Private health providers are NOT more efficient, accountable or medically effective #healthcare


POSTED BY ANNA MARRIOTT ON MAR 28TH, 2013 globalhealthcheck.com
 
 

In 2009 Oxfam published “Blind Optimism: Challenging the Myths about Private Health Care in Poor Countries,” to help redress what we saw as an international health discourse increasingly dominated by unchallenged private sector advocates.  Some of those same advocates accused Oxfam of being purposefully selective with the evidence.

The health team at Oxfam were therefore very pleased to see the recent publication of a thorough and balanced independent appraisal of peer-reviewed evidence on this topic in PloS Medicine. The study supports many (not all) of our conclusions about both the public and private sector.

In their research Basu et al. assess the comparative performance of the private and public sectors in health across a range of health system performance areas. They are clear that comparative evidence is often lacking and that distinctions between what is public and private are often difficult (for example when public facilities act more like commercial operators by charging fees). With these limitations acknowledged, the authors’ own conclusion states:

‘Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients’.   

Like Oxfam, the authors of this comparative study make special note of the World Bank as an influential advocate of public-private partnerships in health, but one whose claims are often unsubstantiated by their own data. The authors raise concerns about a conflict of interest for the World Bank that may undermine the validity of their research and analysis on this topic.

Some highlights from the paper are listed below (though I recommend reading this important article in full – especially for interesting country examples):

Access and responsiveness

  • A significant proportion of services in some developing countries are provided by the private sector but figures vary enormously by country and by income level. When informal or unlicensed providers are excluded, the public sector provided the majority of care in 19 out of 22 low- and middle-income countries for which World Bank data is available.  
  • Studies that measured utilization by income levels tended to find the private sector predominately serves the more affluent. In Colombo, Sri Lanka, where a universal public health service exists, the private sector provided 72% of childhood immunisations for the wealthiest, but only 3% for the poorest.
  • Waiting times are consistently reported to be shorter in private facilities and a number of studies found better hospitality, cleanliness and courtesy and availability of staff in the private sector.

Quality

  • Available studies find diagnostic accuracy, adherence to medical management standards and prescription practices are worse in the private sector.
  • Prescribing subtherapeutic doses, failure to provide oral rehydration salts, and prescribing of unnecessary antibiotics were more likely in the private sector, although there were exceptions.
  • Higher rates of potentially unnecessary procedures, particularly C-sections, were reported at private facilities. In South Africa for example, 62% of women delivering in the private sector had C-sections, compared with 18% in the public sector.
  • Two country studies found a lack of drug availability and service provision at public facilities, while surveys of patients’ perceptions on care quality in the public and private sector provided mixed results.

Patient outcomes

  • Public sector provision was associated with higher rates of treatment success for tuberculosis and HIV as well as vaccination. In South Korea for example, TB treatment success rates were 52% in private and 80% in public clinics. Similar figures were found for HIV treatment in Botswana.

Accountability, transparency and regulation

  • While national statistics collected from public sector clinics vary considerably in quality, private healthcare systems tended to lack published data on outcomes altogether. Public-private partnerships also lacked data.
  • Several reports observed significant public spending being used to regulate the private sector in order to improve patient care quality, and with limited effectiveness.

Fairness and equity

  • Financial barriers to care exist in the public and private sector.
  • Private sector services tend to cater for higher income groups with studies showing exclusion and discrimination against poorer patients and women.
  • Several studies suggested the process of privatizing existing public services increased inequalities in the distribution of services.
  • Private contracting and social franchises showed potential for reaching impoverished groups, though findings are tentative because comparisons to the public sector are unavailable.

Efficiency

  • Contrary to prevailing assumptions, the private sector appeared to have lower efficiency than the public sector, resulting from higher drug costs, perverse incentives for unnecessary testing and treatment, greater risks of complications, and weak regulation.
  • The evidence is mixed (and often weak) on the cost of contracting to private providers – increasing expenditure in some countries whilst reducing it in others.

