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Studie zu den Auswirkungen der Privatisierungsstrategie der Weltbank
WEMOS präsentierte kürzlich eine Studie, die sich mit der Strategie der Weltbank auseinandersetzt, wonach Kredite für Entwicklungsländer an Bedingungen zur Privatisierungen von Gesundheitsdienstleistungen geknüpft werden.
Die offizielle Zusammenfassung:
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The World Bank’s Private Sector Development Strategy: key issues and risks
Executive summary
Leon Bijlmakers and Marianne Lindner
ETC Crystal and Wemos, the Netherlands
April, 2003
Contact addresses: ellen.verheul@wemos.nl and l.bijlmakers@etcnl.nl
Executive summary
Civil society organisations all over the world are worried about privatisation processes that are taking place in the health sector, intended or as a result of failing and under-resourced public systems. Experiences such as in Kenya, where private hospitals tie patients to their beds or force them to work until they can pay their hospital bills, show the risks of privatised health markets for equity and access for the poor, especially in low-income countries where the lack of regulation and control of the private sector is notorious.
The World Bank is the single largest external source of financing health activities in low- and middle-income countries, and the policy directions set out by the Bank are highly influential. In many low-income countries, the World Bank has been an important driving force of privatisation in the health sector. Structural adjustment programmes forced governments to cut public spending while the Bank’s health sector programmes encouraged private providers to fill the gaps. The Bank’s new Private Sector Development (PSD) strategy is another way the Bank encourages privatisation in health.
The paper by ETC and Wemos aims to scrutinise the PSD strategy and assess whether the poor would benefit through increased access to health services. This analysis could help civil society organisations concerned with health and equity in discussing these issues with their government before embarking on PSD activities in health. As international human rights law obliges national governments to ensure access to health services for all and regulate the private sector, it is paramount that ministries of health develop clear policies on the role of the private sector in the health system, that take into account the risks of privatisation and the rights of the poor.
What does the PSD strategy envisage for the health sector?
The World Bank launched its revised Private Sector Development (PSD) strategy early 2002. New in this strategy is the focus on poverty reduction. The Bank sees PSD as critical for poverty reduction in two ways. First, the private sector is the engine of economic growth providing jobs and income. Secondly, the private sector complements the public sector in providing infrastructure, health and education. The PSD strategy implies a shift in the nature and focus of World Bank lending to new sectors, including basic social services and new countries, in particular low-income countries. The PSD strategy would step up efforts to enhance the role of private providers by IDA (the Bank’s concessional lending arm), and by IFC (the Bank’s window providing commercial loans to private firms).
The PSD strategy claims that it is not about indiscriminate privatisation but about a balance between complementary functions of the private sector and the state. The government’s policy, regulatory and funding role needs to be strengthened. The Bank remains ambiguous about the role of the government in public provision of health services. Stating on the one hand that public provision is a key component of health systems, the PSD strategy also advocates for the private sector to relieve the government of some of its duties and enable it to concentrate on its core functions. Private initiatives would be channeled in ways that benefit society as a whole.
The World Bank’s support for PSD would consist of a mixture of analysis, policy advice, provision of loans to governments (by IDA) and direct support to private companies (by IFC). A stronger collaboration between IDA and IFC is envisaged. Although current health-related PSD lending from both IFC and IDA is low (about 1% of total health, nutrition and population portfolio, and less than 1% of the total PSD portfolio), it can be expected to rise with increased PSD activities in the social sector.
The PSD strategy proposes a shift from financing inputs for health care provision to performance based financing, through the development of output-based aid schemes (OBA). OBA schemes are supposed to shift the responsibility and performance risk to the private providers, since they will be paid only if they deliver the output as described in the respective contracts that will be drawn up. The PSD strategy is unclear however whether pilots with OBA schemes in health will be undertaken.
Weaknesses in the strategy
Ignoring empirical evidence that identifies problems with private provision in health
Although the Bank acknowledges that support to PSD in health remains ‘highly contentious’, it does not discuss the reasons for this contention, nor does it review the available evidence. The PSD strategy assumes that involving the private sector is more efficient, increases total resources for health and increases equity and consumer choice. But these assumptions are not backed by empirical evidence. Market failures, such as those arising from the strong power imbalance between providers and patients, are thus overlooked. In reality, the supply-side has a far stronger impact on quality, efficiency and spending than the demand-side in health. In the context of low-income countries where the number of suppliers is often limited and where both health workers and the general public are often not well informed, the notion of competition among providers does not seem to make much sense.
