OXFAM response to the World bank strategy for population health
Chieh-Hsiu Liu
World Bank strategy for health, nutrition and population results 2007 to 2017
Oxfam response
Summary
There is growing international recognition that health systems in poor
countries need extensive strengthening if MDGs are to be met. A
proliferation of disease-specific interventions by global agencies is
undermined by weak health systems. Meantime such initiatives threaten
to undermine the already weak systems. Decades of chronic
under-funding of health systems have led to the current dire
situation. A particular challenge is the massive shortage of
health-workers, the low wages they receive and the poor conditions
under which they work, especially in sub-Saharan Africa.� Oxfam
strongly supports an increased donor focus on strengthening health
systems.
The World Bank strategy for Health, Nutrition and Population, 2007 to
2017, is now being drafted. Recommendations will be presented to the
Board of Directors in December 2006 and the strategy will be launched
in the 2007 financial year.
The strategy envisages greater World Bank spending on strengthening
health systems in low and middle- income countries. There is a new
emphasis on health results rather than system inputs, with support to
data and monitoring systems that can measure those results. Country
teams are to be given more independence to work with recipient
governments, in order to support multi-sectoral arrangements that may
have a positive impact on health. The Bank will collaborate with
vertical, disease-based initiatives such as the Global Fund, rather
than replicating them. Governance issues feature throughout the
strategy document.
Oxfam welcomes those broad outlines, but has serious concerns with a
number of key assumptions in the strategy, with the omission of some
important considerations, and therefore with the Bank's policy
prescriptions for health system strengthening.
1. The Bank claims a unique comparative advantage in
strengthening health systems. There is considerable research
demonstrating the lack of success of the health reforms advocated by
the Bank in the 80's and 90's. In particular the infamous Structural
Adjustment Programmes (SAPs) which advocated cuts in public
expenditure on health that lead to the current health system crisis in
sub-Saharan Africa[i].� The Bank has a role to play in giving
technical advice to recipient countries on how best to organise the
pooling and allocation of funds for health services. However, there is
nothing unique about the Bank's expertise in public health and its
analytical record is weak[ii]. It was the WHO Commission on
Macroeconomics and Health which tackled the question of 'what is
needed and what would it cost' to provide basic health care in
low-income countries.
2. The equation of out-of-pocket payments with ability to pay for
services contradicts the Bank's own analysis on how paying for health
care drives people into poverty- as stated in the same document. The
introduction of user fees, under the Bank's advice, has led to serious
inequity of access given that poor patients, especially women, cannot
pay the cost of treatment. There is considerable research to show that
by preventing people from using the services, user fees have also
landed women with a huge caring burden. Yet the Bank offers paying for
health care as a recipe to generate funds and ensure quality of
service.
3. The Bank's analysis is clouded by a bias towards private
provision without thorough understanding of the fragmented,
unregulated, and small provider nature of the private sector in
developing countries. It is unclear how the Bank envisages weak public
sectors being able to regulate and manage a fair, equitable and
efficient system of privatisation in the context of poor ability to
pay. There is serious evidence that private providers are unable to
deliver equitable access to health services. Oxfam's research in South
Asia shows that Sri Lanka and Kerala State in India have been able to
provide comparatively far greater universal protection from health
risks through publicly financed models of public provision, where
services are free at the point of use. Therefore the prescription that
private sector providers are the panacea to cure health system
failures is erroneous. It is precisely in the countries where weak
public systems prevail that contracts also fail due to weak regulatory
institutions and capacities. Private contracts only provide equitable
access where state revenues, capacities and institutions are
sufficiently robust.
4. The strategy almost exclusively promotes a particular type of
insurance -social health insurance system as a way of financing health
care. However, as the document fleetingly acknowledges[1], there is a
need to leverage many other sources of revenue beyond income-related
contributions in low-income countries. The social Health Insurance
advocated by the Bank may be appropriate in some middle-income
countries, as evidence from Thailand would suggest. However, there is
little evidence that this approach can be used in low-income countries
without creating a two-tier health system that erodes solidarity
between the haves and the have-nots. In Rwanda, the Global Fund pays
insurance premiums for poor people who wish to benefit from
facility-based mutuelles, but these schemes have thus far only worked
in small isolated localities with heavy external financial input.
