The growing movement in favour of the privatisation of public services and the reliance on market forces in many developing countries suggests that the critical role of the district health system needs to be restated.  Research by the Institute of Development Studies, UK, indicates that district health services are the best means of delivering primary health care and basic hospital care and should be made a priority for public funding. The most important task is to develop a special programme of rehabilitation for a demoralised workforce, including improved management of staff mix and distribution, incentives for good performance, support and training as well as better pay.

Immediately following the Alma-Ata Declaration of 1978 on primary health care, the industrialised world entered a long period of recession accompanied by neoliberal economic policies.  In developing countries this caused an economic crisis and the implementation of macroeconomic stabilisation and adjustment programmes.  The need to balance reduced budgets led to cuts in public health expenditure, drug shortages, deteriorating facilities and an overall decline in the standard of health services.  Not surprisingly, people, even the poor, turned to private health care. Some have attributed failures of primary health care to weakness in policy design. But this blames the victim. It fails to take account of how the political economy has starved it of resources.

The study found that:

• The salaries of health workers fell enormously in the 1980s and 1990s with catastrophic results.  Many workers became demoralised, charged patients under-the-table fees, stole drugs, practised privately during working hours and became increasingly uncaring towards patients.
• Although charging for primary care services has on occasion improved the quality and utilisation of care in certain situations, the poor are less likely to use them or else get into debt attempting to pay for the necessary treatment.
• There is little evidence to support proactive privatisation, the use of markets, or introducing competition between different providers of health services.

Improving working and living conditions for health workers is essential for an effective public health service. The report further recommends that:

District health systems should be financed mainly from public funds.  Direct fees should be gradually replaced by public finance and subsidised prepayment schemes.

Cost effectiveness should enter into the selection of treatments for people but not into the selection of 'efficient' patients for treatment. Making sure everyone has an equal chance of achieving their potential for good health should be a priority.

• Decentralisation is likely to be a good thing if it is carried out carefully; district health care should be a publicly provided service although other bodies can be contracted if needed.
• Health programmes are best delivered through integrated district health systems. International assistance for health care should strengthen such systems rather than undermine them by supporting vertical health programmes.

The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of mass campaigns in the past which diverted resources from local health services. It should not set programme targets that are driven by an international agenda and which can be achieved only by slowing the development of sustainable health systems, especially those for poor rural districts.

Source(s):
‘District health systems in a neoliberal world: a review of five key policy areas’, International Journal of Health Planning and Management 18: S5-S26, by M. Segall, 2003

id21 Research Highlight: 11 May 2004

Further Information:
Malcolm Segall
Institute of Development Studies
University of Sussex
Brighton BN1 9RE
UK

Tel: +44 (0) 1273 678450
Fax: +44 (0) 1273 621202
Contact the contributor: m.segall@ids.ac.uk

Institute of Development Studies (IDS), UK

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