Other important findings

  • Rather than adding resources, several studies reported that growth of the private healthcare sector, whether independently or via public-private partnerships, directly reduced public funds and staff available for public provision.

And on the World Bank….

  • The World Bank has made strong claims that investing in public-private partnerships will improve efficiency and effectiveness in the health sector, yet several of its publications revealed that these assertions were either unsupported by data or the data was not provided in sufficient detail to pass minimal inclusion criteria for this review’.
  • Despite the lack of data about private sector performance, recent initiatives by the World Bank’s International Finance Committee (IFC) are underwriting the expansion of private sector services among low- and middle-income countries. For example in sub-Saharan Africa, the IFC has created a private equity fund to make 30 long-term investments in private health companies. These conflicts of interest pose a potential threat to the validity of World Bank-sponsored studies and raise the need for independent scrutiny.

The evidence from this study shows that while public health systems are often weak and under-resourced they still deliver better quality of care, more equitably and with greater efficiency than the private sector.  The study highlights the tendencies of private providers to serve higher socio-economic groups, have higher risk of low-quality care, create perverse incentives for unnecessary testing and treatment, and suffer from weak regulation. It also suggests there are a number of ways public health systems can do better.  They must be more responsive to patients and more accountable to citizens, improve systems for distributing essential inputs like medicines, and address financial barriers to accessing care (such as formal and informal fees).

These are legitimate challenges that deserve thoughtful attention and action, but they should not be used as evidence of the superiority of private sector approaches. Instead, the policy response to these findings should be very clear: far more effort and resources must be mobilized to maximize the clear advantages of public health systems, rather than further starving them of the resources and support they need to deliver equitable and quality health care for all.

 

Sri Lanka – Restricting sterilization: To what purpose? #Vaw #rightoabortion #reproductiverights


 

March 15, 2013,http://www.island.lk/

article_image

I was appalled to read a recent newspaper article that reported a government ban on irreversible methods of contraception. Later I learned that the ban prohibits non-governmental organizations (NGOs) from the provision of sterilization services. According to reliable sources, sterilization services continue to be available through the public sector albeit with additional counseling requirements implemented at some points of access. As this newspaper item coincided with protests against ‘family planning’ held by extremist Buddhist factions concerned about the diminishing ‘Sinhala race’, it is surprising that neither the government nor the Ministry of Health has thus far provided clarification on this issue. In this article, I would like to highlight a few problems with the existing sterilization policy that are unlikely to be resolved through bans or other forms of restriction. Rather than restricting women’s access to contraception to accommodate the views of reactionary groups, it might be more useful to focus our efforts on addressing some of the issues outlined below.

 

General Circular No. 1586 issued by the Office of the Director General of Health Services (1988) includes the following eligibility criteria for sterilization procedures: “1) The clients should be over 26 years of age and should have at least 2 living children; the younger being over 2 years of age. Confirmation of mother’s age should be done by checking the Birth Certificate, Identity Card or any other valid document, which is available; 2) Clients who are over 26 years of age and having 3 or more living children could be sterilized at any time; 3) A client under 26 years of age, and his/her spouse insist on a sterilization, the Medical Officer concerned could use his/her discretion, and perform the sterilization provided the couple has a minimum of 3 living children. In such a situation the officer concerned should personally check the validity of the information provided, in respect of the number of living children, prior to performing the sterilization; and 4) In the event of any medical indication, which warrants sterilization, the client should be referred to a specialist in the relevant field who should make the final decision.”

 

As the subtext of the circular implies, like most contraceptive programmes offered through Ministry of Health, the criteria for sterilization target women. For instance, references to the “mother’s age” and the insistent appeal of the spouse (when the ‘client’ is under 26 years) suggest that women are primary targets of the sterilization programme. In my experience of working for the Ministry of Health, sterilization procedures were, in fact, freely available and did target women, both in terms of availability and accessibility. This is confirmed by data from the most recent Demographic and Health Survey (2006/7): 16.9 % of ‘currently married women’ were sterilized compared with 0.7% of women whose husbands were sterilized (the Demographic and Health Survey is administered to married women and specifies these categories). These statistics must also be considered in light of the fact that the sterilization procedure for men is ‘simpler, safer, easier, and less expensive’ than the procedure for women (WHO, 2007).

