the devil is in the detail
http://www.100md.com
《英国医生杂志》
1 European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London WC1E 7HT, 2 Health Systems Development Programme, London School of Hygiene and Tropical Medicine
Correspondence to: M McKee Martin.McKee@lshtm.ac.uk
Okuonzi argues that the introduction of market reforms, into the Ugandan health system has been a failure.1 However, health systems are extremely complex and, as the debate about the British internal market shows, attribution of cause and effect is far from easy. The situation in Uganda is equally complex, with reforms taking place against a background of regional conflict, growing inequalities, and changes in other sectors. Furthermore, while Okuonzi focuses on hospitals, it is equally important to look at primary care, which the Ugandan reforms have sought to strengthen.
Can we gain insights about market reforms from other low and middle income countries? It is important to distinguish between reforms directed at funding and those directed at delivery of care. Many policies aimed at funding, such as user fees, increase the economic burden on families. This can deter them from seeking necessary care and increases the risk of impoverishment from expenditure on catastrophic illness,2 as is now happening in China.w1
The situation regarding reforms to healthcare delivery is more mixed, although the available evidence is limited and often context specific. One issue is contracting with private providers by public bodies. This offers potential benefits by combining public finance with private provision, but in practice these may not always be realised.3 For example, although a privately owned hospital in Zimbabwe offered services of at least as good quality as a nearby government hospital and at lower prices, the private hospital's failure to control admission thresholds allowed costs to increase.w2 Other research in South Africa and Zimbabwe found that, although costs were lower in private hospitals, any savings were eliminated by the cost of contracting.w3
Private hospitals in Zimbabwe have failed to deliver expected savings
Credit: RON GILING/STILL PICTURES
A second issue is increased autonomy of providers. This has been successful only when facilities invest in management techniques and training linked to appropriate incentive systems for staff.4 Reviews of experience in eastern Europe5 and sub-Saharan Africa have identified only modest success in achieving the stated goals of increasing autonomy.6
A third issue is the question of public or private provision. Enthusiasm for privatising state facilities, to achieve supposed efficiency gains, is being tempered by a realisation that the evidence is rather mixed. A study of government and non-governmental dispensaries in Tanzania found considerable variation in both sectors.w4 This finding was replicated in research on primary care providers in the same country; although quality of care was, on average, better in the private providers, much care was of low quality care in both types of facility.w5 Similar results have been obtained from research in Senegal.w6 In summary, little evidence is available to support the contention that private provision is better than public, and what evidence exists indicates that there is often considerable variation in both.
So are market oriented reforms in health care good or bad? There is no simple answer. Much depends on how they are implemented. This is an area where more evidence rather than ideology is needed.
References w1-w6 are on Bmj.Com
MM and BM are members of the UK Department for International Development's (DfID) health systems development knowledge programme. DfID accepts no responsibility for the views expressed.
Competing interests: None declared.
References
Okuonzi SA. Learning from failed health reform in Uganda. BMJ 2004;329: 1173-5.
Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003;362: 111-7.
McPake B, Banda EE. Contracting out of health services in developing countries. Health Policy Plan 1994;9: 25-30.
Hawkins L, Ham C. Reviewing the case studies: tentative lessons and hypotheses for future testing. In: Preker AS, Harding AL, eds. Innovations in health service delivery: the corporatization of public hospitals. Washington, DC: World Bank, 2003: 169-206.
Healy J, McKee M. Implementing hospital reform in central and eastern Europe. Health Policy 2002;61: 1-19.
McPake BI. Public autonomous hospitals in sub-Saharan Africa: trends and issues. Health Policy 1996;35: 155-77.(Martin McKee, professor o)
Correspondence to: M McKee Martin.McKee@lshtm.ac.uk
Okuonzi argues that the introduction of market reforms, into the Ugandan health system has been a failure.1 However, health systems are extremely complex and, as the debate about the British internal market shows, attribution of cause and effect is far from easy. The situation in Uganda is equally complex, with reforms taking place against a background of regional conflict, growing inequalities, and changes in other sectors. Furthermore, while Okuonzi focuses on hospitals, it is equally important to look at primary care, which the Ugandan reforms have sought to strengthen.
Can we gain insights about market reforms from other low and middle income countries? It is important to distinguish between reforms directed at funding and those directed at delivery of care. Many policies aimed at funding, such as user fees, increase the economic burden on families. This can deter them from seeking necessary care and increases the risk of impoverishment from expenditure on catastrophic illness,2 as is now happening in China.w1
The situation regarding reforms to healthcare delivery is more mixed, although the available evidence is limited and often context specific. One issue is contracting with private providers by public bodies. This offers potential benefits by combining public finance with private provision, but in practice these may not always be realised.3 For example, although a privately owned hospital in Zimbabwe offered services of at least as good quality as a nearby government hospital and at lower prices, the private hospital's failure to control admission thresholds allowed costs to increase.w2 Other research in South Africa and Zimbabwe found that, although costs were lower in private hospitals, any savings were eliminated by the cost of contracting.w3
Private hospitals in Zimbabwe have failed to deliver expected savings
Credit: RON GILING/STILL PICTURES
A second issue is increased autonomy of providers. This has been successful only when facilities invest in management techniques and training linked to appropriate incentive systems for staff.4 Reviews of experience in eastern Europe5 and sub-Saharan Africa have identified only modest success in achieving the stated goals of increasing autonomy.6
A third issue is the question of public or private provision. Enthusiasm for privatising state facilities, to achieve supposed efficiency gains, is being tempered by a realisation that the evidence is rather mixed. A study of government and non-governmental dispensaries in Tanzania found considerable variation in both sectors.w4 This finding was replicated in research on primary care providers in the same country; although quality of care was, on average, better in the private providers, much care was of low quality care in both types of facility.w5 Similar results have been obtained from research in Senegal.w6 In summary, little evidence is available to support the contention that private provision is better than public, and what evidence exists indicates that there is often considerable variation in both.
So are market oriented reforms in health care good or bad? There is no simple answer. Much depends on how they are implemented. This is an area where more evidence rather than ideology is needed.
References w1-w6 are on Bmj.Com
MM and BM are members of the UK Department for International Development's (DfID) health systems development knowledge programme. DfID accepts no responsibility for the views expressed.
Competing interests: None declared.
References
Okuonzi SA. Learning from failed health reform in Uganda. BMJ 2004;329: 1173-5.
Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003;362: 111-7.
McPake B, Banda EE. Contracting out of health services in developing countries. Health Policy Plan 1994;9: 25-30.
Hawkins L, Ham C. Reviewing the case studies: tentative lessons and hypotheses for future testing. In: Preker AS, Harding AL, eds. Innovations in health service delivery: the corporatization of public hospitals. Washington, DC: World Bank, 2003: 169-206.
Healy J, McKee M. Implementing hospital reform in central and eastern Europe. Health Policy 2002;61: 1-19.
McPake BI. Public autonomous hospitals in sub-Saharan Africa: trends and issues. Health Policy 1996;35: 155-77.(Martin McKee, professor o)