Bringing order to unruly health markets
In Nigeria, around half of people who suspect that they have malaria do not see a physician (1). Instead, they purchase drugs directly from medicine vendors. But the malaria parasite is resistant to much of what they buy. In Bangladesh and India, informally trained village doctors provide most outpatient services to the poor. Antibiotics comprise 50% of all prescriptions in developing countries, and more than half are given inappropriately or in insufficient dosages (2).
The rapid expansion of health markets in Asia and Africa has made medicines, information and primary-care services available in all but the most remote areas. But it also creates problems with drug safety and effectiveness, equity of treatment and the cost of care. Poorly trained practitioners often prescribe unnecessary pills or injections, with patients bearing the expense and the costs to their health. Counterfeit drugs are rife and drug resistance is growing.
Bringing order to unruly health markets is a major challenge. Yet the problem is largely ignored by governments and international agencies. The World Health Organization (WHO) continues to highlight a shortage of primary health workers as the main barrier to accessing health care in low- and middle-income countries (3). It neglects the growing presence of drug sellers, rural medical practitioners and other informally trained health-care providers.
To find better ways to meet the health and welfare needs of the poor, we need to look beyond ideological debates about public and private sectors and improve how these evolving markets operate. This will not be easy, because health markets are complicated and interventions have unpredictable consequences. But following the example of China — which reached out to village doctors in 2003 to address the SARS epidemic — governments, citizen groups and companies can build partnerships with local providers to support innovation and improve the delivery of safe, effective and affordable treatments for common conditions.
Many unforeseen factors have contributed to the huge expansion of health markets in Africa and Asia. In countries where government health budgets have been squeezed by economic or social crises, health workers cope by charging patients or selling drugs. Where there has been rapid economic growth, government health services struggle to keep up with demand, and people seek care elsewhere. The projects that train large numbers of community health workers produce numerous graduates who must turn to the market if they are unable to get a government job. The boundary between public and private sectors is often blurred, with many doctors supplementing their income through market activities, legal and illegal.
As in other complex systems, a single intervention is unlikely to lead to sustainable change, so players will need to experiment, adapt and learn. Strategies that could be tested by governments and the medical profession include the formal accreditation or licensing of new categories of health workers. Arrangements for public-sector doctors who supplement their income through private practice should be made transparent.
The urgent need is to protect the poor who rely on unregulated health markets. In the longer term, everyone’s health depends on rising to this challenge.
This blog is extracted from Peters, D.H & G. Bloom (2012) ‘Developing world: Bring order to unregulated health markets’, Nature Issue 487, 12 July 2012, pp163-65.
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