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April HardingToday I had a flashback to the days when the global health community was divided into two bitterly opposed camps, the pro-public and pro-private. Younger global health professionals may not recall the days when the two camps hurled invective at each other across an unbridgeable chasm that precluded any constructive discussion. It was my anecdote versus yours, underlaid by "my values" (infinitely superior) to yours (highly suspect). The folks at Oxfam, it seems, are feeling nostalgic, and their new report would take us back. The report criticizes the "Blind Optimism" of people and organizations who would work with the private health sector to improve access to health services and mortality reduction in developing countries. It kicks off with the inevitable anecdote of superior performance from a largely public system, in this case Sri Lanka. Undoubtedly old members of the pro-private camp will be tempted to toss back their own stories. But must we slide back to the old unconstructive debates? Must we revert to my anecdote versus yours? The stakes are too high to let this happen.

Beyond Anecdotes

Fortunately, we needn't revert to my (strategically selected) case versus yours to inform our thinking any more. Analysis in a recent paper by Peter Boone and Zhauguo Zhan at the London School of Economics looked for any signs of superior, or not, performance in relatively public health systems. Using data from 45 countries with DHS surveys, they created an index of relative publicness vs privateness for each country based on utilization figures - and then looked to see if child mortality was lower in relatively public systems. The answer was no. But what about the poor? Do they have more access to care? Or better outcomes in relatively public systems? Again, no. But nor are the relatively private systems better. There is simply no measurable pattern. Their findings lend support to neither the pro-public nor the pro-private camp. What they do is strengthen the argument of the, thankfully growing, pragmatist camp in the middle, whose members neither bash the public sector for its unfixable nature, nor toss around inflammatory rhetoric about the private.

If neither public nor private is better, what's the harm in the public-sector only approaches Oxfam proposes we revert to? The harm is this: in many countries this would leave behind many poor people and those who live in rural areas who, whether we like it or not, turn to the private sector when they fall ill. Besides trying to push everyone back into their respective camps, the report dismisses arguments to engage the private sector by pointing out that much of this private sector consists of poorly trained, low-skilled providers, to which no one in their right mind would go or take their children. Yes, well, this is precisely the point.

The Informal Sector - We May Not Love It, But Many People Can't Or Won't Leave It

Oxfam points out that many of the private providers people are using are informal, unregulated and unsafe. I've never heard anyone argue otherwise (though Oxfam significantly overstates the proportion of care delivered by the informal sector by presenting figures from Malawi, which as the largest informal sector of the countries for which there is data). But, strangely, from this they conclude that we should ignore them, and focus on strengthening the public provision.

Ignore the informal sector and you ignore the many poor and rural people who go there. I've never come across any research or policy papers proposing that working with drug sellers and untrained healthcare providers is the first resort. The all-too-few attempts to work with informal providers have been justified on the grounds that it is the only way to reach the poor people who go there. Poor women throughout the developing world have their babies with the help of untrained delivery attendants; poor people in rural areas with TB turn to informal health providers; and most people with malaria turn to drugsellers (a review of 15 interventions to improve child health and malaria-related activities of private sector medicine vendors in sub-Saharan Africa found these were used in 15-82% of recent child illnesses, with a median around 50%). What are the options?

Oxfam implies we should get them to stop. Sweeping the challenge of getting people to change their care-seeking behavior under the rug is probably the biggest offence Oxfam makes in the report. It is not simply that evidence indicates it is very hard to improve public provider performance; it is that even when performance is measurably improved, people continue using these providers we wish didn't exist (Arifeen et al present the largest documented shift from private to public of 9% in this paper).

More realistically (or should I say, pragmatically), we can try to improve the quality of treatment received when people go to these poorly qualified providers. Only recently has this been attempted. And it seems this is what has Oxfam up in arms. So what do we know about what can be done with informal healthcare providers?

  • In Bangladesh, village health workers, heavily used by the rural poor, were brought into the national TB control program, and achieved high rates of compliance with the recommended DOTS protocol.
  • In several countries, unskilled delivery attendants; heavily used by rural poor women, were trained on the use of misoprostol, and successfully applied this knowledge to reduce the very high incidence of haemorrhage and related mortality.
  • What about drugsellers, the source of so much handwringing in the report? Frankly, we've tried little. And we know little. We know that trying to reach most of the population of malaria-endemic Africa with the right medicines has, to date, failed (the WHO Malaria Report 2008 documents declining access to malaria medicine in most countries where it is measured). And they have failed largely because the majority of the population who come down with malaria go to the nearest drugseller for medicine, with whom malaria control programs have steadfastly avoided working (see the conclusions of the RBM external evaluation). Attempts to constrain the use of drugsellers by restricting the most effective medicine to the public sector in Tanzania led, rather predictably, to fewer people (again, especially the rural poor) getting the most effective medicine.

There have been a few attempts to improve drug and dispensing quality via accreditation schemes, schemes which give participating drugsellers predictable access to the most effective malaria medicines (see a 2005 review by Brieger et al.). Some improvements resulted, though nothing has been tried at scale. Which brings us to the unpopular-with-Oxfam Affordable Medicines for Malaria (AMFm). The AMFm is a collaborative effort of the World Bank, the Global Fund, the UK and other donors which is attempting to get the most effective malaria medicine (ACT) to everyone by enabling subsidized drugs to flow through both the public and private drug supply chains.

Oxfam characterizes the facility as a subsidy to be applied only to the private sector supply chain (see Box 5 in the report), when the reality is that existing subsidies to the public sector will be augmented by applying the same subsidy to the private suppliers and retailers. Misrepresentation notwithstanding, the pilots are on-going, and being heavily monitored and assessed as we write (or read). Early results, anecdotal because the malaria medicine market context varies greatly within and across countries, indicate that the upstream subsidy mechanism can "crowd out" the ineffective malaria medicines in the drugseller outlets where so many poor people get their drugs. Oxfam also implies that increasing access to effective malaria treatment through the public sector exclusively hasn't been tried. Uh, that's exactly what RBM has been trying to do since 1998. And it hasn't worked.

This Oxfam report aims for a leap backward - to the days when all efforts to help the poor were unthinkingly focused on the public providers that we like, and feel comfortable with. We know now that the poor go where they want to go, and they will persist in doing so. The choice we face is, do we acknowledge this and overcome our discomfort with these untrained people who make their living by selling their services and products or do we not? Clearly, for Oxfam, the answer is no. And, with this report, they would answer not only for their own efforts, but for everyone in the global community.

If we listen, we are giving in to wishful thinking, and at the expense of finding ways to improve the lives of the poor.