 

Importantly, the criteria listed on the circular do not require the ‘client’ to obtain her/his partner’s consent to undergo sterilization (although spousal insistence may add weight to requests from those who are under 26 years of age). Nevertheless, spousal consent is routinely obtained in government institutions before providing sterilization procedures to women (my experience; see also CEDAW Shadow Report, 2010). In my work, I witnessed numerous instances when women’s pleas for sterilization were rejected during Caesarean section simply because the spouse was unavailable to sign a consent form. If these women decide to undergo sterilization on a later date, they are exposed unnecessarily to a second surgical procedure. In this way, doctors take on the role of gatekeepers to contraceptives services, restricting women’s access based on their own gendered presumptions.

 

The Circular of 1988 referenced above was introduced because “[it had] been observed that a significant proportion of females who [underwent] sterilization [were] under 25 years of age, with a notable number being less than 20 years” (General Circular No. 1586). These concerns were valid in the 1980s, a time when coercive tactics were being used as part of the population control agenda imposed on the third world. In 1980, a monetary incentive of Rs. 100 per sterilization procedure was introduced and was subsequently increased to Rs. 500. Surprisingly, this monetary incentive was not omitted in the Circular of 1988 and remains in place today. In fact, another circular was introduced in 2007 in order to “streamline” the payment process so that ‘clients’ would be able to obtain this payment from the institution that provided the sterilization procedure (General Circular No. 01-09/2007). Furthermore, healthcare providers (including the surgeon, anaesthetist and assisting nurses) can still claim, if they so do wish, a negligible sum for sterilization. While Rs. 500 may seem trivial to some of us, continuing to provide incentives for sterilization is problematic and warrants omission.

 

The provision of incentives can be interpreted in many ways, especially when sterilization procedures are mostly sought by particular groups of women. Sterilization is most popular among women in the plantation sector (presumably not Sinhala contradicting the claim of extremist factions in Colombo). According to the Demographic and Health Survey (2006/7), 61% of estate women used a modern method of contraception (including sterilization, contraceptive pills, intra-uterine devices, Depo-Provera, implants, condoms and complete breastfeeding) and 41% resorted to sterilization. In contrast, 54% and 44% of rural and urban women used modern methods of contraception, while 16% and 13% resorted to sterilization (the survey used urban, rural and estate as distinct categories). This set of data completely debunks the proclamations of extremist Buddhist groups who are hell bent on protecting Sinhala women from coercive sterilization. It also makes it incumbent on us to ensure that plantation workers are not coerced into sterilization. On the other hand, the large numbers of estate women accessing sterilization may signify a lack of access to temporary contraceptive options.

 

Imposing restrictions on sterilization may have other implications for women’s health. For instance, it is likely to increase the incidence of unplanned pregnancies. According to the Demographic and Health Survey (2006/7), sterilization is popular among the following categories of women: estate women, women above 35 years of age, women with lower levels of education and women with three or more children. While these associations may point to a need to ensure that these particular groups of women are not coerced into sterilization, it also reflects on who will be most affected by restrictions on sterilization. Not surprisingly, this profile bears similarity to that of women seeking abortion services; induced abortion is most common among rural, married women with at least two children (Senanayake & Willatgamuwa, 2009). Then restrictions on sterilization could result in more women resorting to unsafe abortion, a service that has moved underground since the government led shut down of abortion clinics in 2007.

