Food for a targeter's thought (2)
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...continued from previous e-mail...
EQUITY AND THE PUBLIC/PRIVATE ALLOCATION OF RESOURCES
At the national level, resources allocation to and within health and
nutrition remains skewed and inequitable. Not enough pressures have
been exerted yet to attain more equitable distribution patterns. For
example, pressures to have governments allocate higher percentages of
the national budget to the sector and pressures for a more equitable
distribution of funds among provinces have, for the most part, not
been exerted. Similarly, the distribution of national poverty indica-
tors and the provinces' percentages of minority/remote populations
are not yet sufficiently considered when the 'fiscal pie' is cut
every year. Covering the latter groups' needs is more expensive, but
indispensable.
Concrete actions to allocate government funds according to need are
necessary. With an increasing share of health financing now coming
from user fees, the situation is such that great differences still
exist among provinces since the better off ones collect more revenue
from fees and insurance than poor provinces do. Most central govern-
ment budgets have not yet compensated for these inequities.
In the provision of services, government-directed systems have dif-
ferent impacts on equity than mixed public-private systems. In the
latter system, the rich tend to crowd out the poor at several levels
of consultation, especially hospitals. Moreover, current government
health services expenditures tend, in many countries and in many dif-
ferent ways, to benefit the richer more than the poor. Private for
profit health care, on the other hand, often is of poorer quality
than government services especially in places where it is just emerg-
ing. Country by country analyses of these issues need to be carried
out to assess their impact on actual equity and to find relevant and
balanced local solutions that pre-empt the most abused loopholes.
The general trend is quite clear though: Modern high tech/high cost
private for profit hospitals in poor countries cater to the expatri-
ate community and the most privileged local groups. Private solo
practitioners are likely to cater to the same groups (if they can);
they now constitute an important sector within the urban health care
system even for the near poor. Low budget private for profit hospi-
tals and clinics, on the other hand, tend to give low quality (rather
than low economic access) services. Furthermore, there is a 'grey'
public/private mix sector where, for example, public sector doctors
work privately using public hospital facilities at no charge or pub-
lic hospitals opening private wards charging less than cost prices,
because they do not know their own unit costs. The corollary is that
there is an urgent need to regulate these different types of private
health care -- this surely not being an easy task.
AVENUES AND DEAD-END STREETS TO EQUITY
Despite the fact that many policy-makers among us say they agree with
most of the views expressed above, we nevertheless see that -- in the
name of greater equity -- many currently proposed approaches to re-
solve the problems of health and nutrition still only favor and se-
lect actions covering, for the most part, four strategies:(*)
- targeting of services (the No. 1 choice),
- participatory approaches (a distant second),
- social health insurance schemes, and
- expansion of social security schemes linked to health/nutrition
benefits.
These four strategic approaches -- purportedly leading to equity --
depart from one question: If not PHC, then what?
For the reasons given earlier, I contend that, to start with, this is
the wrong question. Many of us think we do not need to develop alter-
native approaches to PHC. Rather, what is needed is to mobilise a
strong political popular support for a comprehensive truly equity-
oriented health and nutrition policy, using an improved PHC approach
that, at its core, resurrects the Alma Ata spirit; other proven ele-
ments can be added as called for. (See David Werner's "Health and Eq-
uity: Need for a People's Perspective in the Quest for World health",
presented at the 20th anniversary celebration of the Alma Ata decla-
ration, Almaty, Kazakhstan, 27-29 November, 1988).
We need to decisively open up PHC to incorporate more of the (for too
long disregarded) locally arrived at solutions. This avenue requires
demonstrating a willingness (and showing the boldness) to 'risk' a
bottom-centered trial and error period led by repeated people's par-
ticipatory Assessment/Analysis/Action cycles that blend both bottom-
up and top-down approaches. People do (and have) learn(ed) from their
successes and their mistakes!
EQUITY AND TARGETRY(**)
Many of us also think it is a fallacy to propose targeting as an al-
ternative to PHC (if and when applied in its full Alma Ata spirit).
