ARTIGO ARTICLE
International aid policy: public disease control
and private curative care?
Política de ayuda internacional: ¿Control público
de enfermedades y servicios curativos privados?
Pierre De Paepe 1
Werner Soors 1
Jean-Pierre Unger 1
1 Prince Leopold Institute of
Tropical Medicine, Antwerp,
Belgium.
Correspondence
P. De Paepe
Department of Public Health,
Prince Leopold Institute of
Tropical Medicine.
Nationalestraat 155, 2000
Antwerp, Belgium.
pdpaepe@itg.be
Abstract
Introduction
Integrating disease control with health care delivery increases the prospects for successful disease control. This paper examines whether current international aid policy tends to allocate
disease control and curative care to different sectors, preventing such integration. Typically, disease control has been conceptualized in vertical
programs. This changed with the Alma Ata vision
of comprehensive care, but was soon encouraged
again by the Selective Primary Health Care concept. Documents are analyzed from the most influential actors in the field, e.g. World Health Organization, World Bank, and European Union.
These agencies do indeed have a doctrine on international aid policy: to allocate disease control
to the public sector and curative health care to
the private sector, wherever possible. We examine
whether there is evidence to support such a doctrine. Arguments justifying integration are discussed, as well as those that critically analyze the
consequences of non-integration. Answers are
sought to the crucial question of why important
stakeholders continue to insist on separating disease control from curative care. We finally make
a recommendation for all international actors to
address health care and disease control together,
from a systems perspective.
Many authors have stressed the necessity of integrating vertical programs into local health facilities in order to achieve reasonable prospects for
successful disease control 1,2,3,4. Admittedly, there
are clear indications for some non-integrated vertical programs 5. However, any health policy allocating public health activities and disease control
programs to Ministry of Health (MoH) structures
and general health care to private facilities precludes their integration even in circumstances
where it would be sensible to do so.
The present paper examines whether the current international aid policy does indeed tend to
allocate health care and disease control to different health facilities – and thereby undermines
both. To do so, multilateral aid policy papers are
scrutinized. In a second step, we analyze whether
there is evidence to support separate allocation of
disease control programs and curative health care.
Finally, we look for reasons that might explain this
policy promoted by international agencies.
This paper aims at outlining a policy’s doctrine. It does not attempt to assess its actual implementation, which may differ from the theory
due to specific political, social, geo-strategic, and
economic factors. The doctrine’s analysis is relevant per se, since it enlightens the health policies
promoted by international organizations, and it
has influenced national policy design in developing countries.
Health Services; International Acts; Health
Policy
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Do international aid agencies propose
to allocate health care and disease
control to different health facilities?
The history of international aid is one of action
and reaction: the restoration of an order delineated in the 1950s and reconfirmed in the 1990s,
as opposed to the primary health care strategy
parenthesis written in the 1970s. We contend that
the allocation of disease control and health care
to separate sectors is the result of both this history and an explicit doctrine.
Vertical programs are an organized set of resources, management, and activities aiming at
the control of a single or a few health problems.
In the 1950s and 1960s, policies for disease control in many countries of Africa and Asia focused
on vertical programs with a disease-oriented
approach. The most important achievement of
this approach was the eradication of smallpox in
1979. This success eventually became a major argument for this strategy: Foege et al. 6 suggested
organizing health services along the lines of fire
brigades based on epidemiological surveillance
modeled after smallpox control (the techniques
of which inspired the approach). This proposal
failed to recognize the specificity of health service organizations and underestimated the epidemiological features of smallpox, characterized
by very slow transmission. So far, successful disease eradication has not been repeated (the failure of the malaria eradication campaign is a good
example), although the burden of poliomyelitis,
dracunculiasis, onchocerciasis, and measles was
greatly reduced owing to disease control programs.
In 1978 a new approach was approved in
Alma Ata, under the leadership of World Health
Organization (WHO) Director-General Halfdan
Mahler: Primary Health Care. This new vision
on health promoted comprehensive care and
community participation to democratize publicly-oriented services, users being called to comanage health services, together with their professionals and civil servants. This health for all
concept brought WHO several head-on confrontations with multinational companies (on breast
milk substitutes and essential drugs), with the
United States even withholding its contribution
to the WHO’s regular budget in 1985 7.
