Adapted from: Unger JP, De Paepe P, Buitrón R, Soors W. Costa Rica: Achievements of a heterodox health policy. American Journal of Public Health 2008; 98(4): 636–643.

Introduction

Costa Rica is a MIC with a strong governmental emphasis on human development. For more than half a century, its health policies have applied the principles of equity and solidarity to strengthen access to care through public services and universal social health insurance.

Costa Rica's population measures of health service coverage, health service use, and health status are excellent, and in the Americas, life expectancy in Costa Rica is second only to that in Canada. Many of these outcomes can be linked to the performance of the public health care system.

However, the current emphasis of international aid organizations on privatization of health services threatens the accomplishments and universality of the Costa Rican health care system.

For several years, international development agencies, including the WB and the IMF, have promoted the role of for-profit health care facilities and programmes in the delivery of health care services in developing countries while narrowing the role of the not-for-profit sector in disease control (World Bank, 1993). Using as an example the experience of Costa Rica, we question the privatization of health care policy promoted by international aid agencies.

During a 2001 press conference, former WB president James D. Wolfensohn recognized Cuba for having done a ‘terrific job’ in the area of health (World Bank, 2001).

Adapted from: Unger J.-P., De Paepe P., Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countries. Int J Health Planning and Management 2003; 18: S27-S39.

Introduction

In 2002 already, Oxfam had demanded ‘programmes which are designed for and implemented to strengthen existing health systems, in order to ensure effectiveness and sustainable impact’ (Oxfam, 2003). The dilemma of picking up the pieces of decades of neglect and in some cases of devastation remains. Thus the question facing us now is how? To answer this, we re-examined the several possibilities starting from a managerial perspective in order to try and gauge the feasibility of effective integration.

To do this, based on a review of the literature, we first examined mechanisms whereby integrated disease-control activities can jeopardize accessibility and acceptability of general health care delivery, resulting in low service utilization and low programme target detection rates. We then put disease-control programmes into three categories and assessed the impact of each on local health care facilities. Finally, we suggest a series of measures designed to help aid agencies and national governments support local health care infrastructures or, at least, to avoid damaging them (details are given in Section 5, Chapter 16).

In this chapter, integration is defined as a process where disease-control activities are functionally merged or tightly coordinated with polyvalent health care delivery. However, another definition is sometimes used in the technical literature.

Introduction to Section 6

Two policies conflict over the semantics of ‘access.’ For international aid agencies and Global Health Initiatives, access means ‘people's use of disease-specific interventions’ (Gwatkin et al., 2005), but for NGOs and government services acting as ‘outlets’ (Mills & Hanson, 2003) access refers to compliance in disease-control programme interventions (Hardon et al., 2009; Kumaresan et al., 2001; WHO Department of Reproductive Health and Research & United Nations Population Fund, 2003). As in the current chapter some academic institutions (Geneva University Hospitals, 2006; Olivier de Sardan & Jaffré, 2003) and NGOs (Marriott, 2009) have emphasized access to CHC (family and hospital medicine) as the core of the meaning of access.

In parallel with the principles highlighted in the previous section, strategies to improve access to good quality, comprehensive care in participatory, publicly oriented services are presented in this section. Although these strategies might appear somewhat prescriptive, they are in fact derived from professional experience that needs to be adapted in different contexts.

There is a combination of reflection and empirical evidence in this section. The first chapter advocates patient-centred care for general practitioners in LMICs where often there is no such tradition. The second chapter (Parts 1 and 2) reports field experiences in improving access to general practice in public services (in Ecuador, Chapter 18, Part 1), and access to drugs (in Senegal, Chapter 18, Part 2). We have also considered the thorny issue of the purchase of medicines by users of health services.

Chapter 2 contains material previously published in:

Unger J.-P., De Paepe P., Ghilbert P., Soors W., Green A. 1. Disintegrated care: the Achilles heel of international health policies in low and middle-income countries. International Journal of Integrated Care 2006; 6. ISSN 1568–4156.

Introduction

It is clear to many health practitioners throughout the world, and, more recently, to WHO, that disease control, the favoured model of international aid, has failed to produce many of the desired results in LMICs despite intensive financing and political support. Following an insight of the related evidence, we will examine why international aid policies in our view share a large responsibility for this failure, with their promotion of the commodification of care, privatization of services, and a focus on disease control.