Using a limited concept of private sector involvement
Health systems generally exist of a mix of public and private actors. In many countries the private sector is proliferating rapidly and uncontrolled. The crucial question therefore is not whether the private sector should play a role, but rather how it should be involved within the health system so as to contribute optimally to achieve public health goals. This however is not the focus of the PSD strategy. It neglects the widespread problem of incremental or unplanned privatisation. Instead, it encourages programmed privatisation by putting a strong emphasis on the disbursement of public funds to private providers and providing direct support to firms. Alternative mechanisms for involving the private sector other than outright privatisation, such as outsourcing and increasing the autonomy of lower levels of the public health care systems, are ignored as well. Lastly, the strategy does not recognise adequately the wide diversity of private providers active in the health sector. Especially the fundamental difference between for-profit and not-for-profit services providers is not acknowledged. Areas of conflict between commercial and public interests need to be taken seriously. But also forms of partnerships based on mutual trust, such as those being developed between governments and church-related providers in several countries, are not mentioned in the strategy. Although the PSD strategy acknowledges the need for country- and sector specific support, it does not succeed in avoiding the tendency to come up with ‘one-size-fits-all’ approaches.
Ignoring conditions for successful private sector involvement
The strategy does not adequately address the issue of regulation of the private sector. Governments should go beyond establishing minimum regulatory standards; systems to ensure inspection and to enforce sanctions should be in place too. The Bank does not elaborate either on other conditions that need to be fulfilled for successful private provision, such as informed consumers and active consumer organisations, the absence of great inequities in health, strong professional ethics and high standards of care in the public sector. It is clear that most of these conditions are not met in poor countries, meaning that the chances for successful privatisation are very limited.
Reaching the poor?
The PSD strategy has the ambition to increase poor people’s access to good quality services. But reaching the poor has shown to be extremely difficult. While the World Bank recently distanced itself from promoting user fees for the poor for basic health services, acknowledging the difficulties in reaching the poor with exemption schemes, the PSD strategy seems to revert to the old position. The PSD foresees charging patients the full cost price for using services, while subsidies could be used to ensure access for the poor. The strategy however does not elaborate on the problems that have been encountered in targeting assistance to those who are most in need, yet most deprived of such support.
Risks for the poor
Crowding out investments in the public sector
The current health-related PSD lending portfolio is very limited, both as a percentage of total PSD lending (less than 1%) as well as in relation to total HNP lending (1% of $9,3billion in 2000). But the World Bank specifies that the proposed PSD interventions will be financed from existing budgets through internal reallocation. It can therefore be expected that future increases in PSD lending for health will be at the expense of public sector lending. The PSD strategy is likely to accelerate a two-tier system. Rich people will enjoy the services of a well-resourced private health care system. The poor however are surrendered to either a poorly-resourced public health care system that provides poor quality services or to an unregulated private health care system that provides equally poor services.
Experimenting at the expense of the poor
The Bank admits that its knowledge of the private sector role in health is ‘embryonic’, which is illustrated by the above weaknesses in the PSD strategy. The strategy does not provide a convincing answer to the question: why would private sector development be necessary at all? A careful analysis of the experiences so far, not only with World Bank supported initiatives, to shed more light on the current contribution of the private sector and the conditions under which it operates, would be the most appropriate next step. Meanwhile, PSD efforts in health risk distracting time, energy and money from addressing the key challenge to build health systems that are responsive to the needs of the poor.
International agreements on trade in services limit scope for national regulation
Contrary to services provided by public institutions, services provided by the private sector could fall under international trade rules such as those mentioned in the General Agreement of Trade in Services (GATS) of the WTO. Most countries that have liberalised (parts of) the health sector, or are considering further liberalisation in the current round of GATS negotiations, have done this without making a careful assessment of the possible consequences for equity and the ability to regulate the health sector, and without making provisions to prevent adverse effects. This means that national health authorities can be faced with unforeseen consequences, since companies may use GATS rules to fight government decisions (e.g. to ensure that the poor have equal access to services) by claiming that these are unacceptable barriers to trade. Increasing the role of private markets in health, encouraged by the PSD strategy, is making the health sector a possible candidate for liberalisation in GATS negotiations. The PSD strategy is completely silent about the risks involved.
What next: perspectives for civil society responses
Civil society organisations concerned with equity and health could undertake action in several ways. Where possible, they should work in close collaboration with public health specialists and researchers/analysts to do the following:
Analyse what national and local policy frameworks and strategies say about private sector involvement in the provision of health services; and monitor the government’s position in negotiating international trade agreements that may impact on the health sector.
Document the experiences with (programmed) private sector involvement and analyse the impact on equity and access for the poor.
Question national or local authorities about their intentions with regard to development of the private sector for health service provision. Provide them with concrete experiences (positive and negative) from the field.
Advocate for Poverty Reduction Strategy Papers and health sector plans that provide clear guidance for private sector development in health and that ensure that the poor will profit.
Monitor the plans of the World Bank and other lending and aid agencies in relation to private sector development and analyse whether these are coherent with national policy frameworks.
Demand transparent decision making and participation in any new initiatives right from the planning phase onwards.
Exchange the experiences acquired (positive or negative) in national and international fora.
Die gesamte Studie gibt es unter:
http://www.wemos.nl/prs/library/healtheconomic/psd_strategy_worldbank.pdf
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