There’s a good article by Tim Harford in the FT on different accountability structures facing public and private social services, and on why the poor often go with the latter.
It reminded me of a day last year, when I was living in Malawi, when my young housekeeper Mary suddenly got quite ill. I piled her and her best friend into my car and took off to the Lilongwe Central, the biggest free, government-run hospital in the city.
When I parked outside, Mary spoke:
“Wait, take me to the ABC Clinic.”
This was the clinic for for the African Bible College, which charged non-members for medical care.
“But Mary,” I said, “The treatment is free here.”
“I’ll have to wait here,” she said. “Take me to the ABC please.”
After arriving, Mary asked for a loan for 2,000 kwatcha, about $14 , to pay for the consultation and treatment. At the time I was astonished that she chose the large premium (20% of her monthly salary!) over free.
Harford ends the article with a rather ambiguous statement:
By all means let’s work out how to make government facilities more accountable, in order to provide better education for the world’s poor. But we should also investigate how low-cost private services could be nurtured.
For a change I’ll end with questions rather than assertions: Are these two goals complements, or supplements (for both health and education)? I’ve got a friend who is starting a low-cost private education franchise in the slums of Nairobi. He already has fantastic results and it looks to be an intervention worth making – but then again it does nothing to improve a stagnating government school system.
What are your thoughts?
#1 by Kim on August 25th, 2009
Anyone who has the kwacha (or can find it if they don’t) would go to ABC over Kamuzu Central. The same can’t be said of Mai Mwana (private) vs. Queen’s (public) in Blantyre — and that’s because the doctors who work at Mai Mwana also work at Queen’s, so you can get relatively similar care across the public/private divide. The doctor(s) at ABC only work at ABC, not at Kamuzu Central, and to be honest, the docs at ABC are better trained (and better doctors) than those at Central. However, Mary’s statement that she’d have to wait at Central would equally be a problem at Queen’s. And when you’re sick, why wait? Especially if you can afford not to? All the waiting does is put you in a place with a bunch of other sick people for an extended period of time. Even with an azungu there (which, in my experience, inevitably speeds up the process of being seen), she would risk catching some other illness from another patient waiting to be seen. Plus, she may not have felt ill enough to be seen at Central (because it’s free, and it’s in the capital, which is in the center of the country, it’s very very busy, and she could be low priority compared to other patients).
On whether these low-cost private solutions are having an effect: perhaps we can’t see that they’re positively impacting the government health [or in your friend's case, school] system. Still, the private options are providing better care for the growing middle class — a segment that has more potential to spur growth in the country (not just economically, if we believe what Barrington Moore said). As much as I believe in equality of opportunity (and thus think there is a social justice argument about provision of education and health care), I also believe in development and the importance of medium-term goals. If we only focused on improving the government systems, it would take a great deal of time, and I don’t know that citizens or politicians have time horizons long enough to see those through.
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#2 by max lawson on August 26th, 2009
if you are paying your housekeeper 8,000 kwacha a month, then that means she is earning around the same as many primary school teachers in malawi, and sadly this also means she is a long way from being poor by malawi standards. the vast majority of malawians, and particularly women, have nothing like this level of income, and do not have the option of going private. meanwhile, the government continually loses vital nurses and doctors to the private and ngo sectors, meaning the poor have to wait even longer for treatment or bankrupt themselves to get it. what kind of a choice are you exercising if you spend 20% of your income or more on getting health care- this to me is not some argument for private over public but demonstrates the desperate state of public services and a choice that the vast majority sadly are unable to make.
i am curious if you you are that keen on the private heathcare route why you did not just give her the money- perhaps you could set up your own mini insurance scheme and give all of your staff some health coverage.
do read our paper on this issue and recent case study from malawi if you get a chance.
http://www.oxfam.org.uk/resources/policy/health/downloads/malawi_essential_health_services_research_report.pdf
and this our paper which tackles some of the myths around poor people exercising an illusory ‘choice’.
http://www.oxfam.org/policy/bp125-blind-optimism
max
#3 by Ranil Dissanayake on August 26th, 2009
Max – question: in your research, was there any unemployment among healthcare workers in Malawi? The reason I ask is that I read somewhere recently that the commonly asserted claim that Western health services poach African staff and thus damage African services is probably largely over-stated, as many qualified health care workers in African are unemployed, which does not suggest that the constraint is the supply of workers. It’s not an area I am familiar with, so I’d be interested if you’ve come across this phenomenon.
#4 by Kim on August 26th, 2009
All the nurses and doctors I met in Malawi were over-employed: they had more than just one job. If they worked for a government hospital (or clinic), they also had multiple side jobs.
And it’s not just nurses and doctors. People who are trained as HIV testing counselors are also in high demand. In fact, community health workers I interviewed working for a public clinic said that though they were trained to perform HIV testing and counseling (10 weeks of being away from their families), and their training was paid for by a donor (Goal Malawi), at the conclusion of the training, none of the community health workers that came from the government clinic were given a certificate of completion. Without this certificate –issued by the Ministry of Health– none of these people can get jobs as HIV testing counselors in the private sector (either full-time or on the side). Of course, they are all able to perform HIV tests at the government clinic. If there were an abundance of people available to do this job, I don’t think the government would have had any problem giving them certificates upon completion of training (as they had to those who had paid for themselves to participate in the training).
#5 by Matt on August 26th, 2009
Max – thanks for the comment and the info- I never said I was necessarily keen on private health care, just that that it is difficult knowing how to balance these things. I think anyone who thinks one route or the other is a panacea hasn’t spent enough time thinking about it. I wasn’t making an argument either way.
As far as insurance goes, I can see no better insurance than the interest-free loans I gave to my staff. At the time, when interest rates where in their teens and twenties, the loans that I gave allowed perfect income smoothing over the year. Yes, it was 20% of her salary (although I never investigated how much she ended up spending), she only had to pay about 5% of her salary over 4 months, instead of all in one month.