Dancing with the Devil: Health, Human Rights, and the Export of U.S. Models of Managed Care to Developing Countries
The current movement to export prevailing American practices of managed health care to developing countries is a development in need of critical reevaluation. In a shrinking, more complex world where health care must be sensitive to cultural beliefs and practices to be wholly effective, this movement at best represents a misguided attempt to control the burden of disease on developing countries. At worst, the drive to send abroad American-style managed care runs the risk of ignoring or trampling the health-related cultural traditions of indigenous peoples. In this regard, the dual concepts of health and human rights demonstrate a clear association.(1) Human rights and health, particularly public health, thoroughly intertwine at a basic level, especially if one subscribes to the belief that public health is fundamentally a question of social justice.
The United States plays multiple and highly influential roles on the world stage as the provider of an array of commodities extending from items of foreign aid like wheat to weapons or financial credits. The varying systems of managed health care seen in the U.S. are also exported with great fervor to developing countries. Managed health care is touted by many experts -- usually found in USAID, the World Bank, and various havens of academia(2) -- as a tangible model which can be of immense value to developing countries if applied wisely and efficiently. Regardless of the soundness of any theoretical model, though, managed care as it has evolved is a fatally flawed system. The adoption or imposition of such a system into the health plan of a developing country would be a staggering misstep. For almost any developing country, embracing managed health care would not only squander limited financial, material, and human resources, but might very well waste lives. Alternately, a sound, centralized national health care system -- despite the acknowledged problems and inefficiencies of such systems -- should be the favored model employed, both for the benefit of these countries and for the people who live in them.
Anyone contemplating the health needs of developing countries must keep in mind that no two such countries are alike -- a straightforward perception, but one readily forgotten when using broad geographic word strokes like "Southeast Asia," "the Horn of Africa," or even "Russia." For reasons ranging from the historical and cultural to the economic, each country in the developing world has its own unique set of strengths and weaknesses. That the cultures found within these countries would suffer under a managed health care system becomes evident after considering what the late Dr. Jonathan Mann and others referred to as the "three central functions of public health [which] include: assessing health needs and problems; developing policies designed to address priority health issues; and assuring programs to implement strategic health goals." As regards human rights:
[Health] assessment involves collection of data on important health problems in a population. However, data [aren't] collected on all possible health problems, nor does the selection of which issues to assess occur in a societal vacuum. Thus, a state's failure to recognize or acknowledge health problems that preferentially affect a marginalized or stigmatized group may violate the right to non-discrimination by leading to neglect of necessary services, and may adversely affect the realization of other rights, including the right to `security in the event of sickness [or] disability.' (Universal Declaration of Human Rights, Article 25)
The implementation of a managed care health system would likely have just these negative results.
Regardless of noble intent, those who feel that the health sectors of developing countries, even with their commonly bloated, centralized bureaucracies (systems often inherited from former colonialist powers) are ripe for adopting principles of managed care display a gross misunderstanding of ensuring effective health care across cultures. The extreme poverty of many developing countries, including the often accompanying lack of a working economic infrastructure, should make clear that the framework of managed care -- segmented markets, contracted services, and provider competition -- would drain critical national resources from the health requirements of many indigenous peoples and other marginalized groups. Exporting notions of rationed health care under the guise of health management does a tremendous disservice to populations that may have no experience with health equity, let alone health system efficiency.
In the case of relatively richer developing countries, the appearance of managed care markets may still marginalize a significant part of the population, including the truly disenfranchised levels of society such as the very poor, the displaced, migrant workers, and cultural minorities. A strong, counter-balancing public health sector intended to serve a country's disadvantaged is unlikely to be created or survive if human and material resources are devoted to fostering managed health care. An expanded, U.S.-style managed care scenario is asking of developing countries a sophistication in the proficiency and equity of national health care not even seen in the United States. The theoretical market requirements for medical managed care -- called for by Jonathan Broomberg of the London School of Hygiene and Tropical Medicine (LSHTM) -- are lacking in immense tracts of the American landscape. These requirements include the "presence of well-informed, utility-maximizing consumers, numerous profit-maximizing providers, and freedom of entry to and exit from the market." In light of these requirements, often absent even in the U.S., any expectation that managed care will enhance the health services available in far more resource- and technologically-constrained developing countries seems overly optimistic.