Evidence from the Equitap study in Asia suggests that tax-based
funding systems are more effective at protecting poor people against
health risks. Oxfam recommends a normative approach of financing and
provision of health care that explicitly aims for universal, equitable
access if the Bank is serious about health system strengthening and
eradicating poverty. Therefore, the Bank must be willing to support
client countries that wish to develop national revenue-based systems
from tax, aid receipts and other domestic resources.
5. The Bank continues to equate public sector systems and workers
with corrupt services that are unresponsive to user demand. At the
same time, the Bank promotes the idea that the private sector is
inherently more accountable, less corrupt and of a higher quality. The
evidence does not support this argument. Private contracts in
developing and developed countries are a breeding ground for
corruption. There is scant evidence that private providers are more
efficient than public providers.
6. This draft strategy also suffers from some glaring omissions.
There is a total lack of gender perspective. The evidenced conclusion
of private payment mechanisms is that women and children miss out on
health services; women and girls miss work and education opportunities
to care for sick relatives; and thousands of women die in childbirth.
In a related vein, the analysis equates reproductive health with
family planning. There is little emphasis on sexual and reproductive
health services nor is there any clear vision on maternal health.�
7. The role of specialised United Nations agencies is also
omitted. These are the agencies that have comparative advantages in
health policy development, service planning and management, standards
and guidelines- setting, disease surveillance, human resources and
access to medicines. The Bank does not have a comparative advantage in
these areas.
The World Bank draft strategy should be rewritten in order to correct
erroneous assumptions and crucial omissions:
� Out-of-pocket expenditures are not indicative of ability to
pay for health services. In particular, the demand even for small
payments denies women and girls their rights to health.
� Private insurance payments do not achieve the universal
level of health services that guarantee the right to health in low
employment economies.
� Private contractors are not inherently more efficient at
providing quality services.
� Private contractors have proven unable to provide equitable,
universal services.
� There is widespread corruption in the contracting-out of
health services in countries with weak state institutions and
capacities.
� Public health workers are not inherently corrupt. They work
under bad conditions and remedies for their petty corruption should
address the core issues of salary, career and working environment
incentives. Specific measures should be promoted to retain female
health workers in rural areas.
� The health rights of women and girls should be explicitly
acknowledged in the strategy.
� The strategy should acknowledge the comparative advantages
of UN institutions with which the Bank has to collaborate.
1. What does the new health strategy say?
1.1. The Bank has analysed external and internal challenges and
opportunities that enable or hinder it to "assist global partners in
their efforts to achieve the MDGs, additional country-defined HNP
priority results, and to improve health system performance in low- and
middle-income countries". The analysis pointed to a number of
conclusions (with relevant paragraphs in square brackets):
� New development assistance architectures for health have
emerged in the last decade, with proliferating agencies tackling
specific diseases [25c,e].
� This has created change for the good, e.g. new vaccines
under development and cheaper drugs available, but has put strains on
the underlying health delivery systems [25d,e,f,h].
� The Bank's main advantage is helping client countries to
strengthen 'horizontal' systems – within the health sector but also
across many sectors, and with harmonised donor assistance [25d, 42].
� Vertical, disease based initiatives are better served by
other agencies. The Global Fund is singled out in this regard [25c].
� Bank projects have failed to show results in the past,
either because results were not being sought (only inputs were
required) or were not being measured [25b].
� There is substantial out-of-pocket private financing of
health care and substantial private sector provision already in LICs
and MICs, but public-private complementarity is underdeveloped [25g].
� Strong country presence and country focus of the Bank is one
of its most important comparative advantages [45].
1.2. There is a new emphasis on measurable outcomes over a long term
and over many sectors. The paper identifies three main strengths that
will help it to achieve results. ' These are:
�
1. Country focus through the Country Management Units – these
support clients to develop and own their own plans, and will be
strengthened [45-6].
2. Intersectoral approach to HNP results, in support of the fact
that many factors other than health service delivery contribute to HNP
results and performance. Although the paper mentions crucial sectors
such as income, environment, education, water and sanitation� [47-9],
it focuses on the financial sector in the rest of the paper.
3. Health system strengthening approach to HNP results. The Bank
sees its advantage here in health financing, system governance,
accountability for service delivery and demand-side interventions.
[52-5].
1.3. Based on this analysis, the draft strategy proposes new policy objectives:
� Improving sector governance' as a new objective.
