Durham J, Michael Marcos, Hill P S, Paviignani E
University of Queensland, Faculty of Medicine & Biomedical Sciences, School of Public Health, Brisbane, Australia.
BMC Health Serv Res. 2015 Sep 28;15:424. doi: 10.1186/s12913-015-1088-5.
In most societies the health marketplace is pluralistic in character, with a mix of formal and informal providers. In high-income countries, state regulation of the market helps ensure quality and access and mitigate market failures. In the present study, using Haiti as a case study, we explore what happens to the functioning of the pluralistic health marketplace in severely disrupted environments where the informal sector is able to flourish.
The overall research design was qualitative. Research methods included an extensive documentary and policy analysis, based on peer-reviewed articles, books and "grey" literature--government policy and program reports, unpublished research and evaluations, reviews and reviews from key multilateral and bilateral donors, and non-government organisations, combined with field site visits and in-depth key informant interviews (N = 45).
The findings show that state fragility has resulted in a privatised, commoditised and largely unregulated and informal health market. While different market segments can be identified, in reality the boundaries between international/domestic, public/private, for profit/not-for-profit, legal/illegal are hazy and shifting.
The lack of state capacity to provide an enabling environment, establish, and enforce its regulatory framework has resulted in a highly segmented, heterogeneous and informal health market. The result is deplorable health indices which are far below regional averages and many other low-income countries.
Working in fragile states with limited capacity to undertake the core function of securing the health of its population requires new and innovative ways of working. This needs longer time-frames, combining incremental top-down and bottom-up strategies which recognize and work with state and civil society, public and private actors, formal and informal institutions, and progressively facilitate changes in the different market functions of supply, demand, regulation and supporting functions.
在大多数社会中，健康市场具有多元化特征，存在正式和非正式的医疗服务提供者。在高收入国家，国家对市场的监管有助于确保质量、可及性并缓解市场失灵。在本研究中，我们以海地为案例，探讨在非正式部门得以蓬勃发展的严重混乱环境中，多元化健康市场的运作会发生什么情况。
总体研究设计为定性研究。研究方法包括广泛的文献和政策分析，基于同行评议文章、书籍和“灰色”文献（政府政策和项目报告、未发表的研究与评估、主要多边和双边捐助方以及非政府组织的审查和评论），并结合实地考察和深入的关键信息提供者访谈（N = 45）。
研究结果表明，国家脆弱性导致了一个私有化、商品化且基本不受监管的非正式健康市场。虽然可以识别出不同的市场细分，但实际上国际/国内、公共/私人、营利/非营利、合法/非法之间的界限模糊且不断变化。
国家缺乏提供有利环境、建立和执行监管框架的能力，导致了一个高度分割、异质且非正式的健康市场。结果是健康指标令人痛心，远低于区域平均水平以及许多其他低收入国家。
在能力有限、无法履行保障民众健康这一核心职能的脆弱国家开展工作，需要新的创新工作方式。这需要更长的时间框架，结合渐进的自上而下和自下而上战略，承认并与国家和民间社会、公共和私人行为体、正式和非正式机构合作，并逐步推动供应、需求、监管和支持功能等不同市场功能的变革。