Still, public health theorists confidently predict that adopting U.S.-style practices merely involves some universal formula of decentralization, privatization, and software application on (somehow) standardized information systems. The plural health systems in many developing countries are not so easily harmonized. American medical anthropologist Judith Justice and other researchers have demonstrated the pitfalls of ignoring cultural attitudes when approaching health care; more than one imported health policy has been compromised by cultural insensitivity on the part of planners.
The notion that managed care is fundamentally capable of respecting cultural diversity in attitudes toward (and knowledge and practices of) health care in a developing country is a mighty stretch of faith. The still-emerging cultural competence evident in American health care providers as a group (i.e., proper use of translators, recognition of physiological and epidemiological differences in dissimilar cultural groups, and cultural concepts of illness) is at odds with the basic managed care approach of setting time limits to care. Hillary Standing of the Liverpool School of Tropical Medicine (LSTM) argues that another pillar of managed care -- an emphasis on preventive services -- might flounder in less developed countries where a fervent predisposition still exists toward curative services and the peddling of drugs. Given that the incomes of numerous health providers in the private sector of less developed countries are wedded to such services and sales, diluting self-interest would be a colossal hurdle. Even should health providers shift their priorities, the gender inequality evident in many cultures challenges managed care's recommendations regarding user charges and improving access to services. Standing notes that observation in sub-Saharan Africa during the 1980s and 1990s recorded a rise in maternal deaths when user charges were imposed for maternal and child health (MCH) services. Figures also indicated a marked decline in the total numbers of deliveries seen in hospitals, as well as a drop in the overall use of MCH services. This relative deterioration of care is informed by cultural approaches to gender in many developing countries, and, according to Standing, reflects women's basic inability to pay for health services -- either directly or indirectly through pre-paid insurance -- owing to a culturally-influenced financial disadvantage. Women often lack access to an independent income and control over household money, and may face household biases favoring males for medical treatment; many women simply have no time available to leave behind work and family for a visit to a health facility. Underlying each of these variables, of course, is the bedrock dilemma of the pervasive poverty so prevalent in the developing world.
Recognition of the problems with exporting U.S.-style managed care to developing countries does not entail ignorance of the inefficiencies of many current health systems in the developing world. A list of these inefficiencies could fill volumes and includes a collision between technical and financial problems as developing countries strive to find a balance between allocation and consumption of health resources.(3) This search for balance is made more difficult in environments where health policy decisions often stress historical precedent at the expense of the current or emerging health needs of a population. One stark example is the deepening crisis in trying to pay for the prevention or treatment of HIV/AIDS in the developing world.
The current infatuation with U.S.-style managed care is likely to exacerbate these problems. Nevertheless, managed care has gained a firm foothold in many middle-income developing countries, usually through public sector contracting with an array of private and public providers for specific clinical services. The implicit contracting for services with non-profit, private providers (e.g., churches) by the health ministries of certain countries is increasingly prevalent. The public health sectors of such countries would be far better served if more resources were devoted to their basic improvement. Such improvements should encompass the non-glamorous aspects of public health normally given short shrift -- from implementing improvements in training and salaries to strengthening health care delivery and quality assurance. A solid, well-organized central health care system should be the preferred overseas type for struggling countries.(4) Only in specific cases of extreme resource scarcity might certain modes of financing -- community health insurance plans for rural or remote communities for basic health services -- be appropriate. As with any community-driven health care plan, it should be more participatory than bureaucratic, and strive to be both cultural- and gender-responsive, concerns that are more in line with human rights.