This caused a return to the strategies of the
1950 – vertical programs – at least for developing countries. One year after the Alma Ata conference, Walsh & Warren 8, from the Rockefeller
Foundation, wrote a paper in the New England
Journal of Medicine to reduce the scope of Primary Health Care to the control of four or five
diseases, a strategy labeled Selective Primary
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Health Care. This was officially promoted by the
Rockefeller Foundation and the United Nations
Children’s Fund (UNICEF), which contended
that the public sector should be selective in the
services it offers and that most health care is
better delivered and financed privately. The numerous scientists mobilized around the world
against this initiative 9,10 failed to sway the U.S.
policy. Instead, soon after, the World Bank followed the United States. Its 1987 report Financing Health Services in Developing Countries: An
Agenda for Reform 11 (p. 38) began to distinguish
between health care and disease control: “For
some types of health care, especially simple curative care, private providers may well be more efficient than the government and offer comparable
or better services at lower unit cost”, and “many
health-related services such as information and
control of contagious disease are public goods”.
It argued in favor of greater reliance on privatesector health care provision and the reduction of
public involvement in health services delivery.
As a United Nations Research Institute for Social
Development (UNRISD) report states: “What is
not in doubt is the scale of the policy pressures
over the last two decades from, particularly, multilateral donors to commercialize health care. The
World Bank has been particularly influential in
promoting the concept of health care as largely
private good, hence deliverable through the market, all the while downplaying the well-understood perverse incentives structures in health care
markets” 12 (p. 6).
In 1993, echoing the selective primary health
care policy, the World Bank report Investing in
Health 13 proposed a basic service package to be
provided by public health services, and other curative care by private-for-profit providers. The report, the World Bank’s most comprehensive document regarding health, viewed health care not
as a need, much less as a right, but as a demand,
defined by the consumers’ ability and willingness
to pay 14. As observers in developing countries
noticed, the World Bank’s 1993 report opened avenues for private investment in formerly public
programs 15,16.
A 1996 World Bank discussion paper recommended governments not to tie public finance
to public provision, “though that does not necessarily mean eliminating public provision, which
will sometimes be the best solution” 17 (p. 56).
The objective, the paper went on, was to “minimize deadweight losses from public intervention
and leave as much room as possible for private
choices”.
The 1997 Strategy Paper for the World Bank
Health, Nutrition, and Population Program was
even more explicit 18. It stated that “in low-in-
INTERNATIONAL AID POLICY
come countries, where private sector activities
often dominate, governments will be encouraged
to focus their attention on the provision of: services with large externalities (preventive health
services); essential clinical services for the poor;
and more effective regulation for the private sector,
and to promote greater diversity in service delivery systems by providing funding for civil society
and non-governmental providers on a competitive basis, instead of limiting public funds to public facilities” 18 (p. 26). The minimal package for
the poor to be provided or mandated by governments would include “basic immunization, management of sick children, maternal care, family
planning, targeted nutrition, school health, communicable disease control” 18 (p. 26). Excluded
from the package were family medicine, or patient-centered care with an assessment of social,
family, psychological and somatic factors that
may influence the problem and its solution, and
expensive hospital care.
In its 1997 report, The State in a Changing
World, the World Bank recognized that markets
undersupply a range of collective goods, among
which public health goods 19. Still, the report favored the private sector as the provider of choice
for individual health care. It focused on programs
that would take a vertical approach to disease
control while ignoring the effect of non-specific
mortality in deprived groups. The results were
expert-decided standardized disease control
over context-dependent priority setting by the
local community and national MoH, and failure
to support an integrated approach to health services.
The history of competition for leadership in
international health between the World Bank and
the WHO can be written as the record of neoliberal ideology capturing international policy. Neoliberalism refers to political-economical policies
that de-emphasize or reject government intervention in domestic economies, but favor the use
of political power to open foreign nations to entry
by multinational corporations. In a broader sense
it is used to describe the movement towards using the market to achieve a wide range of social
ends previously filled by government. Arguments
for the effectiveness of this movement follow the
neoliberal paradigm of market performing best
in allocating and using resources, even in the
field of public health 20. It is the story of market
values replacing the vision of medical ethos and
humanitarian aid, of industry controlling the
scientific community, of free-market philosophy
overtaking social and democratic ideals. WHO’s
third function, advocacy for changes in health
policy, which came to the fore with the launch of
Health for All in 1977, had been taken over by the
World Bank and the WHO had retreated into its
technical and biomedical shell 20,21.