The poor performance of disease-control programmes (an update)

International health and aid policies have been highly restrictive because they ruled out as a priority access to family medicine and general hospital care. Furthermore, the definition of their priorities is questionable. The promotion of disease-specific programmes has been based on the concept of the ‘burden of disease,’ which functioned as the intellectual rationale for policies being implemented in its name. Its intrinsic logic was flawed (see Section 5, Chapter 12), and it was never used as a practical tool. Consequently, the international coalition (established on the basis of working on the ‘disease burden’) has largely managed to evade the need for scientifically based definitions of priorities (Bossyns, 1997; Shiffman et al., 2002; Shiffman, 2006; Sridhar & Batniji, 2008).

• Acute respiratory infection (ARI) represented 25% of the world's ‘burden of disease’ but receives funds corresponding to 3% of total health-related overseas development aid;

• […]

This chapter is extracted from:

Unger J.-P., De Paepe P., Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countries. Int J Health Planning and Management 2003; 18: S27–S39.

Continuing with some of the essential tenets in the management and delivery of health care, we suggest some principles, designed to avoid aspects of disease-control programmes. These have caused much consternation and challenge for both health practitioners and policy makers, facing different pressures, from donors and the public.

From our own research over the past three decades, we are able to tentatively propose four essential principles that might help avoid disease-specific programmes putting unnecessary pressure on quality health care systems. Through this we also suggest means to improve access to CHC in LMICs.

Disease-control activities should generally be integrated, with the exception of certain well-defined situations. They should be integrated in health centres, which offer patient-centred care

As discussed above, justification for this requirement is two-fold. The early detection of chronic diseases (such as tuberculosis and AIDS) and of acute conditions (such as severe malaria, childhood acute respiratory infections, diarrhoeal diseases) is hindered by low primary care utilization rates. In practice patient loyalty can only be created by good quality primary care. In addition improved doctor/patient communication should result in enhanced continuity of care and better cure rates. Still, there are exceptions for which a vertical organization is still appropriate (see above).

Introduction to Section 3

In this section we question why markets in health care have been so compelling to policy makers, globally and nationally, and scrutinize the evidences to commodify health care delivery in MICs such as those covered in this section. Thus the experience of health sector reforms in three Latin American countries has been presented here in order to understand the nature of the reforms and their variance in impact on health care. This section focuses on primary and secondary data on national health systems, hospitals and first-line health services. We illustrate how global policies shaped both health services and systems, in addition to the pressures placed upon countries to adopt them and explore the extent to which these functioned to serve health needs and demand for access to health care.

Health policies in Costa Rica (Section 3, Chapter 6) have followed the principles of equity and solidarity to strengthen access to care through public services and universal health insurance. The role of the for-profit sector has been limited. Boosted by the robust performance of the public health system, Costa Rica has achieved health status comparable to the most developed countries. Compared to this, in Columbia the health sector was privatized in line with the internationally advocated paradigm (Section 3, Chapter 7). Even following 15 years of implementation the reforms could not deliver the declared goals of universal coverage and equitable access to high quality care, despite an explosion in both public and private expenditures. Furthermore, most key health indicators have deteriorated.

Adapted from the original article ‘A plea for an initiative to strengthen family medicine in public health care services of developing countries,’ by Jean-Pierre Unger, Monique Van Dormael, Bart Criel, Jean Van der Vennet and Paul De Munck, International Journal of Health Services, 32(4), 799–815, 2002.

Introduction

Thirty years after Alma Ata, PHC activists might have strong grounds for optimism. Both evidence (Starfield et al., 2005) and policy guidance (World Health Organization, 2008) now point in the same direction. Starfield and collaborators cleared all doubts about the superior contribution of primary care to health and equity, a conclusion reconfirmed by both the Commission on Social Determinants of Health's Knowledge Network on Health Systems (Gilson et al., 2007) and the Commission's final report (Commission on Social Determinants of Health, 2008). The 2008 World Health Report promoted PHC as ‘coordinator of a comprehensive response (to people's expectations and needs) at all levels’ and some major donor agencies followed suit.

People in need of health care in LMICs might have a different perception. A slum dweller in India consulting in an urban PHC centre might find a doctor once a week, without any other drugs than those for a handful of identified TB patients. A Quechua woman anywhere between Colombia and Chile might not be able to find a doctor speaking her language. In sub-Saharan Africa any patient able to convince a health worker that their illness is other than malaria belongs to the happy few.

Adapted from: Sen, Kasturi and Sibai, Abla (2004). Transnational Capital and Confessional Politics: the Paradox of the Health care system in Lebanon. International Journal of Health Services, Volume 34, Nov. 3 2004. pp. 527–551.

