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Progressive health policies

Access to health care has scored quite low on international agendas since 15 years. The failure of these policies to progress on Millennium Development Goals is now politically acknowledged.

Though recently revamping the PHC strategy and thereby focusing on access to care, international agencies have not analyzed the mechanisms of their policy failure. This is precisely what we do here, so as to derive the features of an alternative policy. This option is based on integration of comprehensive health care delivery and disease control interventions in a new, publicly oriented health sector. Gearing health systems towards the delivery of comprehensive quality care requires strategies to act upon their key functions.

Unger, J.-P, De Paepe, P, Sen, K, Soors, W. International Health and Aid Policies. Cambridge University Press

To be released in October 2010.

4.a Sketching the international health policy

WHO, the World Bank and the European Union do have a doctrine on aid and international health policy. They divide up health institutions into government and private, and classify health interventions into health care and disease control. Whenever possible, they allocate disease control to the public and curative health care to the private sector (1) (Table 2). Such policies are neoliberal in their promotion of commoditization and privatization (2) as they tend to restrict public services to the delivery of disease control programmes, for which there is no demand.

1. De Paepe P, Soors W, Unger JP. International aid policy: public disease control and private curative care? Cadernos de Saúde Pública 2007; 23(Sup. 2): S273-S281.

2. Unger JP, De Paepe P, Ghilbert P, Soors W, Green A. Disintegrated care: the Achilles heel of international health policies in low and middle-income countries. International Journal of Integrated Care 2006; 6: 1-13.

Table 2: Dominant policies and a proposed alternative

International disintegrated aid policy
1, 2, 11, 12

MOH facilities

Private facilities


A proposed integrated policy
13, 15, 16, 26, 27

Publicly oriented facilities
14, 19, 20, 24, 25

Private-for-profit facilities

Health care


9, 10


Health care
14, 16, 17, 18, 23

8, 10, 21, 22


Disease control

3, 4


5, 6, 7

Disease control



4.b Failure of the aid paradigm: Poor disease control in developing countries

Together with other factors, disease control programmes are responsible for the lack of effectiveness of disease control and for many avoidable deaths in LIC/MIC – as suggested by the monitoring of MDGs attainment (Table 3).


Table 3: Millennium Development Goals (UN data, Sept 2005)


Maternal Mortality




Latin America










South Asia





South-East Asia






No improvement or drop


Unattainable objectives



The failure mechanism is as follows. A mathematical model permits to show that to be effective, disease control programmes need to be integrated in health facilities were there are patients, representing a pool for early detection and continuity of care (3). Unfortunately, disease control programmes undermine access to care in these facilities where they are implemented via several mechanisms (4) (e.g. multiplication of disease-specific divisions in national health administrations; failure to clarify the lines of command and opportunity costs).

3. Unger JP, D'Alessandro U, De Paepe P, Green A. Can malaria be controlled where basic health services are not used? Tropical Medicine and International Health 2006; 11(3): 314-322.

4. Unger JP, De Paepe P, Green A. A code of best practice for disease control programmes to avoid damaging health care services in developing countries. International Journal of Health Planning Management 2003; 18: S27-S39.

4.c  Mishaps of privatizing disease control

Conceptually, the divorce of health care delivery and disease control programmes could have been solved by contracting-out disease control to the private-for-profit sector and getting rid of public services, where the former has achieved a good coverage as in India. However, the private sector is just not interested in such a prospect, for lack of profitability (5) (6) (7).

5. Unger JP, De Paepe P, Ghilbert P, Zocchi W. PPM-DOTS strategy for tuberculosis control: how evidence-based is it? Tropical Me 2008 [Submitted].

6. Ghilbert P, De Paepe P, Unger JP. Tuberculosis and the private sector: another wishful thinking? [E-letter]. British Medical Journal 23-10-2003.

7. De Paepe P, Devadasan N, Soors W, Unger JP. Public-private partnership for tuberculosis? [Rapid Response]. British Medical Journal 2006.

4d. Commodification of health insurance and care - an evidence-based solution? Three country case studies

On health care the international policy is not evidence-based either. The analysis of Costa Rican (8), Colombian (9) and Chilean (10) policies does not confirm what a rapid WHO classification of country performances suggested in 2000 (11): that health care privatisation would yield significant efficiency gains. Instead, these reform experiences confirm that health policies based on decently financed publicly oriented services are both effective and efficient. Costa Ricans spend nine times less on health than US citizens, and enjoy a better health status. Hence the question: why does the Costa Rican model not serve as a model for international policies? Colombia has carefully applied the recommendations of Bretton Woods agencies since 1993, and has failed dramatically to secure access to decent quality versatile care and to control costs. Finally, we show that the good output of the Chilean health system is to be attributed to the public services, which managed to survive Pinochet’s dictatorship, and by no means to the private sector.

8. Unger JP, De Paepe P, Buitrón R, Soors W. Costa Rica: Achievements of a Heterodox Health Policy. American Journal of Public Health 2007; 97(11): 1-8.

9. De Groote T, De Paepe P, Unger JP. Colombia: in vivo test of health sector privatization in the developing world. International Journal of Health Services 2005; 35(1): 125-141.

10. Unger J.-P., De Paepe P., Arteaga Herrera O., Solimano Cantuarias G. Chile’s Neoliberal Health Reform: An Assessment and a Critique. PLoS Medicine 2008; 5(4) e79: 0001-0006.

11. Van der Stuyft P, Unger JP. Improving the performance of health systems: the World Health Report as go-between for scientific evidence and ideological discourse. Tropical Medicine and International Health 2000; 5(10): 675-677.