The WHO, in its well-known report Health Systems: Improving Performance 22 in the year 2000,
emphasized the increasing demands on health
systems and the limits as to what governments
can finance. It then recommended a “public process of priority setting to identify the contents of
a benefit package available to all, which should
reflect local disease priorities and cost-effectiveness” 22 (p. 15). In this way, implicitly, it separated
disease control and individual curative care. Besides, it reaffirmed the key role of government as
stewardship, to “row less and steer more”. It also
promoted quality-based competition among
providers, together with a combination of public
subsidy and regulation for private providers in
middle-income countries.
A good example of the heavy influence of the
World Bank on WHO was the 2001 report on Macroeconomics and Health: Investing in Health for
Economic Development 23. Investing in Health,
the subtitle of this Commission’s report, echoed
the World Bank’s controversial World Development Report 1993: Investing in Health 13. The
Report on Macroeconomics and Health updated
the earlier Rockefeller Foundation campaigns
against endemic infections, which were deemed
necessary to improve labor productivity. It recommended, against critiques from several
sources 24, a vertical approach to the eradication
of specific diseases, rather than encouraging the
development of integrated health care systems.
The authors of the report, all of them commissioned by WHO but most holding extensive
experience with the World Bank, the International Monetary Fund (IMF), or other multilateral economic organizations 25, argued that investment to improve health was a key strategy
towards economic development. This development meant reform: “streamlining the public
sector, privatization, public funding of private
services, introduction of market principles based
on competition” 26 (p. 523). The proposed system
would involve a mix of state and non-state health
service providers, with financing guaranteed by
the state. “In this model, the government may
own and operate service units, or it may contract
for services with for-profit and not-for-profit providers” 26 (p. 524). One of the working papers 27 of
the Commission of Macroeconomics and Health
bluntly stated that in order to make progress in
liberalizing health services in the current round
of the General Agreement on Trade in Services
(GATS), more member countries would need to
schedule this sector. “Given privatization trends
and greater public-private cooperation in the delivery of health services around the world, often
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necessitated by declining public sector resources,
more countries may be willing to table health services in this round of GATS discussions” 27 (p. 88).
The neoliberal formula was accepted without
critical analysis and was seen as a desirable goal
in this WHO-funded paper, despite reports on
poor results of health sector reform in countries
like Chile and Colombia, which applied it radically 28,29,30.
The European Union did not lag behind. A
2002 communication from The Commission to
the European Council 31 (p. 14) stated: “The European Community will work closely with development partners including government, civil society,
and the private sector”, “exploring opportunities
to work with the private non-for profit and forprofit sectors”. A more active approach would be
adopted for “community work with the private
for-profit health sector”, and mechanisms would
be sought to “enhance co-operation with private
investors to improve their responsibility for health
in developing countries”.
The World Development Report 2004 32
(p. 215) separated “highly transaction-intensive and individual-oriented clinical services”,
requiring individually tailored diagnostics and
treatment, from “population-oriented outreach
services, services that can be standardized and
include vector control, immunization or vitamin
A supplementation” 32 (p. 133). These were new
ways of denominating and, at the same time, administratively and operationally segregating curative individual medicine and disease control
programs. The report stated that even governments with limited capacity could provide the
latter (or write contracts with public or private
entities to provide them, which now opens the
door for private sector involvement in disease
control programs), while the former were best
left to private initiative.
The report stresses the problems for the
public sector to provide clinical services for the
poor, since both the long route, which requires
the policymaker to monitor the provider, and the
short route of direct control of the patient over
his provider fail. The first fails because of the
complexity of clinical services and the heterogeneity of health needs, which make it difficult
to standardize service provision and to monitor
performance. The second fails because of the
lack of accountability of public providers. It does
not mention that the long route is the one that
worked in Northern European countries. Neither
does it recall that the short route in private practice may not be so short because of information
asymmetry, supplier-induced demand, and the
opportunity cost for communities of monitoring
private providers.
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The World Development Report 2004 recommended private provision of clinical services,
except for the few countries with a strong public
ethos, pro-poor policies, and enforcements of
rules. The Bank maintained its bias against government-provided services, presenting obstacles
to improving traditional public services as ample
justification for shifting to new institutional arrangements. Still, obstacles to market-based approaches, even if severe, were characterized as
challenges that could be met. For instance, according to the World Development Report 2004,
a situation in which a public sector regulator is
not independent from a policy-maker justifies
the contracting-out of care. However, when the
issue is privatization, the absence of regulatory
experience (monitoring quality and compliance
of private providers) only leads to recommendations for regulatory capacity-building.
