Standing, Gerry Bloom, David Peters, Kate Hawkins and Henry Lucas

In its recent publication, “Blind Optimism: Challenging the myths about private health care in poor countries”, Oxfam has produced a substantial report on the state and future direction of health systems in developing countries (1). We welcome this contribution to an increasingly important debate as the issue of how to move to universal access to health care continues to be high on the agenda of advocates, governments and funders. Interest in this area is likely to intensify as we reach the target date of the Millennium Development Goals.

Oxfam’s report raises very important issues on the roles of public and private sectors, but we find it disappointing.  Our primary aim in this commentary is not to add to the critiques others have made of the author’s selective use of evidence (2). We would simply note that where there is a patchy evidence base and wide variation in context, as is common in many subjects in international health, it is possible to make a case for any number of advocacy positions.  We would also note that the selective use of evidence in the report is compounded by an Anglocentric bias in what counts as evidence and therefore in setting the terms of debate. The diversity of health systems development in large parts of the world is excluded by either language or lack of institutionally dominant “voice” or both.  

The discussion of health markets is often emotive - which is unsurprising when one considers the importance of a functioning health system providing accessible, quality services to the well being of individuals, communities and nations. There is a need to recognise the many problems associated with an unscrupulous private sector – be it for profit or non profit. But an undue focus on the relative merits of public and private sectors, broadly defined, diverts attention from the big challenges that countries face in managing health system reforms that can better meet the needs of the poor. We need to understand alternative approaches for influencing unprincipled public or private actors to perform better and foster innovations for equity.

Through this commentary we want to note some fundamental challenges countries face as they attempt to improve the performance of their health systems. We believe the Oxfam report misses much of the reality of health system change in many low and middle income countries, the challenges they face, and the dynamic responses which are already emerging from those countries. Our aim is to stimulate a debate about how governments, donors and others can intervene in contexts of pluralistic health systems with blurred boundaries between public and private.

Beyond ‘privatisation’ - understanding complexity
The first difficulty that we have with the Oxfam report is the lack of a clear analysis of how health markets operate and the complex links between states and markets in high income as well as low and middle income countries. We want to stress that understanding the role and functions of health markets, formal and informal, is not the same as talking about, still less advocating, privatisation. Informal markets in health care were not produced by a deliberate policy of privatisation but by a whole range of political economy factors which go well beyond the conventional critique of neo-liberalism.

For example, in some countries, large numbers of informal providers are a direct consequence of earlier government programmes to train paramedics and community health workers.  The ‘barefoot doctors’ in China are a well-known example. During China’s transition to a market economy, many of the barefoot doctors left health work and others earned money by selling drugs. By the late 1980s village doctors mostly functioned as private practitioners, although they continued to undertake some public health work. Ex-community health workers in many other countries have found roles as drug sellers or providers of health informal health services. 

The development of large pharmaceutical and health service delivery companies in several rapidly growing middle income countries is also not a result of privatisation of health programmes, but a result of economic growth, the development of sophisticated manufacturing capacity and the emergence of commercial market opportunities. The formulation of systematic strategies for governments and other social actors to influence the impact of these developments on the poor depends on a capacity to understand the wide range of transactions which characterise health systems in rapidly changing economies.

Health markets are much more than the delivery of services or sale of drugs. They involve a wide variety of organisations, both upstream and downstream, that produce knowledge and products train personnel, organise the provision of services, provide expert advice in person, by telephone and over the internet, and undertake many other functions. They have complex legal and political relationships with each other and with the state (3). In many countries the boundaries between public and private are porous. Many government employees provide services or drugs for a charge (legal or illegal) and/or they work part-time in a private facility. In most cases, formal user charges are much smaller than informal payments. It is often difficult to determine who is a “public” or “private” provider because of the interlocking relations, transactions and incentives in which they are embedded. The challenges in aligning incentives with health system objectives and in influencing the quality and safety of services are therefore often as great in the “public” sector. The simple dichotomies between “public” and “private” sectors and between “social” and “commercial” motivations and incentives bear little resemblance to this complex reality. Solutions to the very real problems of equity, access and quality which neglect these realities will continue to fail.

The evidence base
The second difficulty with the Oxfam report is that the appeal to systematic and rigorous evidence is seductive but unrealistic in any context of rapid change, particularly when what counts for “evidence” is limited by conventions of “evidence-based medicine” (4). Figures on international and bilateral aid and loan expenditure indicate that very large health transfers go to governments for health sector programmes and direct budget support, but we are not aware of any significant “evidence base” that demonstrates the particular effectiveness of this form of aid in changing quality of health services, expanding coverage, or improving health outcomes for the poor. Aid architecture is crafted for a gamut of political economy reasons. In the case of macro level policy instruments, these are profoundly tied to the politics of relations with and between national governments. It is likely that most major policy decisions are not founded on the kind of evidence that the report advocates. But even more importantly, it is difficult to see how they can be.
The success or failure of health sector interventions is typically highly context-specific. We can often learn valuable lessons by careful analysis of the implementation of such an intervention within a given context but will rarely be able to argue convincingly that outcomes can be extrapolated to other locations, populations or time periods. The initial excitement generated by the Mwanza HIV prevention trials and subsequent disappointing results from “similar” exercises provide a salutary lesson on the need for a more realistic approach both to the evaluation of such interventions and the use of those evaluations in policy (5).

