A Private-Public Dilemma

This summer, I had the pleasure of visiting a government hospital in Naivasha, a town in the Rift Valley Province of Kenya. Naivasha is home to the largest cut-flower exporting company in the world and a weekend getaway spot for throngs of Nairobi ex-pats. It is the breadbasket of Kenya. Given the fertile lands, employment from the flower farms, and touristy nature of the place, you’d think that Naivashans are doing pretty well. They must have a pretty decent clinic.

                That would depend on your definition of decent. True, the clinic was pretty well-maintained. I didn’t see any gaping holes in the wall, the place seemed pretty clean, and I saw at least a couple of clean drinking water pumps. Patients waited in nice waiting rooms. Compared to Karachi Hospital or clinics in rural Sindh, the place was a gem.

There was only one problem. There were no doctors. Or nurses. Just plenty of waiting patients.

                I was told that the problem of doctor absenteeism was pretty common up there. The doctors would show up for a couple of hours in the mornings some days and then take off for the rest of the day. Other times, they wouldn’t show up at all.

                The doctors weren’t just skipping town or hanging out at home. They were out visiting patients at their homes for a higher fee. Often, they would take nurses with them.

                I later learned that this problem was endemic in rural Kenya. Governments had scarce resources to allocate throughout the country. Once they built the big hospitals in Nairobi, little was left for places like Naivasha. Of course, this meant that doctors and nurses were paid a paltry amount. Since we know that even the poorest of the poor will actually pay for health services, health professionals found it pretty useful to turn to private practice to make ends meet. So while some patients have to wait around forever, other (not richer, just other potentially smarter, more resourceful) patients get door-to-door service.

Yes, it’s unfair. But it happens. And not just in Kenya, but throughout the Developing World, in places like Tanzania, India, and Pakistan. Why? Because people, even really poor people, are willing to pay for health. They are willing to pay for quality.

This then raises the question of how governments should allocate resources to not only deal with public health crises and achieve health goals, but to distribute the costs of these achieving these goals fairly (read: poor people should not have to spending their meager resources on health, but rich people probably should).

A Health Finance Officer in the Nairobi office of the International Finance Corporation told me that over 70% of people in urban areas use private health providers. This means that even people in the worst slums you can think of (read: Kibera) go to private providers rather than Nairobi Hospital. It’s mostly because even though service is free, the other costs, particularly opportunity costs, eventually add up. Just try getting your file at Nairobi Hospital and tell me that five hours later, you wouldn’t pay $100 just to get out of there.

If we know that people in urban areas use private health care facilities, and we know that poor people are willing to pay for health care, then does it make sense to allocate a ton of public funds to building fancy hospitals in urban centers? Or, should some of these funds be diverted to rural areas? Let the private hospitals—which are widely known to be better quality and preferable—take care of the City folk. Not just so we could build better hospitals in rural areas, but so we could build better incentive structures that would help the problem of doctor absenteeism. Or, so that we could focus training programs on building the skills of less than qualified practitioners, which in many places (i.e. India) are the preferred providers anyway.

Better yet, can we allocate public funds on mass campaigns and specific interventions—like bednet distribution in malaria prevalent areas? A recent evaluation of the Millennium Villages Project by the World Bank and Center for Global Development shows that bednet distribution has done wonders to curb malarial incidence.

Monitoring and evaluation are obviously key to ensuring that public funds are allocated effectively and efficiently. Doctor absenteeism would definitely be curbed if there were consequences to their actions. And bednet distribution would certainly be a priority if we knew exactly where the funds were going once they reached the Ministry of Health.

Now, if only I could come up with a five-pronged strategy to deal with that pesky  little problem of corruption….

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