Those proposing the installation of managed health care for developing countries establish their enthusiasm in what LSHTM's Broomberg terms three central claims: first, that managed markets advance increased provider competition and that this competition boosts supply-side competence; secondly, that the substitution of direct management for contractual relationships between purchasers and health providers encourages increased clearness of costs and quality; and third, that the overall benefits of managed health care markets overshadow the costs involved in creating and maintaining them.(5)
In contrast, the argument for a vibrant centralized health care model in developing countries emphasizes meeting the needs and expectations of people in those countries. An integrated arrangement of health districts, hospitals, and health posts that are culturally and medically responsive to local conditions and under the direction of a dedicated health ministry is in a far better position to serve the collective health of a nation. Unfortunately, some governments in the developing world still refuse to protect or enhance the health-related human rights of indigenous or otherwise marginalized peoples. This stance is short-sighted, especially if a government seeks to extend its presence and influence into areas occupied by marginalized groups. A government might find its efforts to develop support among indigenous people enhanced by the integration of traditional health practitioners and traditional birth attendants into a centralized health care system. Not only would such integration have the potential to make a central health care system more cost-effective, it could also lead to the professionalization of traditional medicine.
There is, of course, no magic answer to the crisis of making health care in developing countries more equitable and responsive to their populations. Even a call for more cultural and gender responsiveness in health care, for example, runs into the very complex dilemma of how to react to the cultural practice of female genital mutilation, also known as female circumcision, which is the surgically pointless alteration of the female genitalia. Governments and their attendant health ministries have an obligation to provide high-quality and culturally sensitive health care. Well-meaning attempts to import U.S.-style managed care techniques and practices do little to serve any developing country's diverse population, particularly indigenous people who may reside on the fringes of society. Health care is more than a market commodity; it is an essential right that reflects a quality of life. To subject health care to the vagaries of the marketplace will only fragment health services and further ostracize people in need.
References & further reading
Hagland, M. (1999, July). American managed care organization creates a global product. Healthcare Informatics: International. www.healthcareinformatics.com/issues/1999/07_99/international.html
Broomberg, J. (1994). Managing the health care market in developing countries: prospects and problems. Health Policy and Planning 9:3, pp 237-251.
Justice, J. (1987). The bureaucratic context of international health: a social scientist's view. Social Science and Medicine 25, pp 1301-06.
Lankinen, K., Bergström, S., Mäkelä, P., & Peltomaa, M. (1994). Health and disease in developing countries. London and Basingstoke: The Macmillan Press, Ltd.
Mann et al. (1994). Health and human rights. Health and Human Rights.
Standing, H. (1999). Frameworks for understanding gender inequalities and health sector reform: an analysis and review of policy issues. Harvard School of Public Health/Healthnet. www.hsph.harvard.edu/ Organizations/healthnet/HUpapers/gender/standing.html
The International Bank for Reconstruction and Development/The World Bank (1993). Better health in Africa. Washington, DC: Shaw, R.P., & Elmendorf, A.E.
(1998, July 4). The health service at 50: Bevan's baby hits middle age. The Economist (UK).
(1). They do, of course, have common concerns when individual or group health suffers at the hands of human rights abuses such as torture.
(2). Advocates of U.S.-style managed care for developing countries include Richard Feeley, professor at the Boston University School of Public Health (BUSPH) and member of BUSPH's Center for International Health; A. Edward Elmendorf, co-Editor of the World Bank publication Better Health in Africa: Experience and Lessons Learned, 1993; and Donald Pressley, USAID's Europe and Eurasia Bureau Assistant Administrator. Pressley, in remarks to the Annual Meeting of the Partners of the American International Health Alliance (AIHA) in Arlington, Virginia on November 15, 1999, said:
We will work to implement legal and regulatory frameworks that promote fiscal and policy decentralization, thereby allowing public and private providers to address the needs of their local communities.... We will work to ensure that countries -- as well as communities -- have the financial means to manage and sustain sound social programs. This means working to improve tax collection, for example....
USAID pledges to "be active in identifying and resolving policy constraints and supporting development of policies that remove barriers to effective and accessible health care. Key policy areas include: decentralization, cost recovery, private sector involvement, policies to support focused interventions, and budget allocations for curative and preventive care." (An African Framework for Design and Implementation of Child Survival Interventions. To obtain a printed copy of this publication, contact USAID Development Experience Clearinghouse/DDU, 1611 N. Kent Street, Suite 200, Arlington, Virginia 22209-2111)
(3). Broomberg, 1994.
(4). This assertion doesn't subscribe to the myth -- illustrated in The Economist -- that the demand for health care is finite and that tossing in a certain amount of money can solve any country's health dilemmas. Rather, the application of financial resources should be made with the care of a surgical incision.
(5). Broomberg, 1994.
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