Will more private healthcare help the poor?

VSO is great. It aims to make life better for the poorest people in the world. And an important part of a better life has to be better health.

I was proud to work for the UK’s National Health Service. Its founding principle was healthcare free at the point of use. Access to care depends only on clinical need, not on ability to pay. It isn’t perfect, but Britain's health system is a profoundly civilised arrangement.

In my new home, Cambodia, things are very different. Sadly, access to healthcare here depends almost entirely on ability to pay, and has little to do with clinical need.

Here’s how it works (prepare for a mini-lecture!):

A small number of rich people (including elite wealthy Cambodians and most foreigners - including me) can afford almost western standards of healthcare in expensive private facilities, either here or in Bangkok or Singapore.

Cambodians on modest incomes either buy health insurance where available, or pay the fees for public health centres and hospitals in provincial towns. They need money for travel, food and personal care, and must be able to afford not work whilst away. Some choose private clinics, pharmacies or traditional medicines as they don't trust public healthcare (with some justification).

The poorest Cambodians can’t afford to pay for public health facilities or health insurance. Only if they are lucky enough to live in an area which (apparently randomly) is covered by a ‘Health Equity Fund’, or if they can get to hospitals such as Angkor Hospital for Children or Kantha Bopha, might they get decent healthcare. Otherwise they simply suffer or die silently in their villages.

Doesn’t sound good does it?

So what is the international community doing in our name to help make sure the poorest and most needy get access the healthcare they need?

Well, the clever folks in organisations such as the United Nations Development Programme say the answer is to encourage more private sector provision.

Really? Sorry, but how exactly is encouraging more private provision of healthcare going to help those most in need? How will quality and access be improved for the poor?

For quality, private treatment is better for the rich, but is not better for the less wealthy. In fact, many private clinics are seriously dodgy, with regulation even more lax than in public hospitals. As for private pharmacies, get this: an estimated 80% of medicines sold in Cambodia are fakes, ranging from the expensive and useless to the highly dangerous. The private sector actively harms public healthcare: public hospitals routinely deal with late presentation by patients who have first been treated unsuccessfully in (unregulated) private clinics and pharmacies. Staff routinely abandon their patients in public hospitals during the day to work in their private clinics. Worse still, they often take the hospital’s drugs and equipment with them. It’s an absolute scandal, but it happens every day here. Do we really want to encourage even more of this?

For access, more private provision will lead to more inequalities. Only the rich people will be able to go - when did you last hear of a private hospital exempting poor patients from fees? Private providers are driven by the profit motive, so ‘cherry pick’ profitable sectors (imaging, cancer, cosmetic surgery), and will not offer services in areas where there’s little money to be made (including the areas where VSO Cambodia’s health programme focuses - reproductive and child health).

So will more private healthcare help the poor? Of course it bloody won't!

Well thankfully there are the good guys like VSO around. Right now in Cambodia the organisation is discussing its strategy for the coming years. My suggestion is that we must urgently challenge the move towards private health provision. There is a critical need for analysis of the impacts of such a move on the quality and access of healthcare for all Cambodians, and especially the poor and marginalised.

In fact, we should learn something from the UK’s health service, whilst it is still standing. If we truly want poor people to have better health, we must make sure healthcare is free at the point of use. Not only should we fight the slide towards more private care, we should reverse the privatisation of public hospitals, abolishing the existing payment systems which exclude the poor people from care. The funding arrangements will have to be made, but it's possible - the government and donors actually have plenty of money - it's just a matter of getting priorities right.

On behalf of the poorest people in this country, I for one would be proud to be part of such a campaign.