The poor receive low-quality care from the private sector because doctors
do not know much and low-quality care from the public sector because doctors
do not do much. These results suggest that poor-quality medical services for
the poor are a result of both incentives and competence of providers. For the
private sector any solution is likely to come from improving information to
consumers and greater regulatory oversight by the state which together can
help to reduce demand for excessive and inappropriate treatment.
Mortality reduction in rich countries, where most deaths are from cancers and
cardiovascular diseases (Cutler et al., 2006:107) is closely associated with
expensive hospital care. There is a widespread view in developing countries that
the existing allocation of health resources in curative care in hospitals is inappro-
priate and that a reorientation of government spending to primary health care
would bring about health gains and cost savings. Some of the inspiration comes
from the ‘barefoot doctors’ model (Box 6.3). There are problems with this argu-
ment. Advocates of primary health care often assume that the public sector can
deliver whatever the government (or some international donor) decides ought to
be delivered. The argument then jumps to the idea that if government supplies
the right things then patients will receive the right things (here primary health
care). There is, however, little empirical support for the link between more
spending on primary health care activities and greater access to primary health
care services,or for the argument that greater access to primary health care facil-
ities reduces mortality (Filmer and Pritchett, 1999). In general socioeconomic
(rather than healthcare) characteristics explain nearly all of the variation in
mortality rates across developing countries. Studies show that virtually all of the
cross-country variation in child mortality can be explained by six variables
(average GDP per capita, a measure of the distribution of income, level of
female education, a dummy variable for predominantly Muslim countries, an
index of ethno-linguistic diversity, and a set of dummy variables for regions).
Public expenditure on health as a share of GDP has only a small and statistically
insignificant impact on child mortality (Filmer and Prichett, 1999).
In 1977,for example, a very intensive maternal and child health and family
planning programme was started in a set of treatment villages in the Matlab
region of Bangladesh. In the treatment area mothers and children were visited
every 15 days by a female health worker. Mortality rates among children did
fall but this was attributed almost exclusively to measles immunization, not
primary health care more generally (Koenig et al., 1991). Another example is
a study based on unannounced visits to 150 health facilities in Bangladesh.
Here, depressingly familiar results in terms of staff absence were found. But
important for the pro-hospital argument was that primary/village facilities
performed worse than urban hospitals. Again absence rates of staff were
around a quarter with highly trained physicians showing the highest rates of
absenteeism. Absenteeism was very high in small rural posts where it reached
74 per cent. These empirical results suggest that enhancing health outcomes is
not simply a matter of providing additional funds or increasing access to
primary health care services and services (Filmer et al., 2000).
Education and Health 141