Safeguarding the Health Sector in Times of Macroeconomic Instability This page intentionally left blank Safeguarding the Health Sector in Times of Macroeconomic Instability Policy Lessons for Low- and Middle-Income Countries Edited by Slim Haddad, Enis Bari§, Delampady Narayana Africa World Press. Inc. P.O. Box 1892 /ff^Ejh P.O. Box 4B Trenton, NJ OM07 ^^jff Asmara, ERITREA International Development Research Centre Ottawa • Cairo • Dakar • Montevideo • Nairobi • New Delhi • Singapore Africa World Press, Inc. P.O. Box 1892 nSRSvt P.O. Box 48 Trenton, N) 08607 Asmara, ERITREA Copyright © 2008 International Development Research Centre (IDRC) First Printing 2008 Jointly Published by AFRICA WORLD PRESS P.O. Box 1892, Trenton, New Jersey 08607 [email protected]/www.africaworldpressbooks.com and the International Development Research Centre PO Box 8500, Ottawa, ON Canada KIG 3149 info@idrc/www.idrc.ca ISBN (e-book): 978-1-55250-370-6 The findings, interpretations and conclusions expressed in this study are entirely those of the authors and should not be attributed in any manner to the institutions with which they are, or have been, affiliated or employed. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopy- ing, recording or otherwise without the prior written permission of the publisher. Book and cover design: Saverance Publishing Services Library of Congress Cataloging-in-Publication Data Safeguarding the health sector in times of macroeconomic instability : policy lessons for low- and middle-in come countries / editors: Slim Haddad, Enis Baris, Delampady Narayana. p.; cm. Includes bibliographical references and index. ISBN-10: 1-59221-596-3 (hardcover) ISBN-10:1-59221-597-1 (pbk.) 1. Health care reform—Economic aspects—Developing countries. 2. Medical policy- -Economic aspects—Developing countries. 3. Public policy—Developing countries- -Finance. 4. Structural adjustment (Economic policy)—Developing countries. 5. Economic stabilization—Developing countries. 6. Medical economics—Developing countries. I. Haddad, Slim. II. Baris, Enis. III. Narayana, D. [DNLM: 1. Health Care Reform—economics. 2. Developing Countries. 3. Public Policy. 4. Socioeconomic Factors. WA 530.1 S128 2007] RA395.D44S34 2007 362.109172'4-dc22 2007028214 In memory of our friend and esteemed colleague Stephen Chandiwana, an ardent advocate for health policy and systems research as a key ingredient in improving the health of sub-Saharan African communities. This page intentionally left blank TABLE OF CONTENTS Foreword vii Acknowledgments xi CHAPTER 1 The MAPHealth Project: a Multi-Country Initiative 1 Slim Haddad, Enis Bans,, Delampady Narayana CHAPTER 2 Macroeconomic Adjustment Policies and Health Sector Reform: Surveying the Literature 13 Katherine S. Mohindm CHAPTERS Methodological Issues in Evaluating Public Policy 53 SlimHaddad, Enis Ban/, and the MAPHealth team CHAPTER 4 Health Sector Reform under Macroeconomic Adjustment in Burkina Faso: Lost Opportunities? 87 Adrien Nougtam, Slim Haddad, Jacques Gueda Ouedraogo, Salimata Ky-Ouedraogo, Valery Ridde, Pierre Fournier CHAPTER 5 Aiming for Equity in Colombia's Health System Reform: Achievements and Continuing Challenges 131 Francisco Jose Yepes, Manuel Ramirez, Maria Gloria Ca.no, Rodrigo Bustamante CHAPTER 6 Adjustment and Health Sector Reforms: the Solution to Low Public Spending on Health Care in India? 159 Delampady Narayana viii Safeguarding the Health Sector in Times of Macroeconomic Instability CHAPTER? High Health Achievements and Good Access to Health Care at Great Cost: the Emerging Kerala Situation 199 Delampady Narayana CHAPTER 8 Reform without Structural Change: Conserving Traditional Sources of Power and Prestige in Mexico's Segmented Health Market 225 LuisDurdn, Sofia Arjonilla, Viviane Brachet-Mdrquez, Jeannie Haggerty CHAPTER 9 The Evolution of Thailand's Health System after Three Crises, Three Adjustments, and Three Decades of Growth 255 Sanguan Nittayaramphong, Yaotvarat Porapa.kkha.rn, Supattra Srivanichakorn, Sunee Wbngkongkathep, Enis Barif CHAPTER 10 Striving to Safeguard a Health System Undermined by Adjustment: Policy Lessons from Zimbabwe 287 Stephen K. Chandiwana, Tapiwajhamba, Charles Mutasa, Brian Chandiwana, Boy Sebit, Henry Chikotva, Paulinus L.N. Sikosana, Levon Arevshatian CHAPTER 11 Political Will and Adaptive Strategies: Keys to Safeguarding the Health Sector in Times of Macroeconomic Instability 327 Slim Haddad, Delampady Narayana, Enis Ban$ Contributors 343 Index 347 FOREWORD Structural adjustment, macroeconomic adjustment, and health sector reform are loaded terms. Each has become a kind of shorthand for diverse and frequently opposing health and devel- opment constituencies, signalling for each