IPN Health Blog

Note to Oxfam: Foreign aid undermines democratic accountability

I recently received an interesting email from Jerry Norris at the Center for Science in Public Policy.

Like us at the CFD, he was somewhat taken aback by the recent Oxfam paper attacking private healthcare provision:

The Oxfam study, "Blind Optimism", challenges so-called myths about private health care in poor countries. It is a contemporary re-statement of the decades-old argument for universal health care.  This ignores the fact that as post-colonial nations emerged from Africa and the Sub-continent of Asia in the early 1960s, everyone of them had embedded in their new Constitutions the provision for free, universal health care.

 

The problem in bringing this provision into reality was that while everything was free, the governments had little or nothing to offer. Into this vacuum, the donor community found a ready receptacle for aid to the point where today some 55 of the poorest countries in the world have more than 50% of their government budgets provided by external assistance. Another 10 are at 75%!

This removes politicians from accountability to their own citizens for the enforcement of universal health care provisions. It is replaced with a dependence on non-tax revenue from overseas governments.  In the absence of fiscal support from citizens, state elites retain power by converting their governance structures to wholly owned subsidiary organizations of foreign aid agencies. 

 

Still, people in all societies have an insatiable desire for choice. As economies in developing countries improved, growing numbers of their citizens migrated to non-governmental or private provision, expressing in the process, a willingness to pay--if a service could be provided.

 

These citizens are not blind. Oxfam is railing against this evolution without understanding that it has been a participant in the failure of developing countries to sustain their Constitutional provisions for universal health care. By placing a greater reliance on aid agencies than on a general taxation of their own citizens, these countries have subordinated their sovereign responsibilities to the kindness of strangers.

Malaria: putting health before business

A new child-friendly malaria medicine could prevent thousands of deaths in Africa every year.

The drug comes in a variety of sweet flavours, making it far easier to convince children to swallow than existing, bitter pills.

As a child dies of malaria every thirty seconds, this is a wonderful development; and what's more, it will cost just $0.37 per treatment.

Good news all round, yes?

Well apparently not, according to an article in Uganda's New Vision website entitled:

"Launch of child malaria drug threatens local industry"

Therein the Ugandan "primary healthcare minister" is quoted as saying:

“The only fear is that we [already] have a factory manufacturing Anti-malarial drugs (Luzira-based Quality Chemicals)”.

This factory, it seems, has not been cleared for Good Manufacturing Practice by the WHO. Even under the extremely lax "Option C", donors like the Global Fund cannot purchase from the factory, as there is no guarantee that their drugs are of high quality.

So why are government ministers concerning themselves with its profits?

The quotation is a stark reminder of how politicians can be influenced by vested interests.

Instead of prioritising business interests above health, ministers should simply allow the market to provide the best drugs that people need and trust.

Is Bill Gates exaggerating anti-malaria success?

In his 2009 Annual Letter published recently, Bill Gates stated:

"I am ... confident that our maniacal focus on ... measuring results will make a difference."

On the face of it, a "maniacal focus" on measuring results is commendable, and a welcome change from donors citing costs (ie. how much is being spent) as if they were benefits.

Yet today William Easterly reveals that Bill and Melinda Gates have been citing discredited statistics on success rates against malaria in several African countries.

A 50 per cent drop in the number of children infected in Zambia was one claim, leading to Gates exclaming: “Look, aid is making a huge difference, we are literally saving people’s lives."

But this statistic came from a WHO report that was never finalised and has subsequently "disappeared", and was contradicted by the 2008 World Malaria Report.

In that report, a small footnote explains the reliability of their measures:

“...in most countries of Africa, where 86% cases occur, reliable data on malaria are scarce. In these countries estimates were developed based on local climate conditions, which correlate with malaria risk, and the average rate at which people become ill with the disease in the area.”

So, to clarify, these figures are based on "local climate conditions".

As we've commented previously, conflicts of interest commonly result in inflated statistics--which in turn seriously warp the allocation of resources.

The Gates Foundation should be more careful with its figures.

Oxfam's 1950s ideology

Oxfam, a state-funded pro-aid lobby group, released a major report yesterday slamming the World Bank for supporting private sector healthcare in less developed countries. (Blind Optimism: challenging the myths about private health provision in poor countries)

Its objections, according to Andrew Jack's report in the FT, are that private care boosts inequality of access, costs more and contributed to a brain drawn of trained health workers.

The study might have more credibility if it wasn't so wilfully selective of evidence.

To determine the level of private coverage, it cited World Bank Demographic Surveys, but then selects only 15 of the 21 countries they cover.  Oxfam only counts visits to private doctors, ignoring visits to private clinics and hospitals. It also ignores the private drug shops where the poor get most their care.  This is how Oxfam arrives at a figure for private health coverage that is ten times less than the reality.

Oxfam seems to be arguing that donors should place all their eggs in the public sector basket.  But we know public sector health does not produce better quality care.  A 2006 study of 278,000 children in 45 countries found "no evidence that nations . . . with relatively large public health systems perform better or worse than those with larger private systems”. 

We also know that that "free" public sector health tends to be captured by more affluent, urban dwellers, at the expense of the poor in rural areas.

It is strange that in this day and age Oxfam should be advocating monolithic state health provision, when this approach has failed to deliver after many decades of trying and plenty of money. This is hardly surprising - monopolies rarely benefit consumers, whether they be in supermarkets or mobile phones. 