In a way, individual targeting is a new variant of a selective PHC
approach: "Go for the worst cases, fix them, and improve the statis-
tics". But where are the sustainable changes to avoid the recurrence
of the same problems being addressed? Unfortunately, individual tar-
geting is seen as central among the alternatives being proposed by
the World Bank and other major funding agencies (together with geo-
graphical and other types of targeting).
In an era of fee for service delivery systems promoted by free-market
proponents, one of the key issues for individual targeting to keep a
semblance of equity seems to be the exemption from user fees for the
poor. Unfortunately, these waiver schemes, with all the variations of
it we have seen worldwide, have proven to be mostly catastrophes. On
top of this, from the way they look, these fee exemption schemes are
often implemented insincerely, only as a political manoeuvre to make
user fees more palatable to the population when first introduced.
In short, to many of us, individual targeting cannot be made to work
equitably and effectively -- and weeding-out and providing the needed
services to the target individuals or groups is definitely a costly
alternative for what one can potentially get... Moreover, targeting
can and does stigmatise people by creating a clientele of second-
class citizens who can be easily manipulated by those in power. Tar-
geting simply cannot be a full substitute for redistributive public
policy. (See UNRISD News, No. 20, "Follow-up to the Social Summit",
summer 1999, p.7).
Geographical targeting has probably more potential, but more so in
the realm of a revised PHC approach. Nevertheless, one has to keep in
mind that poor areas have little political clout to fight for their
share and are also usually administratively weak to implement the
needed changes. Even at somewhat higher costs, this type of geo-
graphical zeroing-in on the poorest makes sense in terms of equity.
Starting with targeting interventions as the central thrust to
achieve equity (no matter how carefully designed) thus seems the
wrong approach to put most of our efforts in. It is a dangerous and
wholly insufficient path to follow; it pursues what rather is a 'mi-
rage of equity' that basically leaves the perennial determinants of
the rich-poor gap untouched. It tacitly blames the most vulnerable
for being where they are and then tends them a rescuing hand.
What we desperately need at this time (to satisfy the remaining scep-
tics amongst us -- if that is worth the time and the money...) is to
compare the effects on health/ nutrition indicators AND on long-term
equity of selected individual targeting interventions and of a host
of already tried direct poverty alleviation measures. The data for
this may already be there or may be still missing, I acknowledge my
ignorance.
EQUITY AND PARTICIPATION
On the other end of the spectrum, and for quite some time, a few
genuine participatory approaches have coexisted with mainstream more
top-down health/nutrition approaches. The former have often faced an
uphill battle with the respective Establishments to gain recognition.
Nevertheless, enough (small) success stories have been reported for
planners, as well as local communities, to draw valuable experiences
from. Beware though that the sector is full of what in reality are
pseudo-participatory approaches since almost no project in the 1990's
dares to lack a 'community participation' component. In the latter,
local communities are called-upon to give limited inputs, but are not
on the driver's seat when it comes to steer project activities. One
can genuinely be sceptical when one sees calls for participatory ap-
proaches in projects that have not taken the poverty reduction and
the promotion of greater equity as their central thrust. Most often,
communities are not being empowered to implement measures that di-
rectly aim at having them gain growing control over the assets and
resources they need to improve their own lives.
EQUITY AND PREPAYMENT SCHEMES
Let us now turn to health insurance schemes (which cover almost noth-
ing in the realm of nutrition). So far, planners have brought these
schemes to the fore more (or only) as a priority health care financ-
ing mechanism rather than as a measure to further equity. Health in-
surance schemes -- especially when compulsory -- raise funds for the
struggling public health sector (far more than fee for service
schemes) and complement the governments' dwindling investments in the
health sector. For now, these insurance schemes remain a direct
(health) tax that benefits mostly the (often coaxed to participate)
non-poor (such as civil servants).
Therefore, beware: health insurance schemes do spread risks, but --
in and by themselves -- do not redress rich-poor differences! They do
not necessarily improve the quality of care for the insured either.
These schemes may actually worsen the rich-poor differences: e.g.
hospitals give preference to hospitalise insured patients to the dis-
advantage of the uninsured poor.
It is time now for insurance schemes to look for avenues to address
equity issues by, for example, introducing tax-financed subsidies for
the provision of free or subsidised health insurance cards for the
poorest (as Vietnam is now getting embarked on).
...continued in last email....