� Not including� 'strengthening health systems' as an
objective, but rather as 'a means for Bank country assistance to
achieve all [objectives]'.
� The other objectives remain from the 1997 strategy: improve
HNP outcomes for the poor; protect households from impoverishing
effects of illness; work with countries to ensure sustainable
financing [60].
1.4. The recommendations for internal change at the Bank centre on the
need to integrate HNP sector with other sectors, so that different
sector, country and regional units have the skills and incentives to
address all factors that affect the HNP sector, especially fiscal
space and governance. [88-90].
A new sector team is proposed, a 'rapid response health team' of five
experts to advise on integration of health sector priorities with
other strategic issues, particularly fiscal space, public sector
governance, financial services and social protection [94].
Finally, the Bank intends to withdraw from vertical, disease-based
initiatives but will aim to coordinate with global partners to
complement the Bank's comparative advantages [95-104].
2. What are Oxfam's concerns with the strategy?
Oxfam is concerned about a number of erroneous assumptions in the
strategy, as well as some glaring omissions:
2.1. The Bank is right to state that most payments for health services
in low-income countries are private. So what's wrong with formalising
those payments?
Paragraph 57 states that "private provision and private funding
dominate health systems in LICs and in many MICs… thus, improving HNP
results requires the Bank to provide sound policy advice to client
countries on how to engage with private providers and how to leverage
out-of-pocket expenditures so that households demand, and insurers
supply, more insurance services." Translated this means 'Poor people
are already paying, so lets have a system that organises that payment
and makes it fairer, and seeks to spread the risk'.
The Bank recognises that out-of-pocket expenditures (OOPs) in LICs
drive whole families, and even generations of families into dire
poverty. The document itself states as much (para 67) and provides
statistical evidence in fig. 24, annex A- although it ignores the
specific impact on women and girls. The poorest people are often
unable to pay and therefore do not use health services whether public
or private.� When they do pay it is often by selling their assets,
borrowing money, withdrawing girls from schools, and decreasing
spending on essential items such as food and treatment for other sick
members of the family. An episode of ill health is one of the key
reasons families are driven into poverty, as the paper itself
confirms. Experiments with exemptions from formal fees for poor people
have failed to protect destitute households, who remain excluded from
health services. Exemption systems are notoriously hard to implement,
subject to widespread corruption, and often end up being 'captured' by
relatively wealthier households.
It is therefore erroneous to claim that the scale of OOPs shown in
fig. 2 is a given fact and can be harnessed into pre-payment systems
and pooled across populations.� Many people pay for health care
because they have no choice: user fees introduced under the auspices
of the WB are a key factor in this lack of choice.
Based on the mounting evidence of a negative relationship between OOPs
and equity, the Bank must commit to abolishing user fees.
2.2. What is wrong with social insurance systems?
Social health insurance is one way of financing services but it is not
the only way or necessarily the best way in most developing
countries.� It relies on the existence of a large formal sector, where
health insurance can be taken from wages, and where people can afford
it. In many LICs the formal sector is tiny: it accounts for just 5% of
the employed population. The vast majority are simply too poor to pay
for healthcare, especially in sub-Saharan Africa. Income-related
insurance schemes have so far created two-tier health systems that
further erode national solidarity and undermine the long-term pursuit
of universal and equitable health systems.
In Germany and France the system of social insurance based on people's
employment took over 100 years to establish universal coverage. When
insurance is not available to all then it becomes affordable for a
few, as is the case in the US where 18,000[iii] people die every year
because they do not have health insurance. Successful developing
countries have for the most part relied on paying for health services
from general taxation, natural resource revenue and aid receipts. Sri
Lanka, Botswana, Cuba and Malaysia are cases in point. More recently
Uganda, which removed user fees for health in 2001, saw an immediate
50 to 100 percent increase in attendance at clinics and a 105 percent
increase in immunisation rates[iv].� This removal of fees was
accompanied by massive investment in expanding health services to
reach poor people in rural areas. The success of such public sector
examples is not mentioned in the new strategy.
The Bank must stop promoting social health insurance as the only way
to finance health systems in low-income countries. Countries must be
free to choose to pursue public investment in public services.
