Global Health Watch 1 in one file

3 Resurrecting the ‘public’ in health care systems
The previous sections have outlined the key processes that have undermined
the PHC Approach, while recognizing that different factors and forces
have had different effects in different contexts. Figure B1.3 below illustrates
the interactions and pathways that have hindered equity and efficiency within
health care systems. Reversing these trends sustainably and effectively requires
addressing all these factors simultaneously – simple, quick fixes will not suffice
or be effective. It requires the involvement of more than health care providers,
managers and health sector policy makers – many of the solutions involve
political, social and economic interventions.
There is a need to resurrect and revitalize the ‘public’ within health care
systems as part of an agenda for change. The goals of such an agenda should
be to restore a proper balance and relationships between the public and private
sectors as well as between public health care (population and communitybased
approaches to health) and individual private health care.
For several years, a prevailing view in certain media and amongst many
policy makers has been that the private sector is better than the public sector.
This is usually accompanied by another view that suggests that incentives
formed through market dynamics result in ‘better’ and more efficient performance
of health care systems than those of bureaucratic systems. While there are
certainly problems within the public sector that need addressing, the record
of public sector success is substantial. Added to this are the achievements of
non-government actors, universities and charities, which may not be part of
the public sector but which operate with a public ethic rather than one driven
by competition, self-interest or market signals.
Public sector social welfare has been the bedrock of European social and
economic development since the Second World War. Furthermore, low-income
countries like Sri Lanka, Costa Rica and Cuba have had well-performing public
health services for decades. The rapid and equitable decline in maternal mortality
in Malaysia after independence from Britain in 1957 was due to government
leadership (Pathmanathan et al 2003). Publicly-funded research in national
institutes of science and universities has laid the foundations for many, if not
most, developments in the medical sciences. Hundreds of thousands of public
servants across the world are currently helping to make societies work in hundreds
of different ways through bureaucracies – forms of organization characterized
by a clear division of labour; clearly defined authority and responsibility;
and administration and decision-making based on transparent rules.
For health care systems, several arguments point to the need for the public
sector to take a central role. The first is that people have a right to health care
Approaches to health care
79