New approaches to medical care can improve health outcomes (Credit: World Bank, Flickr)
In many poor countries, a large proportion of health services is provided by the private sector, including services to the poor. However, the private sector is highly fragmented and the quality of services varies widely. Private health markets consist of providers with very diverse levels of qualification, ranging from formally trained doctors with medical degrees to informal practitioners without any formal medical training. According to Jishnu Das, in rural Madhya Pradesh— one of the poorest states in India, households can access on average 7.5 private providers, 0.6 public providers and 3.04 public paramedical staff. Of those identified as doctors, 65% had no formal medical training and of every 100 visits to healthcare providers, eight were to the public sector and 70 to untrained private sector providers.
health care delivery
I recently attended a community paralegal training on promoting accountability in health care delivery in Makeni, Sierra Leone. During the training, a community paralegal named Elizabeth Massalay talked about bringing her niece to a clinic in Moyamba district to receive immunizations that the government provides free of charge thanks to the Free Health Care Initiative (FHCI), which offers free health services to pregnant and breastfeeding women and children under five. Mothers queued for free immunizations, painting a hopeful picture for a country that ranks 180 out of 187 in the 2011 Human Development Index and where almost one in three children die before reaching the age of five.
However, against this promising backdrop, Elizabeth saw that the nurse was demanding six cups of rice from each mother before providing the immunization. Elizabeth was witnessing how breakdowns within state institutions—including absent nurses, improper user fees, and “leakage” of up to 30% of FHCI drugs (according to government and UNICEF statistics)—undermine health care delivery. Responding to such breakdowns requires an understanding of health policy and regulations—what the state must provide and to whom—and knowing where and how to apply pressure when the state fails to do so.