 

Religious extremism is frequently accompanied by restrictions on access to reproductive health services for women. Although the existing policy is problematic for the reason that in targeting women it burdens them with the responsibility of adopting contraceptive measures, the policy does ensure that sterilization is quite easily accessible to women through the public sector. While there is much room for improvement around health policies governing contraceptive services, such as the removal of incentives and the unofficial requirement of spousal consent for sterilization, imposing restrictions or banning sterilization altogether is hardly the solution. Such restrictions are not only an extension of policies that assume that women are incapable of making decisions concerning their health, but may well be interpreted as an attempt by the state to regulate women’s reproduction in the service of a retrograde agenda of nationalism.

 

Ramya Kumar, MBBS

 

Kandy

 

Sunita Bhuyan performs at #1billionrising -Mumbai #Vaw


Submitted by AT News on Sat, 16/02/2013 – 12:20

Violinist Sunita Bhuyan , the cultural Ambassador to the South Asia Women’s Fund, Sri Lanka performs at Bandstand amphitheatre, Mumbai during the celebration ofOne Billion Rising – Mumbai on February 14, 2013.

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#Srilanka- #Gangrape – Peoples’ sovereignty and the absence of protest #Vaw


 #India- Chastity, Virginity, Marriageability, and Rape Sentencing #Vaw  #Justice #mustread

A 45 year-old woman was gang raped in the early hours of January 23 in Wijerama, Nugegoda (some reports give her age as 47). This gruesome incident only received a few lines in some of the newspapers and in the media. Yet a similar incident that occurred in New Delhi, India, when a medical student was gang raped on a bus, provoked a nation-wide protest for several days and, in fact, the protests continue internationally even up to now. This protest caused the Indian Prime Minister to intervene and take action, not only to ensure medical treatment and justice for the young girl but also to take steps towards bringing in speedy legislation to prevent the re-occurrence of similar incidents. Protests took place also in Nepal when a similar case came to the notice of the public. There too, heavy demands have been made of the government, not only to bring legislation but also to achieve other reforms needed to protect women.

The media and the active participation of the people and women’s movements, including local politicians, both in India and Nepal reflected the active participation of the people to ensure protection and to express outrage at the malfunctioning of the law enforcement agencies which are duty bound to protect the public.

In both countries, the media responded to these protests and ensured that the unfortunate event came to be an occasion for the whole nation to introspect and to discuss the crisis of the law enforcement agencies and the failure of the government to ensure that these agencies act with the required diligence in future. On the one hand, the role of the media represented the problems of the conscience of the public. On the other hand, the media also created a discussion among the people in order to express concern as well as to critically discuss the deficiencies of the government that make it possible for such crimes to occur.

According to the short reports that appeared in the Sri Lankan media, the police reported that the woman who became the victim of the gang rape had gone to the market and having lost her way, made some inquiries as to directions from a three-wheeler driver. Under the pretext of offering help, the driver took her into the three-wheeler and then, against her will, took her near a well and threatened her. Thereafter, several persons who came in another three-wheeler, gang raped her. She is said to be taking treatment at the Kalubowila Hospital. The items discovered from the three-wheelers include some condoms which, according to observers, suggest that the attackers may have been engaged in such activities on a regular basis.

New approach to scandal management under peoples’ sovereignty 

In recent times when such scandals occurred, the police filed reports of arrest and this appeased the public by creating the impression that the law was being enforced. However, shortly after arrest, these matters were forgotten. Through all kinds of negotiations and bribery exchanges, or by the intervention of politicians, the process of justice was subverted. The cases of the murder of several persons, together with a government politician, Baratha Lakhsman Premachandra and the recent murder of an elected local government official in Kelaniya are public events which demonstrate this quite strikingly. The murder of a British national and the rape and assault of his Russian companion at Tangalle, allegedly by the Urban Council Chairman of Tangalle and others, was also hushed up. The gang rape of a child by several local area politicians in another rural locality in the South underwent a similar fate. Similarly there were allegations of rape against government member of parliament, Duminda Silva which too, came to nothing. In fact, the list of crimes that have been followed by no real consequences is quite long.

