Pluralism and Marketisation in the Health Sector

This 35-page paper focuses on the health sector in order to identify the key producers of social goods and how social policy interventions can support them.

From the summary:

This paper… "focus[es] on the health sector in order to:

• Examine the changing roles of health care providers and the management of health expertise in the context of pluralism and increasing marketisation of health goods and services.
  
• Explore how pluralism of provisioning and increasing markets for health goods have affected the ways households meet their health needs.
  
• Stimulate a reassessment of what governments should or could do to enable delivery of competent health care under conditions of pluralism and marketisation."

The document argues that over the last few decades there have been profound changes in the ways health goods are being produced and consumed in low income and transitional countries. It examines the changing roles and functions of providers, asking what services health workers provide, what the structure of rewards and incentives is for health providers, and how current arrangements affect transactions, costs, and quality of services. It considers how households, particularly economically poor ones, manage health provisioning in a pluralistic environment where health goods and services have become increasingly marketised (made available for purchase, generally at an unregulated price). The document examines the role of governments and institutions, the financing of health services, the management of the knowledge of health experts, and the skill needs of practitioners.

In looking for ways forward for low and middle income countries, the authors suggest the minimum government achievement should aim to:

1. Enforce public health regulation;
   
2. Assist in sanitation and clean water access;
   
3. Reduce exposure to malaria, tuberculosis, sexually transmitted diseases, and water-borne epidemic diseases;
   
4. Enforce regulation of health practitioners, drugs, and other health products; and
   
5. Provide information to enable people to cope with health problems more effectively and use available resources.
   

Regarding contracting for the provision of health services, the report stresses looking for new models of accountability using community representatives and civil society or community based organisations (CBOs) to monitor the provision of services. The authors argue that the chief reason against allowing the market to determine access to health goods and services is the impact on health system ethics. They suggest that the role of external incentives and sanctions can improve health worker performance and promote an ethos of good practice, changing the situation from one of competition based on cost to one in which trusted workers are paid adequately. In promoting community health self-regulation, they give examples of other highly self-regulated industries and professions: airlines, civil engineering, and veterinary services.

Finally, the document focuses particularly on shifts in the location of specialised knowledge, such as strategies for disseminating health-related knowledge. The suggestion for economies where, due to increased literacy and access to health information, there is more access to privatised medicine (instead of or in addition to government-sponsored community health services) is the following: a shift might be made towards providing users of privatised health care with basic information on how to judge provider competence, how to purchase safe and effective drugs, and where to get cost-effective treatments.


A possible role of information technology (IT) might be to link households and communities to increased healthcare information, including using and obtaining appropriate drugs for medical treatment. Low cost computers in small clinics might support the dissemination of health information for the dispensing of drugs and the monitoring of their prescription. While not sufficing for problems beyond the common ones, this kind of knowledge management, as stated here, might produce more competent, accessible, and affordable options for managing routine problems in economically poor countries, moving them towards a new kind of segmentation of the health sector, “with an industrialisation of basic services across the population, and a continued use of professional models for complex advice and interventions.”