The challenge of scaling up to universal access
There is wide agreement that something needs to be done to substantially increase access to effective health services in low and middle income countries. This includes advocacy to build political commitment in these countries and in countries which contribute to international aid efforts. The real blind optimists have tended to ignore the magnitude of the challenge of translating large financial commitments into effective health services in different contexts. A series of papers on the costs of scaling up high priority interventions in health are based on replicating a common set of health interventions with identical effectiveness and costs through entirely public sector delivery, notwithstanding the vast differences in contexts and implementation capabilities (6). A much more modest effort has focused on a search for a small number of private sector service delivery models as potential candidates for rapid scaling up through external funding. Advocates for both scenarios have tended to disregard or play down the huge non-technical challenges that scaling up faces (for instance the often intractable “governance” problems in the public sector and the absence of regulatory oversight in the private sector). Over-optimistic advocacy for rapid scaling up of interventions through either public or private sectors is often tied to implicit or explicit ideological positions. It ignores the long experience of development projects which fail to deliver or do more harm than good. The creation of an effective health system is difficult and the history in many countries of the creation and subsequent decay of a government health system means that we need to acknowledge that the challenges are much more complex than the analysis and recommendations in the Oxfam report.

There is one place where we may learn more from the evidence, and that is history. This perspective is generally lacking from debates about health systems, where evidential needs are too often constructed around normative positions and what it would take to reach them. History shows us the path dependency of health systems and the complex interactions between “public” and “private” that were involved in the move towards universal coverage systems in high income countries and continue to define their health systems (for instance, General Practitioners as “private” contractors in the UK). These countries exemplify a wide range of settlements, institutional arrangements and financing mechanisms which evolved in highly specific ways in different places.

There will almost certainly be many roads to universal access in the low and middle income countries involving different institutional arrangements and ways of managing health markets.  And there will be contexts where markets and market driven innovation in health sector supply and delivery chains will help accelerate the goal of universal access.  It is time to draw a close to the era of health systems paternalism, however well intentioned (“be like us – we know how to do it best”).  And repeating the familiar mantra that “we need more evidence” before anything involving the so-called “private sector” is tried is not a helpful prescription in a complex and rapidly changing environment where active experimentation is already going on and will not stop at the behest of academic researchers or advocates no matter how impassioned their arguments. We need to acknowledge the real challenges and risks that the drive to build effective health systems must address. What is badly needed is more not less funding to support promising innovation and learning, wherever it is taking place, alongside systemic monitoring and evaluation, as these efforts to work with rather than against complex realities unfold in real time (7).

References:

1. Marriott A, 2009, “Blind Optimism: Challenging the myths about private health care in poor countries”, Oxfam Briefing Paper.
2. See for example, Harding A, 2009, “Oxfam – this is not how to help the poor” Centre for Global Development blog, February 11th, 2009 (url last visited 15 April 2009); World Bank, 2009, World Bank responds to new Oxfam health report, World Bank web page
   (url last visited 15 April 2009); Montague D, 2009 “Oxfam must shed its ideological bias to be taken seriously” BMJ 2009;338:b1202
   (url last visited 15 April 2009).
3. Bloom G, Standing H, “Future health systems: Why future? Why now?” Special Issue of Social Science and Medicine; 2008. Volume 66, Issue 10,Pages 2067-2075
4. Peters DH, El-Saharty S, Siadat B, Janovsky K, Vujicic M. 2009. Improving Health Services Delivery in Developing Countries: From Evidence to Action.  Washington: The World Bank.  Forthcoming May, 2009.
5. Grosskurth, Heiner, Ronald Gray, Richard Hayes, David Mabey, Maria Wawer. 2000. Control of sexually transmitted diseases for HIV-1 prevention: understanding the implications of the Mwanza and Rakai trials. Lancet 2000; 355: 1981–87.
6. Johns, B, and T.T. Torres, 2005, “Costs of Scaling Up Health Interventions: A Systematic Review.” Health Policy and Planning 20(1): 1–13.
7. Peters DH, El-Saharty S, Siadat B, Janovsky K, Vujicic M, 2009, Improving Health Services Delivery in Developing Countries: From Evidence to Action, Washington: The World Bank, Forthcoming May, 2009.