It will not be surprising, if one of these days, the rape victim of this present incident and her family are called to Temple Trees and given some money from the President’s Fund. Such examples of so-called mercy have been evidenced many times, when such scandals happen. After neglecting Rizana Nafeek’s case resulting in her beheading in Saudi Arabia, her mother was called to the palace and some money was given.

Lawlessness and public apathy

In Sri Lanka while there is a public acknowledgement of the existence of widespread lawlessness involving particularly shocking offenses against women, the public itself reacts to these events apathetically. There is no energetic pursuit of justice or demands for accountability from the government.

Such apathy that prevails amongst the public regarding heinous crimes as well as the criminal negligence on the part of the government to resolve the problems of the law enforcement agencies is indicative of the deeper malaise in the Sri Lankan society and the Sri Lankan system of justice.

The collapse of the policing system has been acknowledged. This was the direct result of the politicisation process which in turn is a product of the total control of the state by the executive president which has paralysed the bureaucratic apparatus in Sri Lanka. Naturally, it is not within the capacity of the Sri Lankan president to enquire into all crimes and to deal with them. The task of controlling crime could only take place through the functioning of the law enforcement agencies within the framework of the law. The duty of the president and the government is to ensure that these agencies function and deliver the necessary services to the public. However, the nature of the Sri Lankan system at present is such that the president and the government do not have a reliable bureaucratic apparatus through which law enforcement as well as other aspects of the running of governance can be effected.

The result is crimes that re-occur and the gimmicks that are played by politicians to create the impression of law enforcement while there is no real attempt to ensure protection to the people. This situation has resulted in the creation of a sense of apathy in the society as a whole, even in the face of gruesome crimes such as the gang rape of this woman.

As an independent media is suppressed, there is apathy, widespread cynicism and shameless manipulation of news in the state media which is the only media that is allowed to function without hindrance.

While the rest of the south Asian countries are rising to demand better performance from their governments and the creation of efficiently functioning law enforcement agencies to protect all citizens with particular emphasis on the more vulnerable groups such as women, in Sri Lanka crimes continue to take place with impunity.

 

source- http://www.humanrights.asia

 

Political Prisoner Judgment Calcutta High Court


English: Gandhi meeting political prisoners at...

English: Gandhi meeting political prisoners at Dum Dum (Photo credit: Wikipedia)

8th august, 2012

CRR 463 of 2012
With
CRR 1312 of 2012
With
CRR 4000 of 2011
Mr. Subhasish Roy.
… for the petitioners.
Ms. Anusuya Sinha.
… for the State.

What are political offences? Who are political
prisoners? What is the role of political violence for
achieving the political goal professed by its believers?
What is the treatment which State should administer to
those who use political violence/activities to terrorize
others for achievement of their objective? Should means
defeat the end? What is the state of affairs in prison? and
How the prisoners should bedealt within socio-economic
realities of our nation? are a few questions which, being
unpalatable, have been thrown as dice on the board of
this Court.
These questions also test the ability of the
believer of liberty and democracy to keep his prejudices
and bias at bay to strictly confine to the provisions of the
statute believing in the maxim “those who believe in the
system, it is their duty to ensure fairness to those who
question the system”.

Before a humble effort is made to answer
these questions, it will be appropriate to divide this
judgment into five parts, (a) Facts, (b) Broad background,
(c) Provisions of the West Bengal Correctional Services
Act, 1992 (hereinafter referred to as, ‘the Correctional
Services Act’); its classificationof political prisoners; their
rights and the conveniences extended to them, (d)
Remedial measures which this Court propose as
recommendations, and (e) Conclusions and the prayer
clause.
(a) Facts
By this common judgment, three petitions,
viz. (1) Criminal Revision No.4000 of 2011, (2) Criminal
Revision No.463 of 2012 and (3) Criminal Revision
No.1312 of 2012 shall be decided together.
The petitioners herein, at one point of time,
claimed themselves to be Maoists and are dubbed by the
State as Naxalites. Maoists or Naxalites, being
interchangeable words, are tobe broadly understood in
reference to those persons who take up arms to dislodge
the existing system being aggrieved of socio-economic
disparities prevailing in the State.
The petitioners in all the three revisions
petitions have assailed the orders passed by the Courts
3below, whereby their prayer tobe declared as political
prisoners has been declined. They have approached this
Court with a prayer that they be treated as political
prisoners within the meaningof Section 24 of the
Correctional Services Act and a few conveniences which
the Correctional Services Act ensures to the political
prisoners be granted to them over and above the ordinary prisoners.

