In the public interest...

How do not-for-profit non-governmental health service providers perceive their role in the national provision of healthcare? How do they steer a course between their mission and changes in national and international operating conditions?

Pursat Hospital, Combodia (Photo: Swiss Red Cross)

The topic

Filling gaps... In many countries, the market-oriented programmes of structural change initiated by the World Bank and the IMF in the 1980s led to cutbacks in government expenditure on education and health. This weakening of the state and the reduction in state benefits resulted in a degree of "passive privatization", i.e. the emergence of an unregulated health market with a large number of commercial providers at all levels. At the same time, not-for-profit groups and institutions endeavoured to fill the gaps in service provision and financing and take the place of the public sector in the national health system. These endeavours enjoyed international support: given the weakness of the state and with a view to change from the bottom up, the development organizations regarded promoting the emer-gence of civil-society structures and strengthening of their effectiveness as a strategy that promised to be successful.

The return of the state. In recent years, however, there has been a further shift in emphasis in the international debate on development policy. A weak, functionally disabled state is considered to be a barrier to development, and private organizations are no longer regarded as effective and sustainable substitutes. As a result of the poverty reduction strategies of the World Bank and the efforts to coordi-nate development cooperation (Declaration of Paris), hopes are once again being placed – and money invested – in support for national development strategies, in conjunction with strengthening of state institutions and their capacities. So the state is making a comeback – at a time when the enormous challenges and health crises with which it is confronted are making it increasingly dependent on civil society.

More steering – less oar-work. The state need not - and cannot – do everything itself: "new public management" or "stewardship" are catchwords for the policy pursued by many states in redefining their duties and responsibilities in the healthcare system and in other supply sectors: by defining a national health policy and regulating the healthcare sector, the state focuses on providing the direction and framework that enable both public and private-sector players to provide their services.

Cooperation with this state?! In practice, however, many developing countries still have weak and, in many respects, incompetent state administrations. For non-governmental health service providers and their backers, the path that leads from parallel to integrated service provision, from replacing the public sector to being incorporated into a national health system, is neither straightforward nor obvious. They formulate conditions that have to be met – and in turn they have to consider how legitimate and sustainable their staying on the sidelines would be.

Positioning, strengthening, cooperating. Even though operating conditions may vary considerably from country to country, not-for-profit non-governmental health service providers and their backers and international partners everywhere are now obliged to reconsider their own identity and to position their services clearly, while also strengthening their structures and capacities. If they are to hold their own in the face of new competition in the health market and in the political dialogue and negotiations with the state, they will also have to consider the question of synergies and increased cooperation between the not-for-profit health service providers of a country or health district.

The Swiss Health Cooperation Symposium

Discussing international cooperation and development policy. The Swiss Health Cooperation Symposium targets a broad spectrum of participants active at the na-tional or international level and is organized by Medicus Mundi Switzerland, Network Health for All, which comprises 46 Swiss agencies operating in the field of international health cooperation. The sym-posium is part of a long-term cooperation agreement with the Swiss Agency for Development and Co-operation SDC, which helps fund the event and provides support with the programming.

Contact: Thomas Schwarz, tschwarz@medicusmundi.ch