In conclusion, industrialized countries do
have a doctrine on international aid policy in
health. Multilateral agencies unanimously promote disease control programs without the possibility to integrate them into first line health
services as they allocate disease control to the
public sector and curative health care to the private sector. International financing and trade
organizations present a construction that favors
privatization of health services, and a limited role
for public sector activities, focusing mainly on
unprofitable but necessary public health functions 26.
Is there evidence to support this policy
of allocation to separate facilities?
As stated in this paper’s introduction, most
authors agree that the vast majority of disease
control programs should be integrated into first
line health services. Programs that cannot be
integrated are the exception, and a few examples include: (a) breakdown or absence of health
centers; (b) vector control; (c) disease control
activities for which there is no demand, such as
epidemiological surveillance; (d) diseases too
rare for health professionals to maintain their
skills; (e) outreach to specific risk groups, such
as commercial sex workers and drug addicts;
and (f ) control of some epidemics and emergencies.
Disease control programs require a network
of first line health services and a referral system
toward second line services, the district hospitals 33. In addition, to produce good results,
health services hosting them need to achieve
decent general utilization rates of individual curative care 34.
INTERNATIONAL AID POLICY
Clues contradicting the international aid
doctrine on this issue can be classified into two
categories. Some justify integration and others
critically examine the consequences of nonintegration. Let us scrutinize the first evidence
group.
1) According to the World Bank, the essential
clinical package comprises tuberculosis, but ignores a much larger morbidity caused by acute
lower respiratory infections, chronic obstructive
pulmonary disease, and asthma. The narrow disease control approach not only leaves too many
avoidable deaths unattended, it also fails to approach all these respiratory diseases as a group of
symptoms. To detect a patient with tuberculosis,
the program clinician needs accessing patients
with cough because patients ignore their condition’s etiology. Therefore, disease control programs lack effectiveness if they are carried out in
(government) services abandoned by patients.
2) The aid agencies’ recommendations invariably
end in a dual system, with good clinical care for
the wealthy and low-quality “essential” care for
the poor. They act as if expansion of the private
sector were compatible with public provision of
the essential clinical package for the poor, as if
the private sector would not drain limited personnel and other resources, as if reform of the
referral level (hospitals) were not critical for success. Nevertheless, the two vessels are connected.
Instead of adding extra capacity, the commercial
presence of the private sector undermines public
services by drawing away key medical personnel
and picking the “low-hanging fruit”, the healthiest and wealthiest consumers, destroying the
possibility of cross-subsidization and risk pooling on which universal access is based.
3) Barbara Starfield 35 demonstrated that health
systems with a strong, comprehensive publiclyoriented first line obtained significantly better
results in terms of health indicators and satisfaction of their populations in ten industrialized
countries, in relation to overall costs of the systems. Similar research in developing countries
has not been done, but countries like Costa Rica,
India (Kerala State), and Cuba seem to show the
same tendency 36, especially when first line services are equipped with general practitioners or
family physicians.
In the second category of evidence we find
the following:
1) Evidence against separation of disease control and curative care comes from health economists: a recent paper assesses the relationship
between public spending on health care and
the health status of the poor, from demographic
health surveys in 44 countries. Results show that
public spending on health care has a consistent
and significant impact on child mortality among
the poor, as well as on infant mortality and birth
attendance by skilled staff 37. In absolute terms
(number of deaths per 1,000 live births), since
child mortality is much higher among the poor,
public spending has a larger impact on the poor. A
1% increase in public spending on health reduces
child mortality nearly three times more among
the poor as compared to the non-poor. This effect is stronger in low-income countries. Knowing that in developing countries, public spending
for the poor is mainly channeled through public
services, these findings constitute a strong argument for continuing public investment in comprehensive public health services. A recent, influent editorial 38 on bacterial infections as a major
cause of death among children in Africa stresses
the need for comprehensive, integrated, and accessible health services and questions whether
the dominating, narrow, disease-based approach
is appropriate.
2) Public health specialists agree that a high degree of well-planned decentralization, down to
the level of the health district with first and second level services, is the most effective and efficient way of organizing health systems 39. Vertical
programs do not mix well with decentralization.