More Below

Political Prisoner judgment Calcutta High Court

At Home with Violence: Ethnic LIfe in Colombo by Sharika Thiranagama


 

Colombo, where every anti-Tamil riot in Sri Lanka has begun, is, at the same time, a city of many Tamil-speaking (and other) minorities. This paper takes Colombo, the capital of Sri Lanka and the urban heart of Sri Lanka to argue that Colombo has had to perform its Sinhala nationalist credentials constantly because it is “a city which is not one” (Tagg 1996). The paper examines the ways in which people make themselves at home in an ethnically divided city that has never fully been intelligible to its dwellers as one city. Here violence is taken as critical to Tamil phenemenologies of the city. Riots, bombs, and the checkpoints that crisscrossed Colombo made violence a constant feared spectacle of the urban, images of the possible bound by past violence. Yet Tamil spaces of relative safety also presented themselves, due to fear of the separatist LTTE and exploitation by other Tamils, as spaces of un-safety. This paper will takes these everyday practices of inhabiting Colombo as a minority to reflect further on the major dilemmas and political conflicts now facing Sri Lanka in its post-war future.

Speaker Bio: Sharika Thiranagama’s research has focused on various aspects of the Sri Lankan civil war. Primarily, she has conducted research with two different ethnic groups, Sri Lankan Tamils and Sri Lankan Muslims. Her research explores changing forms of ethnicisation, the effects of protracted civil war on ideas of home in the midst of profound displacement and the transformations in and relationships between the political and the familial in the midst of political repression and militarization.

DNA investigations: Kudankulam’s lurking dangers


English: Construction site of the Koodankulam ...

Image via Wikipedia

Feb 28, 2012, 10:30 IST
By Gangadhar S Patil | Place: Mumbai | Agency: DNA

While the prime minister (PM) accuses NGOs funded from abroad of trying to sabotage the ‘state-of-the-art’ Kudankulam nuclear power plant (KKNPP), various studies carried out by government agencies as well as experts suggest that the site is unsafe for a nuclear project.

The studies reveal potential threats to the nuclear reactor campus from near-shore tsunami, volcanic eruptions, and Karst (vulnerable landscape). DNA has a copy of the reports submitted by the agencies and experts.

A 15-member expert group set up by the Centre cleared the project. “The Kudankulam site is located far off (about 1,500km) from the tsunamigenic fault [where tsunamis originate]. Thus a tsunami would take time and lose some of its energy by the time it strikes Kudankulam,” according to the group’s official document.

However, a 1982 study reported in a noted journal documents the presence of two slumps — the East Comorin and Colombo — in the vicinity of the site. A ‘slump’ is a massive agglomeration of loosely-bound sediment on the sea bed that may suffer large submarine landslides, causing mega-tsunamis.

The expert group’s first report failed to identify the presence of a slump that is about 100km from the plant. After activists brought it to the group’s notice, its second report noted the presence of the slumps and the possibility of a near-field tsunami.

“This is against their earlier position and to that of the Atomic Energy Regulatory Board (AERB) which said near-field tsunamis are not possible at the KNPP site,” People’s Movement Against Nuclear Energy (PMANE) functionary M Pushparayan said.

“It is suggested that large submarine landslides can generate a tsunami and may cause coastal hazard. An attempt has been made to quantify the amount of possible water displacement from the above slump belts in the Gulf of Mannar that may occur during a worst case scenario,” the expert group’s second report said. However, it added that the amount of water displacement will be too small to produce a serious tsunami.

Read DNA full story here

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