How do not-for-profit non-governmental health service providers perceive
their role in the national provision of healthcare? How do they steer a course
between their mission and changes in national and international operating conditions?
Pursat Hospital, Combodia (Photo: Swiss Red Cross)
The topic
Filling gaps... In many countries, the market-oriented
programmes of structural change initiated by the World Bank and the IMF in the
1980s led to cutbacks in government expenditure on education and health. This
weakening of the state and the reduction in state benefits resulted in a degree
of "passive privatization", i.e. the emergence of an unregulated health
market with a large number of commercial providers at all levels. At the same
time, not-for-profit groups and institutions endeavoured to fill the gaps in
service provision and financing and take the place of the public sector in the
national health system. These endeavours enjoyed international support: given
the weakness of the state and with a view to change from the bottom up, the
development organizations regarded promoting the emer-gence of civil-society
structures and strengthening of their effectiveness as a strategy that promised
to be successful.
The return of the state. In recent years, however, there
has been a further shift in emphasis in the international debate on development
policy. A weak, functionally disabled state is considered to be a barrier to
development, and private organizations are no longer regarded as effective and
sustainable substitutes. As a result of the poverty reduction strategies of
the World Bank and the efforts to coordi-nate development cooperation (Declaration
of Paris), hopes are once again being placed – and money invested – in support
for national development strategies, in conjunction with strengthening of state
institutions and their capacities. So the state is making a comeback – at a
time when the enormous challenges and health crises with which it is confronted
are making it increasingly dependent on civil society.
More steering – less oar-work. The state need not -
and cannot – do everything itself: "new public management" or "stewardship"
are catchwords for the policy pursued by many states in redefining their duties
and responsibilities in the healthcare system and in other supply sectors: by
defining a national health policy and regulating the healthcare sector, the
state focuses on providing the direction and framework that enable both public
and private-sector players to provide their services.
Cooperation with this state?! In practice, however,
many developing countries still have weak and, in many respects, incompetent
state administrations. For non-governmental health service providers and their
backers, the path that leads from parallel to integrated service provision,
from replacing the public sector to being incorporated into a national health
system, is neither straightforward nor obvious. They formulate conditions that
have to be met – and in turn they have to consider how legitimate and sustainable
their staying on the sidelines would be.
Positioning, strengthening, cooperating. Even though
operating conditions may vary considerably from country to country, not-for-profit
non-governmental health service providers and their backers and international
partners everywhere are now obliged to reconsider their own identity and to
position their services clearly, while also strengthening their structures and
capacities. If they are to hold their own in the face of new competition in
the health market and in the political dialogue and negotiations with the state,
they will also have to consider the question of synergies and increased cooperation
between the not-for-profit health service providers of a country or health district.
The Swiss Health Cooperation Symposium
Discussing international cooperation and development policy.
The Swiss Health Cooperation Symposium targets a broad spectrum of participants
active at the na-tional or international level and is organized by Medicus Mundi
Switzerland, Network Health for All, which comprises 46 Swiss agencies operating
in the field of international health cooperation. The sym-posium is part of
a long-term cooperation agreement with the Swiss Agency for Development and
Co-operation SDC, which helps fund the event and provides support with the programming.
Contact: Thomas Schwarz,
tschwarz@medicusmundi.ch