When health centers consist mainly of a collection of vertical programs, scope for local decision-making is very limited and strategic decisions remain with central program managers and
government 40.
3) There is no evidence that accountability, problem number one in public services according to
the World Bank, would be better assured in contracts with private-for-profit providers. Indeed,
experience in the Philippines 41 and many other
developing countries shows the emergence of
private monopolies or oligopolies that easily get
their way by contributing funds to the electoral
campaigns of their favored politicians. In developing countries, where social control of the state
apparatus is limited, these political connections
might protect business from accounting for their
inability or unwillingness to provide quality services.
4) One key condition to ensure that the private
health sector does not undermine public health
and contributes properly to control disease is
through close regulation based on quality standards and control. However, because of regulatory limitations that GATS places on the exercise
of health sovereignty, in order to remove “unnecessary trade barriers” the treaty substantively
undermines a country’s capacity to regulate its
health services. Moreover, the lock-in feature of
GATS means that commitments to liberalization are effectively irreversible. Pollock & Price 42
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(p. 1075) emphasize that “there is compelling
evidence to show that GATS and the World Trade
Organization (WTO) involve national governments in trading some of their sovereignty for the
putative economic gains of liberalization. In the
process, governments lose rights to regulate and to
protect non-economic values and the principles
that shape provision of public services”.
Within its limited objectives, disease control
has failed in developing countries by all standards. Despite a ten-fold increase in external
financing for tuberculosis control over the last
decade, only a quarter of confirmed pulmonary
tuberculosis cases have access to the package
foreseen by the Directly Observed Treatment
Short-Course (DOTS) strategy. Less than 1% of
AIDS patients in Africa and 5% in Asia are under
appropriate treatment. As for malaria, the WHO
estimates 1.5 to 2.5 million deaths per year, compared to one million per year 20 years ago. Our
discussion suggests that these figures represent
the failure of a policy and not only the “developing” condition of poor countries.
If there is no evidence to support
separation of disease control and
general health care, why do
international agencies promote it?
The World Development Report 2004 somewhat
surprisingly states that technical quality of services is often slightly better in public than in private services. It also aims a spotlight on Cuba
and Costa Rica, commenting quite positively on
the Cuban health system, which has obtained
good health without growth, basically thanks to
three pillars: providing unequivocal instructions
to public providers (the only ones), motivating
staff, and monitoring and evaluating the system
32. Both countries provide useful examples of
how not to separate disease control and clinical
services.
Ideally, public health practitioners incorporate scientific evidence in developing policies
and implementing programs. In reality, however,
these decisions are often based on short-term demands rather than long-term study: policies and
programs are sometimes developed around anecdotal evidence 43. As the Institute of Medicine
stated a decade ago in its landmark report The
Future of Public Health, decision-making in public health is often driven by crises, hot issues, and
concerns of organized interest groups 44. It goes
on to say that decisions are made largely on the
basis of competition, bargaining, and influence
rather than comprehensive analysis. The idea
that politics can be restricted to the legislative
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area, while the work of public agencies remains
neutral and expert, has been discredited.
If there is no evidence in favor of separating
disease control programs and curative health
care, why do multilateral organizations insist
on it? There is of course the almost hegemonic
neoliberal doctrine, and one additional hypothesis could be that multilateral organizations are
under pressure from international companies in
quest of new health care markets. According to a
recent report by the influential non-governmental organization Save the Children UK 45 (p. 8),
“the commercial presence of foreign health care
companies in domestic systems is counted as trade
in health services under GATS, and several companies see the expansion of investment opportunities
as one of their chief gains from ongoing GATS negotiations”. Private sector health care and health
insurance companies from the United States and
Europe have already expanded their operations
into the lucrative markets of Latin America 46,47.
Health care expenditures account for over US$
3 trillion a year in OECD countries alone, yet
contribute comparatively little to international
trade. The GATS 2000 negotiations are intended
to remedy this perceived failing. The US Coalition of Services Industries has stated that “GATS
negotiations are an opportunity for US business to
expand into foreign health care markets (…) Until
now, public ownership of health care has made
it difficult for US private-sector health care providers to market in foreign countries…” 48 (p. 28)
49,50. There is a clear conflict between many governments, for instance in Latin America, which
define health as a right and health services as a
public good, and US government and agencies’
philosophy of free trade and promotion of a market economy, which assumes that by expanding
the private sector, economic conditions and thus
overall health will improve, with a minimum government provision of health care 51.
