The Washington PostDemocracy Dies in Darkness

Opinion Why is the U.S. trying to export its flawed health-care policies around the world?

A health worker administers a dose of a coronavirus vaccine in Nairobi in July. (Patrick Meinhardt/Bloomberg)

Rebecca Riddell co-directs the Human Rights and Privatization Project at New York University School of Law.

“That’s the only time you’ve received free health care? How in the world have they normalized that?” a Kenyan colleague asked after hearing that my coronavirus vaccine was the only instance in which I, an American, had ever received free public health care. We were months into a research project on the U.S.-backed growth of the for-profit private health sector in Kenya. The irony was not lost on us.

The United States famously spends more per capita on health care than any other country, even though the system performs far worse than that of many peer countries. Access is highly unequal, and sky-high prices push millions into poverty and discourage others from seeking care altogether. This heavily privatized system is indisputably excellent at one thing: generating profits. And powerful vested interests have blocked serious reforms for nearly a century.

Yet the U.S. government is pushing private health care around the world — including in countries that already have robust public health-care systems, such as Kenya.

In 2018, the U.S. Agency for International Development adopted a new private-sector engagement policy — a “call to action” to “embrace market-based approaches.” It calls for “aggressive deployment of the full breadth of USAID’s financial and nonfinancial resources” to incentivize private actors.

The policy is explicitly a “mandate” to “provide opportunities for U.S. businesses” while delivering humanitarian programs. Such an approach is nominally justified by the assertion that U.S. corporate interests are aligned with those of the communities they impact, a sunny theory supported by a quote from Larry Fink, the chief executive of BlackRock, the world’s largest asset manager.

But private interests aren’t aligned with public goals just because policymakers or executives declare it so. In fact, relying on private actors to achieve development goals can have disastrous effects.

Our recent report, published by New York University’s Center for Human Rights and Global Justice and Kenyan human rights organization Hakijamii, finds that privatizing health care has proved costly for individuals and the government, deepened inequality in access, and pushed people into poverty and crushing debt. Private actors tend to focus on the patients and services that generate the greatest revenue and neglect important but less-profitable forms of care — such as immunizations, treatment for HIV/AIDS and services for survivors of sexual abuse. We spoke with people who had been forced to sell land and livestock, sacrifice educational opportunities, and take on substantial debt to pay for private care — and others who were turned away from private facilities because of their inability to pay. And that’s just the tip of the iceberg. We also documented a serious lack of transparency, waste of public money and disproportionate impacts on groups including women and people in rural areas.

But these failings haven’t stopped USAID from pushing full steam ahead to privatize more health care in Kenya. In 2020, referencing the private-sector engagement policy, USAID requested bids for a multimillion-dollar project to “reshape the healthcare supply in Kenya using market-based approaches.” The project sought to “shift significant patient volumes to private-sector care.”

USAID’s own statements show it is aware that privatized health care isn’t a viable solution for many Kenyans, more than a third of whom live under the national poverty line. Its November announcement of a $10 million private health initiative specified that the project would focus on Kenyans “who can pay for the full cost of their care in the private sector” and leave “members of poor and vulnerable populations” to the “overburdened” public health sector.

Kenya is no outlier. USAID has undertaken initiatives to expand the role of the private health-care sector in places such as South Africa and Mozambique. In November, USAID Administrator Samantha Power announced the launch of a major fund designed to help vastly expand the agency’s work with private actors.

The ways this policy pushes public money toward the private sector is obscured by corporate doublespeak: vague jargon like “leverage,” liberal sprinkling of the word “sustainable,” and the reframing of transactions as “partnerships.” But the “win-win” theory putatively supporting this approach is often magical thinking that does not deliver broad access to vital services.

It is unclear how USAID squares its policy of prioritizing private actors with contexts in which doing so could run counter to the achievement of development goals or what steps it takes to ensure its support of for-profit “solutions” does not exacerbate inequalities.

Amid a pandemic that has highlighted the gravely unjust and counterproductive consequences of allowing corporate interests to dominate the global response, USAID should prioritize supporting strong public health systems — instead of exporting a dysfunctional approach that benefits U.S. companies but harms people and communities.