constituency a very different constellation of goals, assumptions, values, ideologies, methodologies, technical content and results. At one fundamen- tal level, these differences reflect very different visions of how societies should function. Recent and ongoing debates about globalization, market-based approaches to service delivery, and roles of the state and active civil society are helping to sharpen these alternative visions and continue to play an important role in unpacking the contents of such seemingly bland terms as mac- roeconomic adjustment and health sector reform. At another level, the debates and growing evidence base around globaliza- tion highlight how entangled national and local policy and prac- tice are with decisions and political and economic imperatives elsewhere. Yet at a third level, the level on the ground where macroeconomic policies and realities, health policies, health- care delivery systems, and people intersect, we see a much more complex and subtle situation unfolding. At this third level, contexts, policy choices, personalities, policy-implementation capabilities, cultural and social norms, and political and economic history interact to produce outcomes that are both promising and troubling. It is this reality on the ground that is too often neglected or avoided by sweeping tri- umphalist or catastrophist narratives, the reality where govern- ments must make choices in circumstances they may ardently x Safeguarding the Health Sector in Times of Macroeconomic Instability wish were different, where ministries and clinics alike are short of skilled staff, where sudden shifts in commodity prices or weather may precipitate a crisis with which a health department must somehow deal, where both noble and venal motives and actions are in evidence, but where there may just be ways to safeguard the health sector while the higher-level debates about politics and vision continue both in-country and around the world. It is this third level which the researchers of the MAPHealth study so rig- orously and thoughtfully address, and the result is an exceptional collection of analyses, reflections, and recommendations. Some of the results confirm prior findings, while others are surprising and on the surface may be counterintuitive. The conclusions and recommendations within each case study, and of the overall comparative work, make for sobering but also hopeful reading. There are no easy answers. The continued importance of politi- cal will points to the critical role that broad-based public debate and real—not pro forma—civic engagement play in informing and shaping power and politics, in and between societies, to the benefit of all, especially the poor. "Governance" is indeed politi- cal, despite what the more technocratic among us might wish. But as all the case studies show, action to safeguard the health sector is possible, even in countries as poor as Burkina Faso, as crisis-ridden during the period examined here as Zimbabwe, Mexico, Colombia, and Thailand, or as complex as India. The vision is crucial but the devil, as always, is in the details—hence the importance of the careful, systematic work presented here. This book and other studies support the view that some kinds of imposed policy choices, such as the first generation of structural adjustment, leave very little room for action or mitiga- tion at the country level. However, neither the study design nor the analysis presented here are aimed specifically at these macro- level political and philosophical debates, though the reader will find frequent, thoughtful, and challenging contributions to these debates throughout the chapters. The debates are longstanding, with modernization and dependency theory still being played Foreword xi out under new names as the pendulum swings back and forth in global development policy. It is perhaps worth noting, in the foreword to a book which reports on many years of careful effort to collect and interpret evidence of policy impact, how seldom these sweeping and enthusiastic policy shifts are actually informed by careful ex ante analysis, or even concurrent rigorous evaluation of implemen- tation and impact. This is one admonition the book's authors delicately avoid making, but which needs to made. Fortunately, recent initiatives around the world reflect a growing impatience with making the developing world a kind of global social policy laboratory, minus the careful lab science. We hope the method- ological challenges experienced by these and other researchers, discussed in Chapter 3, will become less of an obstacle to future researchers and decision-makers. As this book goes to press, the WHO Commission on Social Determinants of Health is