AFRO-NETS> New food for a wrong thought - from Hanoi (2)

[Claudio Schuftan <aviva@netnam.org.vn>]

New food for a wrong thought - from Hanoi (2)
---------------------------------------------

(continued)

So, what would be more effective and sustainable?

Perhaps the best response to a part of this question is in another 
question: Why not ask the beneficiaries directly to respond to this 
question?

This is not an evasive response! This response has the wisdom of - on 
top of so much that has already been said about it - accepting the 
fact that:

- localised responses will (and should) be multiple and varied;

- there is not one response that fits all (or even many) diverse
  situations;

- our technical expertise can be put to a more effective use in a
  genuine (humble) dialogue with community representatives than in an
  (incestuous) technical dialogue among us as self-proclaimed ex-
  perts;

- an all-encompassing wisdom is not necessarily a trade mark of com-
  munities (as so often is romantically implied): communities do not
  always know best (!), so mistakes will be made (but how many multi-
  million dollar mistakes have we technical people made... do we need
  to remind ourselves of that?);

- quickly learning from mistakes in an ongoing dialogue between com-
  munities and us professionals can lead to quicker sustainability
  than applying schemes imposed from outside, no matter how promising
  these look.

Paraphrasing Amartya Sen, our new Nobel laureate, he contends that in 
order to understand people's choices, one must know which alterna-
tives are open to them in (the) real life. Such a grassroot-centered 
approach calls for an unprecedented change in our priorities and our 
modus operandi. The locus of control has to shift to beneficiaries 
for decisions that affect them directly on an everyday basis; and we 
ought to be instrumental in such a transition.

At the same time, equity oriented measures have to be implemented 
from the central level. And that is the other part of the response to 
the question posed above. For the time being, and until the equity 
situation drastically changes for the better, some of the key ele-
ments of such reforms could be the following (percentages are mostly 
illustrative and will change in each concrete context):

- Public rural health care services will still need to be primarily
  financed by governments (central and local). Governments should
  cover around 70-75% of total costs; only up to 10-15% can be real-
  istically expected to be raised by community contributions or rural
  health insurance schemes; 5% can come from direct user fees, and an
  additional 10% perhaps from foreign aid.

- Financing public urban health care services will probably still
  need 50-60% government financing; health insurance could cover
  around 30% of costs and user charges 15%; the rest could come from
  foreign aid.

- Financing of health care will have to progressively move away from
  regressive fee for service schemes and towards prepayment schemes
  where the whole population - not only the sick - contribute.

- Direct and indirect progressive taxes must, therefore, constitute
  the financial base in an efficient, equity-oriented health care
  system. Government funds thus collected can then be used directly
  to fund public health services or can subsidise social health in-
  surance schemes that will gradually cover the whole population.

- The issue of offering insured patients better care than to the gen-
  eral uninsured public is an issue that will need very careful
  analysis before a decision is made.

- If communities do contribute to the financing of health care serv-
  ices, they will have to have more de-facto control over how the
  funds are used.

- Governments will have to gradually reallocate resources from rich
  provinces/districts to poorer ones according to a set of needs-
  based indices and by then amending both recurrent and development
  central budgets accordingly. [Note that with the often growing
  presence of health insurance and user fee revenues, such realloca-
  tions will now have to take into account these revenues and add 
  them to other financial resources invested by the government]. - 
  General tax revenues that apply more to the rich (e.g., taxes on
  luxury items, spirits, tobacco, or on assets, estate and wealth)
  will have to be considered more seriously as a source to bring in
  financial resources from other sectors to the health sector.

- Health staff will have to become more accountable to local communi-
  ties.

- The use of existing resources (human, material, organisational and
  financial) should be rationalised to better adapt them to actual
  needs. This will mean reallocating (or even shedding) personnel and
  mobilising more resources to outreach work outside the health sta-
  tions. All this should also be linked to medium term reforms that
  bring health staff income up to minimum standards of living pref-
  erably based on a system of monetary and non monetary incentives.

- The roots of the twin trend towards self-medication and underutili-
  sation of PHC facilities will have to be studied in each locality
  and ad-hoc measures taken with major inputs from the community it-
  self; existing essential drug programs have to be made to work, but
  starting from the bottom up so as to make sure one is addressing
  people's felt needs at the base of their drug procurement/consump-
  tion/utilisation behaviour; drug companies (and clinical health
  staff...) have to be made to comply!

- Growth monitoring - an activity at the base of nutrition surveil-
  lance - will have to move out from the health facilities to become
  community-based and more preventive and promotive in scope.

These are but a few of the central and local level options that merit 
being looked at more carefully again. But this listing is not the 
purpose of this review. The idea is that the process opening the 
doors to a more participatory and empowering dialogue (especially en-
gaging women) has to come up with more of the answers and options. 
But for this to happen, said process has to be more decisively 
steered to a concrete departure and finishing line; and this is a 
task where health and nutrition professionals can help. This article 
is a wake up call.

One is left to wonder how many of the what one could call the more 
sustainable Equity-Oriented Health Sector Reform (EOHSR) measures 
quickly reviewed here have a chance of being seriously considered and 
implemented in the near future, even if it is on a pilot basis... The 
bottom line here is that we remain convinced that tinkering with the 
so far proposed HSRs will not do. That is the sad reality. Precious 
time is likely to be lost only to see the problems of inequity 
worsen.

We think that what is really needed is a 'HSR of the public health 
care sector', not one overwhelmingly in the direction of the private 
sector. The so often touted non-service-mindedness of the public sec-
tor is not a given. We need to fix a system that - granted - has many 
flaws. But it also has many strong points! As its core is streamlined 
and strengthened, one can indeed contract out some ancillary services 
to the private sector - provided there is a fair system of competi-
tion in place. The new EOHSRs will explore these possibilities for 
improving the public sector in health and nutrition and keeping it at 
the core of a delivery system that can keep equity at the highest 
levels of priority. Because equity is so important to us - and in the 
absence of strong enough evidence to the contrary - we ask ourselves 
why the latter option is flatly left out in mainstream HSR discus-
sions and only more absolute market-oriented options are explored / 
proposed.

This brings us back full-circle to the old 'political will' issue 
which - we would like everybody to understand - is not really an is-
sue of "will" as such: it is an issue of "choice", of political 
choice. And being an issue of choice, for the time being - short of 
an awakening of civil society initiatives and movements in many 
places around the world at about the same time - the responsibility 
to move towards EOHSRs is still squarely back on the lap of the re-
spective governments. Much advocacy and lobbying, as well as opposi-
tion to powerful internal and external forces, are still needed in 
order to put the last first....

Claudio Schuftan
mailto:aviva@netnam.org.vn

Goran Dahlgren
mailto:dahlgren@hn.vnn.vn

Hanoi, Vietnam


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