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Health dragons or health hydras? The challenges of regulation in Asian health systems

Future Health Systems

Dr Asha George of JHSPH discusses rural medical practitioners in India at HSRA


Like most aspects of life in Asia, health systems have undergone massive changes in the last twenty years. And if we’ve seen some economic dragons, we’ve also seen some health dragons – with several countries posting impressive gains in health outcomes. For example, official figures indicate China has already achieved MDG 4 by reducing infant mortality rates from over 50 per 1000 live births in 1991 to under 14 in 2009, while under-five mortality has also dropped from 61 per 1000 live births in 1991 to just over 17 in 2009.

But ‘health dragons’ doesn’t quite capture the full picture. For the most part these changes have not been happening as a result of a controlled change process. Rather, they’ve been emerging from the diverse, unguided responses of some of the most populous countries in the world. This means they look more like another mythical creature: the many-headed hydra. 

This was made very apparent at this year’s Health System Reform in Asia conference held from 10-12 December at Hong Kong University. Organised by Elsevier and their journal, Social Science and Medicine (be on the lookout for a special issue from the conference out in 2012), the conference brought together some of the biggest names in health systems in Asia. The organisers of the 2nd Global Symposium on Health System Research, which will be held in November 2012 in Beijing, had a strong presence, for example.

As I presented at the conference, the story of the Indian health system is a good example of the health hydra. Following significant economic reforms in the 1990s, the private sector soon outstripped the public in terms of health service provision – not only in hard-to-reach rural areas, but even in major urban hubs. Utilisation of in-patient care by private providers, for instance, jumped from less than 40% in the late 80s to more than 60% in the last decade. And outpatient care has even higher private sector penetration at roughly 77% across the country. 

Of course, when I say the ‘private sector’ the majority of those providers, especially in the outpatient care market, have little to no formal medical training. My colleague at JHSPH, Dr Asha George, presented a more detailed discussion of who these informal ‘rural medical providers’ are and why they play such an important role in the Indian health system. And indeed, the Future Health Systems consortium has a substantial body of work on the role of informal providers not just in Bangladesh and India, but also in Nigeria.

Our recent study of health care service provision in the Sundarbans of West Bengal paints an even messier picture. In addition to the publicly funded health clinics and hospitals and the raft of informal providers, the area is also serviced by an array of both local and international NGOs. Coupled with rapid advances in health technologies and pharmaceuticals – not to mention a fragile environment susceptible to frequent climate shocks, like Cyclone Aila which devastated the area in 2009 – it’s easy to understand how the system became so complex. 

But this poses a significant challenge: how can we improve these systems, with all their perverse incentives, to better serve the poor? In other words, how can we better regulate these health markets?

One phrase that kept popping up throughout the conference was the idea of ‘command and control’ – that through strong government intervention we could make significant and intentional changes in the way these health systems worked. But there was an even larger group who suggested that, when working in complex adaptive systems, ‘command and control’ is inefficient. There are simply too many interconnections that we cannot understand, which lead to a variety of unintended consequences when we intervene in these systems. 

Finding a model that works somewhere between ‘command and control’ and utter chaos was one of the challenges my colleague at IDS, Dr Gerry Bloom, put forward to the conference.

This led to a lot of discussion about ‘poly-centric governance models’, where the challenge of regulation doesn’t lie simply in the hands of the government. Rather, the argument goes, we must be working on all fronts: institutionalising professional bodies and standards to promote self-regulation in the private sector; establishing patient support groups – like the diabetes-related peer group MoPoTsyo in Cambodia – and improving their access to health information; and recognising non-traditional actors as part of the health system.

We tend to overlook the role that non-traditional actors, like social change entrepreneurs, the media and advertisers play in health markets. However, Dr Sachiko Ozawa’s presentation on trust in injections in Cambodia underscores this point. The average Cambodian receives six injections per year, usually because they think injections are more efficacious than other forms of treatment (e.g. oral tablets). This is such a firmly held belief that often patients will seek care outside of the formal sector (who usually deny inappropriate injections) to get what they want. Although her research didn’t delve too deeply into why there was such misplaced trust in injections, it might be at least in part due to substantial vaccination education campaigns from public health advocates. Working with media and advertisers will be an important part of improving knowledge here about appropriate use of injections.

They say that the best way to fight fire is with fire. Perhaps this ‘poly-centric governance structure’ is attempting just that – fighting hydra with hydra. I would expect to be hearing much more about what this model might look like in different Asian contexts in the near future.