2.3. What is wrong with contracting out the provision of health care?
This strategy ignores the evidence that contracting out has not been
the method used in the vast majority of countries that have
successfully expanded health care for all.� Research cited in Oxfam's
report, In the Public Interest, shows that public financing of
national services based on large-scale government provision has had a
far greater impact on providing services to poor people. The history
of health service development in Europe shows that universal coverage
(still not available in the USA) has been achieved only through
government financing and organisation with highly sophisticated
national government institutions regulating and providing services.
The same has happened in developing countries such as Sri Lanka, where
political values and commitment were crucial in developing services
that slashed maternal mortality rates over a very short period.� In
developing countries that have succeeded in expanding healthcare,
government has virtually always been the largest provider of simple
and applicable health services for all.
This does not mean contracting out does not have its place, or that
private providers are not important. But evidence shows that
market-oriented reforms consolidate power "with central decision
makers and privately interested service delivery organisations" rather
than transferring power to service users, which is the Bank's stated
interest in promoting such reforms[v].
The strategy is wrong to equate contracting out services with less
corruption and greater accountability. Box 1 on page 27 is a further
example of erroneous argument in this document. Oxfam does not accept
the statement that 'contracting out services and overseeing
performance' leads to 'accountability tightening'. There is hardly any
evidence to support this. On the contrary, there is plenty of evidence
to suggest that contracts account for a large proportion of
unaccountable fraud, even in industrial countries with sophisticated
accountability systems in place. The 2006 Transparency International
report on health services and corruption clearly identifies
contracting out as a major source of health care fraud. In developing
countries with extremely weak systems of regulation, contracting
services out to the private sector is extremely likely to lead to
opportunities for fraud, bribery and corruption.�
There are no grounds for the a priori assumption that contracting out
services and charging fees will automatically lead to greater
accountability, or that public provision and free services are
automatically more prone to corruption.
The Bank should review its assumptions and base its policy on
evidence. In particular it should review the erroneous equation of
contracting out with decreased corruption and increased
accountability. The Bank should question the wisdom of contracting out
health services and should emphasise the need to build and improve
government provision of services in poor countries.
2.4. Why does gender matter?
The burden of diseases and caring for the sick falls
disproportionately on women and girls. Girls can be pulled out of
school in order to look after a sick relative and/or to save money to
pay for treatment. Women have less access to resources, so they are
less able to make independent decisions on payment for health
services. When fees are charged, women miss out on seeking medical
care. After introducing fees for health care in Nigeria, research in
Zaria district found that the number of babies delivered in hospital
halved, and the number of mothers dying in childbirth doubled. Every
day, 1,400 women die needlessly in pregnancy or childbirth. Only
countries like Sri Lanka that have ensured access to maternal services
in rural areas have been able to address this unjust situation – very
few Sri Lankan women live more than 1.4km from a health clinic, and 96
percent of births are now attended by a qualified professional. But
overall, women in developing countries have a 1 in 60 chance of dying
from pregnancy-related causes. Compare that to 1 in 2,800 in developed
countries.
The Bank must fully integrate gender considerations into this 10- year
strategy. The health of women has an impact on the health and
productivity of the entire household and vice-versa.
End
3rd November 2006
________________________________
[1] paragraph 68
________________________________
[i] See 2004 editorial by WHO African Regional Director Dr Ebrahim
Samba. www.afro.who.int/regionaldirector/emeriti/samba/reports/afrhealthsys200412en.doc�
"[Structural Adjustment] reforms were originally designed to stabilize
developing country economies. In reality, they imposed harsh measures
which deepened poverty, undermined food security and self-reliance,
and led to resource exploitation, environmental destruction and
population displacement. The health sector was particularly adversely
affected, and few proactive steps were taken to protect vulnerable
populations and basic services.
[ii] The IEG's 2004 Review of Development Effectiveness found that
health and education projects were unsuccessful in improving outcomes
in 16 out of 21 countries because they were "limited by complex and
ambitious project designs, lack of grounding in the countries' fiscal
and institutional contexts, and an overcentralized approach to sector
management".
[iii] Institute of Medicine (2002), Care Without Coverage: Too Little,
Too Late, p. 165.
[iv] Deininger and Mpuga (2003) for World Bank, and Yates (2004)
[v] Martin, Brendan (2004) Delivering good quality public services:
health and education. A report for Oxfam GB by Public World. The
report examined findings from Mozambique, Yemen, Mali and Tanzania.