A donor's perspective on tuberculosis in international health

Disintegrated care: the Achilles heel of international health policies in low and middle-income countries

PURPOSE

To review the evidence basis of international aid and health policy.

CONTEXT OF CASE

Current international aid policy is largely neoliberal in its promotion of commoditization and privatisation. We review this policy's responsibility for the lack of effectiveness in disease control and poor access to care in low and middle-income countries.

DATA SOURCES

National policies, international programmes and pilot experiments are examined in both scientific and grey literature.

CONCLUSIONS AND DISCUSSION

We document how health care privatisation has led to the pool of patients being cut off from public disease control interventions--causing health care disintegration--which in turn resulted in substandard performance of disease control. Privatisation of health care also resulted in poor access. Our analysis consists of three steps. Pilot local contracting-out experiments are scrutinized; national health care records of Colombia and Chile, two countries having adopted contracting-out as a basis for health care delivery, are critically examined against Costa Rica; and specific failure mechanisms of the policy in low and middle-income countries are explored. We conclude by arguing that the negative impact of neoliberal health policy on disease control and health care in low and middle-income countries justifies an alternative aid policy to improve both disease control and health care.

Integrated care: a fresh perspective for international health policies in low and middle-income countries

Purpose

To propose a social-and-democrat health policy alternative to the current neoliberal one.

Context of case

The general failure of neoliberal health policies in low and middle-income countries justifies the design of an alternative to bring disease control and health care back in step with ethical principles and desired outcomes.

Data sources

National policies, international programmes and pilot experiments—including those led by the authors—are examined in both scientific and grey literature.

Case description

We call for the promotion of a publicly-oriented health sector as a cornerstone of such alternative policy. We define ‘publicly-oriented’ as opposed to ‘private-for-profit’ in terms of objectives and commitment, not of ownership. We classify development strategies for such a sector according to an organisation-based typology of health systems defined by Mintzberg. As such, strategies are adapted to three types of health systems: machine bureaucracies, professional bureaucracies and divisionalized forms.

We describe avenues for family and community health and for hospital care. We stress social control at the peripheral level to increase accountability and responsiveness. Community-based, national and international sources are required to provide viable financing.

Conclusions and discussion

Our proposed social-and-democrat health policy calls for networking, lobbying and training as a joint effort in which committed health professionals can lead the way.