Regional background – The Mashreq

Many countries in the Arab world promised education and health care free for all, as part of the post independence revival of nationalism. However, a variety of factors prevented the development of universal access to health care. These include the high proportion of countries in the region experiencing some sort of conflict: capital flight, a poor tax base and dependence on donor assistance. There has also been a significant effect on the ability to deliver this promise due to the existence of oil-rich Gulf cooperation countries, whose high-tech, high-cost medical priorities, have an impact on the nature of health services in other countries of the region, through migratory flows and economic cooperation.

A focus on specialized rather than comprehensive care has also been encouraged by donors, most notably the WB among others, through the doctrine of privatization and contracting out of health services, that has led to specialization often to the detriment of access and equitable distribution of services (Kronfol, 2002).

Moreover, observers note that, in a majority of countries of the Mashreq region (the Arab-speaking world stretching from east of Egypt to north of the Arabian peninsular), civil society organization is weak and often unable to place pressure on their respective governments for the basic rights of citizens (Jabbour et al., 2006).

This book explores health policies through examining patterns of commercialization that have underpinned the vast majority of these policies in different regions of the world, at the same time providing the reader with both concepts in public health and techniques to develop health services with a social mission. The chapters in the book include case studies and an extensive review of the literature.

We began this task with one main purpose: to explore the extent to which donors and international agencies have, over the past two decades, shared the same underlying motivation: that is to primarily commercialize the health sector of low-income countries (LIC) and middle-income countries (MIC), despite the stated aim of improving access to health care and addressing issues of poverty and exclusion. In this book, we provide evidence showing the contradictions between access to care and strengthening health systems on the one hand and increased commercialization on the other.

The ideas and evidence presented in this book thus call for an exploration of the contradictions of commercialized health care delivery under the guise of maintaining public provision. The book challenges the discourse and status quo among national bodies, in global policy circles, among donors and northern governments. It argues for

1. – the creation of health care services that have a social rather than a commercial motivation, and

2. – delivery of publicly oriented health care based on (professionally defined) ‘needs’ and on the (population) ‘demand’ to access quality, polyvalent health care, rather than on health interventions efficiency only.

Adapted from: Unger J.-P., De Paepe J.-P., Ghilbert P., Soors W., Green A. Integrated care: a fresh perspective for international health policies in low and middle-income countries. International Journal of Integrated Care 2006; 6. ISSN 1568–4156.

Introduction

In Section 1, we reviewed the role that international aid and health policies have played in the disappointing health sector results in LMICs. Both policies are neoliberal in their promotion of commodification of health care. We argued that the combination of government-operated DSPs together with privatized health care services constrained both programme performance and people's access to care. Whilst we also recognized other factors that contributed to this failure (including, for example, state crisis, debt, corruption and patronage), we concluded that the only way forward was to support an alternative aid policy towards health services.

In this chapter we call for the promotion of a publicly oriented integrated health sector as a cornerstone of such a health policy, conceived to overcome the fragmentation and segmentation of LMIC health systems as it currently exists. We define ‘publicly oriented’ as opposed to ‘private for-profit’ in terms of objectives and commitment, not of (government vs. private) ownership. The combination of public aims and co-management with users and health professionals gives the name ‘social-and-democratic’ to such a policy.

We outline health system-specific strategies consistent with this policy, with the potential to improve both health care and disease control in LMICs.

Introduction

Policy fundamentally determines both the delivery and management of health care. In theory policy makers should collect information on the performance of health services based on explicit criteria – which is what this section explores – in order to influence health care services and systems. In practice, however, this evaluation of field results and experiences has rarely taken place, leading to malfunctioning health systems in many regions of the world. We have argued that both alternative health care and models of service delivery should be promoted with appropriate resources while health professionals and citizens should have the opportunity to influence this process.

We have made a case throughout this book that neoliberal health policies have had a pernicious effect on health systems worldwide. However, challenging these policies also requires us to formulate alternative principles – not only for the sake of showing that another paradigm is feasible but also to offer different criteria for policy evaluation and to ground alternative initiatives in knowledge, experience, and history.

The first four sections of this book questioned the credibility of dominant health policies, for instance by contrasting them with success stories of heterodox health systems such as that of Costa Rica or the failures of others which, like Colombia, followed neoliberal policies. Whilst such evidence nested in practice is necessary, it is perhaps not sufficient to shake the conceptual model that has become so embedded in aid and trade circles. For instance, Costa Rica could be presented as an idiosyncratic accident of history.

Adapted from: Unger J.-P., Marchal B., Green A. Quality standards for health care delivery and management in publicly-oriented health services. Int J Health Planning and Management 2003; 18: S79–S88.

Throughout this book, we have advocated the delivery of CHC. But the expected output of publicly oriented services also needs to be defined. This chapter therefore aims at specifying quality standards for health care delivery and management when the goal is not-for-profit. It argues that there is not one medicine, nor one science for the management of health but two, according to whether their purpose is social or commercial. The proposed criteria may be viewed as a complement to medical ethics (deontology).