4e.  Loans and trade agreements

Structural Adjustment Programmes and international financing institutions used loans as a leverage to reorient LIC / MIC health policies towards health care privatization. Today, both regional economic treaties (such as TLC between Latin American countries and USA) and WTO GATS negotiations will force developing countries to implement such policies and open their market to international health care trade – with catastrophic consequences (12). The similarity between international trade treaties and the rationale of international aid suggests that return and profit for industrialized countries were real motives of the latter.

12. Unger JP, De Paepe P, Ghilbert P, De Groote T. Public health implications of world trade negotiations [Letter]. Lancet 2004; 363(9402): 83.

4f.   What would an integrated, social and democratic international health policy look like?

As an alternative aid and international health policy, we propose an integrated, social and democratic strategy (13) based on the financing of – and technical support to - publicly oriented (not-for-profit, socially motivated) health services. The kind of medical care it would deliver, and the sort of management needed to run these services are specific. This implies that there is not one medicine but two, and not one managerial science for health but two, according to whether the motive is profit or not (14). Similarly, we plead for a specific disease control organization, likely to protect access to versatile health care (4).

13. Unger JP, De Paepe P, Ghilbert P, Soors W, Green A. Integrated care: a fresh perspective for international health policies. International Journal of Integrated Care 2006; 6

14. Unger JP, Marchal B, Green A. Quality standards for health care delivery and management in publicly oriented health services. International Journal of Health Planning Management 2003; 18: s79-s88.

4g.  Alternative implementation strategies for an integrated policy

To implement this policy, we consider different strategies fit for different health systems categories(15). These strategies encompass:

  • The development of family and community health in publicly oriented services (16) (17) (18) (topic 3);
  • The promotion of publicly oriented hospitals with systemic responsibilities (19);
  • The organization of districts (20) and local health systems (21) (22) (23);
  • The use of reflexive methods to bridge the gap between medical and public health identities of health professionals (24) (topic 2);
  • The improvement of access to drugs (25);
  • The social control at the peripheral level to increase accountability and responsiveness in publicly oriented facilities (26, 27);
  • The reorientation of international research (28) and in-service training (29) efforts (topic 2).


15. Unger JP, Macq J, Bredo F, Boelaert M. Through Mintzberg's glasses: a fresh look at the organization of ministries of health. Bulletin of the World Health Organization 2000; 78(8): 1005-1014.

16. Unger JP, Van Dormael M, Criel B, Van der Vennet J, De Munck P. A plea for an initiative to strengthen family medicine in public health care services of developing countries. International Journal of Health Services 2002; 32(4): 799-815.

17. Van Dormael M, Unger JP, Murthy RS. First line care facilities and support for providers have to be improved. [Rapid Response Letter to The global response to mental illness]. British Medical Journal 2002; 325(7370): 967.

18. Unger JP, Ghilbert P, Fisher JP. Doctor-patient communication in developing countries [Letter]. British Medical Journal 2003; 327(7412): 450.

19. Unger JP. Les responsabilités systémiques des hôpitaux publics. De systeemverantwoordelijkheden van de openbare ziekenhuizen. The systemic responsibilities of public hospitals. 2005; 3(1): 27-34.

20. Unger JP, Criel B. Principles of health infrastructure planning in less developed countries. International Journal of Health Planning Management 1995; 10(2): 113-128.

21. The Local Health Systems (LHS) project in Belgium. Abstract for oral presentation on health care reform. 11th annual EUPHA conference: Globalisation and health in Europe: harmonising public health practices (20-22 Nov 2003, Europe Congress Centre, Catholic University of the Sacred Heart, Rome).

22. Unger JP, Criel B, Van der Vennet J, Dugas S, Ghilbert P, De Paepe P et al. Health districts in Western Europe: the Belgian local health systems project. Rapid response to Learning from developing countries: what are the lessons? British Medical Journal 2004.

23. Van Dormael M (2006). Le systéme de soins et les soins de santé primaries au Mali. Keynote speech to a seminar on “Quality of Health Systems” organised by the Direction Nationale de la Santé, RIAC Mali and WHO, Bamako, April 2006

24. Unger JP, Marchal B, Dugas S, Wuidar MJ, Burdet D, Leemans P et al. Interface flow process audit: using the patient's career as a tracer of quality of care and of system organisation [E-letter]. International Journal of Integrated Care 4. 2004.

25. Unger JP, Mbaye A, Diao M. From Bamako to Kolda: a case study of medicines and the financing of district health services. Health Policy & Planning 1990; 5(4): 367-377.

26. Unger JP, De Paepe P, Ghilbert P, Green A. Public involvement in health care: Lessons from developing countries [E-letter]. British Medical Journal 22-1-2004.

27. Criel B, Alpha Ahmadou Diallo, Van der Vennet J, Waelkens M-P & Wiegandt A (2005). La difficulté du partenariat entre professionnels de santé et mutualistes: le cas de la mutuelle de santé Maliando en Guinée-Conakry. Tropical Medicine & International Health, Vol 10, N°5, pp 450-463.

28. Unger JP, De Paepe P, Ghilbert P, Green A. Relevant research for health-systems management and policy [Letter]. Lancet 2004; 363: 573.

29. Unger JP, Ghilbert P, De Paepe P. Continuous medical education with(out) coaching? [Rapid response]. British Medical Journal 2004; 328: 999.

National (tax-based or social health insurance) and additional international sources are required to provide viable financing for this alternative strategy. Supply-side subsidies and contracting of not-for-profit health facilities responsible for care delivery as well as disease control is a concrete way to implement the widely advocated strengthening of health systems.