Surely the answer to the healthcare problems of the developing world lies in diversity of provision, with as many players as possible brought to the table? Even countries that are deeply concerned with 'social solidarity' favour this approach (the Netherlands, Germany, France etc).

Fortunately, most journalists have seen this paper for the bit of ideological advocacy that it is, and have not covered it (except the FT).  Obviously Oxfam's massive press office needs to be working a bit harder!

April Harding over at the Center for Global Development has more.

Oxfam's "Blind Optimism" can't see truth behind fakes

Today Oxfam has released a new report (‘Blind Optimism: Challenging the myths about private health care in poor countries') attacking private sector involvement in healthcare.

Strangely their press release blames the scourge of fake drugs in poor countries on "the private sector".

"In China one third of drugs dispensed by private vendors are counterfeit" they declare.

But how about governments? Are they never responsible for fakes?

Here's a quotation from an article in the Indian press from just last week:

"State-approved drugs with less than the required efficacy ... get included in state procurement programmes and form the staple of medicines distributed through the public healthcare system."

The author adds:

"No wonder that there is a widespread notion that sarkari medicines do not work and if you want medicines which will then go and buy them from private shops.”

So let's get this straight - in India if you want good quality drugs you go to "private shops" and not "the public healthcare system".

But Oxfam's report does not mention this, nor any case of governments producing or disseminating substandard medicines - perhaps because the report is designed to argue that even more millions of dollars should be transferred from international donors to such governments.

The report calls for donors to:

"Rapidly increase funding for the expansion of free universal public health-care"

This can take the form of "general budget support" to governments, they propose.

Let's look at one example of such donor-to-government "health aid": back in 2002, the Global Fund to fight AIDS, Tuberculosis and Malaria granted $133 million of aid to the Thai government, to produce the drug “GPO-Vir”—an antiretroviral to treat HIV / AIDS. The drug manufactured was substandard, and by 2007 there were estimates that up to half of its users had developed drug resistance.

Even worse, this kind of system is extremely prone to corruption. An investigation in Uganda in 1999 suggested that 70 per cent of drugs in the public sector went missing.

But back to fakes: last week the BBC reported that 30,000 packets of fake medicines may have been consumed by NHS patients in the UK. So much for governments guaranteeing a supply of genuine drugs - even in wealthy countries.

In poor countries, patients are plagued by substandard and counterfeit medicines; this is due to weak or non-existent trademark protection, high corruption, and low access to good quality medicines. The CFD is disappointed to discover Oxfam using such a serious issue to defend a political call for donor-to-government aid.

Unfair levels of funding still plague the poor

A report published in peer-reviewed journal PLoS Medicine this week reveals warped levels of R&D funding for the diseases of poverty.

Of the $2.5bn that was spent on R&D in 2007, a massive 42% was channelled towards HIV / AIDS, according to the report.

As previously noted in the British Medical Journal, HIV / AIDS causes just 3.7 percent of deaths in low- and middle-income countries, yet consumes 25 percent of international healthcare aid.

Meanwhile 1.8 million people die annually from diarrhoeal illnesses, yet these account for little more than one tenth of the funding spent on HIV / AIDS.

Respiratory illnesses are an even greater cause of mortality than both, accounting for around 4 million deaths per annum.

So why are there such disproportionate levels of spending? The report offers one explanation:

‘…some donors do not make investment decisions based on “scientific or epidemiological considerations”’ it states. Instead donors are influenced by:

•    “the presence of advocacy and fundraising groups”
•    “by funder perceptions or preferences”
•    “by the presence of policy frameworks and funding mechanisms that prioritize specific diseases”

Professor Karol Sikora wrote last summer about the politicisation of disease. Some diseases become ‘romantic’ in the public mind due to high publicity campaigns, often led by celebrities and rock stars. Politicians then direct greater levels of funds towards the these diseases—at the expense of other, less ‘romantic’ causes.

“Funding should be divided according to real need on the ground, not misleading scares nor fashionable causes” he says.

Sadly it seems no one’s listening, and a plethora of single-issue NGOs and self-interested politicians continue to warp investments.

Faked in China, continued

This week news emerges of the latest counterfeit drugs scandal to hit China.

5,000 more bottles of faked diabetes medicine have been found, with the product known to have resulted in two deaths so far.

The bottles purport to be made by the Guangxi Pingnan Pharmaceutical Co., yet are apparently counterfeit, and are now spread into several provinces.

The government continues to pose as “being tough” on counterfeit and substandard products and has claimed it dealt with almost 300,000 cases of “illegal drugs and medical equipment” last year.

As previously discussed by Roger Bate, the Chinese authorities need to look at the environment that has been so conducive to counterfeiting. Why is it occurring so much in the first place?

A free media, rigorous trademark law and courts free from political interference remain the strongest protection from counterfeit products.

Resistance is futile

Over at the Center for Global Development there is much wringing of hands at the worrying news from SE Asia that resistance is beginning to develop to artemisinin-based combination therapies (the most effective treatment for malaria).

The CGD has many worthy suggestions for tackling the problem, including "step-wise containment strategies" and enhancing "drug resistance surveillance efforts."

But everyone - including the NYT journalist who raised the issue last week -- is ignoring the elephant in the dining room: SE Asia has long been awash with fake and substandard artesunate. 

Surely this has got more than a little to do with it?