Introduction

As early as 1997, an editorial in the British Medical Journal (BMJ) stated a case for a shared code of ethics that might bond all health care stakeholders into a consistent moral framework (Berwick et al., 1997). To elicit comments and discussion the multidisciplinary ‘Tavistock group’ issued five ethical principles that should govern all health care systems (Smith et al., 1999), in essence:

• Health care is a human right.

• The care of individuals is at the centre of health care delivery, within an overall preoccupation for generating the greatest possible health gains for groups and populations.

• The responsibilities of a health care delivery system include the prevention of illness and the alleviation of disability.

• Cooperation between providers and with those served is imperative.

• All individuals and groups providing access or services have a continuing responsibility to help improve its quality.

This paper elaborates these principles further in two directions.

Chapter 1 contains material previously published in:

De Paepe P., Soors W., Unger J. -P. International Aid Policy: Public Disease Control and Private Curative Care? Cadernos de Saude Publica 2007; 23(Suppl. 2): S273–281.

Introduction

Many authors advocate integrating vertical programmes into local health facilities in order to achieve reasonable prospects for successful disease control (Bossyns, 1997; Loretti, 1989; Oxfam, 2003; Tulloch, 1999). An editorial in the influential New England Journal of Medicine (Mulholland & Adegbola, 2005) on bacterial infections (as a major cause of death among children in Africa), for example, stressed the need for comprehensive, integrated and accessible health services to address health needs and questioned the narrow, disease-based approach that has prevailed to date.

Whilst there is a need for some non-integrated vertical programmes in most countries (Criel et al., 1997), any health policy allocating public health activities and disease-control programmes to Ministry of Health (MoH) structures and general health care to private facilities remains highly problematic since it precludes the integration of disease control with general health care.

Through a review of multilateral aid policies, this chapter examines whether current international aid policies have supported the allocation of health care and disease control to different health facilities rather than integrating them into one. In other words this section will focus on outlining the doctrines informing policy rather than describing their implementation, which will be addressed in later sections. The actual implementation may differ due to specific political, social, geo-strategic, and economic factors.

Adapted from: Jean-Pierre Unger, Patrick Van Dessel. Teaching and training of health professionals. Health and Development. July 2009, special issue. ‘Equal opportunities for health: Action for development.’ Conference. CUAMM, Padova, June 2009–06–16A: 50–55.

Introduction

Improving the autonomy of LMIC health sectors from donor dependence and influence requires not only sufficient government financing, but also the broadening and transfer of knowledge within these countries. The managerial skills to run publicly oriented services and the conceptual framework needed by them to assess health policies were the subject of Sections 5 and 6. In Chapter 19 we explored some techniques of knowledge transfer from hospitals to health centres and vice-versa. In this final chapter of this section we examine how academic and public health departments can best contribute to the break from commercially motivated health policies, in preparing health professionals in publicly oriented services to improve access to comprehensive care.

Schools of public health, especially those concerned with LMIC, rarely treat health care delivery and medicine as a priority domain of study. Rather, they tend to concentrate on disease control and focus on policies related to this, and therefore teach in the main epidemiology, demography, statistics, and management of disease-specific programmes and their resources.

This is no mean paradox, since recent studies show that access to comprehensive care is probably the most important determinant of health. For instance, among women in Poland, up to 80% of premature deaths were related to conditions amenable to medical care (Nolte et al., 2002).

Adapted from: Unger J.-P., d'Alessandro U., De Paepe P., Green A. Can malaria be controlled where basic health services are not used? Tropical Medicine and International Health 2006; 11(3): 314–322.

Introduction

In this chapter, we aim to demonstrate that successful implementation of disease-control programmes requires health facilities that are being used by patients. Intuitively these patients, presenting with various symptoms, represent a pool of users that the programmes require for early case detection and adequate follow-up. We assess the potential of integrating malaria control interventions in basic health services with low levels of utilization of curative care. To do so we examined the expected malaria cure rate with a predictive model that includes parameters influencing access to anti-malarial treatment at home and in health facilities. The parametric values were selected from published African programmes that gave the best results. They were applied to the population in a district in Mali (Yanfolila), where the health-seeking behaviour of mothers/guardians with children with a fever had been quantified over a period in time.

One important component of the malaria control strategy promoted by WHO (Brugha et al., 2002; World Health Organization, 2003) is that of having adequate case management (early diagnosis and prompt and effective treatment). The cost-effectiveness of improvement in case management has been estimated around USD 1–8 per disease-adjusted life years averted.