Moreover, many physicians in developing
countries with dual private/public employment
are happy with a prosperous private market and a
deficient public sector, since they poach patients
from the latter to the former. Finally, Western
politicians and donors support the battle against
infectious epidemics that emerge in developing
countries and threaten rich countries (tuberculosis, AIDS, SARS, Asian flu etc.).
Conclusion
Does international aid have an underlying “doctrine”? The answer is yes: it allocates public
health and disease control activities to Ministries
of Health and health care to the private sector.
INTERNATIONAL AID POLICY
And as we have shown, there is scant evidence to
support this doctrine.
However, these theoretical conclusions need
to be interpreted carefully, in light of this study’s
methodology: first, our literature review is limited to multilateral aid, while bilateral aid was
not assessed. Second, the international agencies
that formulated this doctrine did not implement
it bluntly or homogeneously everywhere. International investments in public facilities are well
known in numerous circumstances. In fact, international agencies have complex decision-making mechanisms, with different countervailing
forces operating on different subjects at different
points in time, as shown by the following examples. The World Bank policy of the World Development Report 1993 was not fully reflected in actual
World Bank health disbursements. Neither was
this doctrine applied when private expenditures
were so low that no investors were interested in a
particular market (for instance in some West and
Central African countries).
Successful disease control requires integration with curative care, and both require accountable, responsive, and decently financed publiclyoriented services. These objectives can only be
achieved through an attempt to make them more
democratic and responsive through community
participation, along the primary health care lines
designed in the 1970s. Coverage with publiclyoriented services could build upon Ministry of
Health facilities but also NGOs, denominational
facilities, mutual aid, social security, and municipal institutions. Community participation in
health services management is badly needed to
improve the score of all these public health services on responsiveness and accountability, and
to acquire the characteristics of a public interest
organization: a social population-based perspective without any kind of discrimination and with
not-for-profit objectives.
International aid should address communicable disease control priorities in ways that
strengthen rather than undermine local health
systems. This applies particularly to initiatives like
the Global Fund to Fight AIDS, Tuberculosis, and
Malaria. Although welcome as complementary
funding to existing donor aid, it should not repeat
the errors of past mass campaigns and hamper
the development of district health systems with
internationally driven ambitious targets.
A sign of policy change has recently been sent
by the late WHO Director General Dr. Jong-Wook,
recommending the reconstruction of health systems and increase in access to general, appropriate health care in the services, while at the same
time developing disease control. It is too early to
assess how deep this reorientation will reach.
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Resumen
Contributors
El control de enfermedades es más factible cuando se
encuentra integrado con los servicios curativos de salud. Este artículo examina si la actual política de cooperación tiende a atribuir el control de enfermedades
y servicios curativos a distintos sectores, impidiendo
así su integración. Tradicionalmente, el control de enfermedades fue conceptualizado en programas verticales. Eso cambió mediante la visión comprensiva de
Alma Ata, para luego ser reinstaurado por el enfoque
de la Salud Primaria Selectiva. Analizamos documentos de los actores más influyentes, tales como la
Organización Mundial de la Salud (OMS), el Banco
Mundial y la Unión Europea. Estas agencias sí tienen
una doctrina en cooperación: la de colocar control de
enfermedades dentro del sector público y servicios curativos dentro del sector privado, donde sea posible.
Examinamos si hay un respaldo científico detrás de
esta doctrina. Ponderamos los argumentos en pro de
integración con las consecuencias descritas de no-integración. Determinamos cuáles son los motivos de los
actores claves para seguir separando el control de enfermedades de los servicios curativos. Recomendamos,
finalmente, a los actores que apoyen simultáneamente
el control de enfermedades, los servicios y los sistemas
de salud.
The authors participated in the paper’s design, execution, and analysis and have seen and approved the final
version.
Acknowledgment
This study was funded by Beleids Voorbereidend
Onderzoek, Research to Prepare Policies/Health Care
for All – General Directorate of Development Cooperation – Belgian Cooperation.
Servicios de Salud; Actos Internacionales; Política de
Salud
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Submitted on 17/Apr/2006
Final version resubmitted on 28/Aug/2006
Approved on 01/Sep/2006
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