Public-Private Mix

What can be done about the private health sector in low-income countries?

Improving the quality of private health care provision in developing countries is of major importance to the livelihoods of poor people. This article was published in the ‘Bulletin of the World Health Organisation’ and summarises how the activities of the private health sector in low-income countries can be influenced so that national health objectives are met. The article begins with an overview of the characteristics of the private health sector in developing countries. It continues with a summary of how to improve both the supply and the demand for private health care. To close, the authors list the possibilities available to governments for improved stewardship of the private sector.

What can be done about the private health sector in low-income countries?

Anne Mills, Health Policy Unit, London School of Hygiene and Tropical Medicine. Ruairi Brugha, Kara Hanson, Barbara McPake. Bulletin of the World Health Organization 2002;80(4):325-330. April 2002. Available on PDF. A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.

What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries
Mackintosh M; Channon A; Karan A; Selvaraj S; Cavagnero E; Zhao H: The Lancet, June 2016, doi:

Private health care in low-income and middle-income countries is noted to be extensive and heterogeneous, ranging from medicine sellers, through millions of independent practitioners—both unlicensed and licensed—to corporate hospital chains and large private insurers. Policies for universal health coverage (UHC) must address this complex private sector. However, no agreed measures exist to assess the scale and scope of the private health sector in these countries, and policy makers tasked with managing and regulating mixed health systems struggle to identify the key features of their private sectors. In this paper, the authors propose a set of metrics, drawn from existing data that can form a starting point for policy makers to identify the structure and dynamics of private provision in their particular mixed health systems; that is, to identify the consequences of specific structures, the drivers of change, and levers available to improve efficiency and outcomes. The central message is that private sectors cannot be understood except within their context of mixed health systems since private and public sectors interact. The authors develop an illustrative and partial country typology, using the metrics and other country information, to illustrate how the scale and operation of the public sector can shape the private sector's structure and behaviour, and vice versa.

What price health?
User fees and the poor in Sierra Leone

User fees are an increasingly common component of public health financing. The intention is to provide patients with a cheaper but high quality alternative to private healthcare. But does it work? What is the impact on the poorest households? Do poor people still use public health services when they have to pay fees?

Where there is no regulator

Until very recently, the healthcare sector in developed industrialised countries consisted largely of public services for curative and preventive care provided by governments and the regulated private sector. These services were organised into different levels from primary care facilities up to tertiary hospitals providing specialist care, with a referral mechanism from one level to the next. But in many low and middle income countries healthcare has moved away from this model. People, including many of the poor, use a wide range of different service providers, all of which they have to pay. The healthcare sector increasingly resembles an unregulated marketplace rather than an organised public service. How has this come about, what does this marketplace look like and what does it mean for health policy and planning?


Paper prepared for WHO’s Commission on Macroeconomics and Health by Adam Wagstaff The World Bank, The University of Sussex, UK
There are three key levels of government action—the macro level, the health system, and the micro level. Government decisions and actions at each level influence the amount households pay for their health care (financing), and the quantity, quality and type of services they receive (delivery). At the macro level, governments decide how much to spend on health care (and related services) and where, and how to raise the revenues to finance them. At the system level, they decide the mode of service delivery and how to regulate the private sector, and how much to charge for different services and how far to exempt the poor from fees. At the micro level, they influence the accountability of providers and the services and interventions they deliver, and how best to implement facility-based revenue collection schemes. There are, in short, many ways that governments can potentially influence both health gaps between the poor and better-off, and the degree to which poor households are affected disproportionately by the costs of health services.

Who goes where and why? Examining HIV counseling and testing services in the public and private sectors in Zambia
Ron I, Wang W and Magvanjav O: PSP-One, January 2010

The main objectives of this study were to document the role of the private for-profit sector in voluntary counseling and testing (VCT) service delivery and to establish whether there are significant differences in the quality of VCT services, particularly in counseling and referral practices, between public, private for-profit, non-governmental (NGO) and mission health providers. Copperbelt and Luapula were selected, which are urban and rural provinces. HIV prevalence among adults is approximately 17% in Copperbelt and 13% in Luapula. Geographic proximity and the cost of transportation were found to be important factors for clients in selecting a facility, as well as the specialised reputations of NGOs. Clients were drawn to the private sector because of its ability to offer high-quality general health services, in comparison with other medical sectors. This finding suggests that the private sector may be uniquely positioned to pilot more extensive integrated HIV services. However, no one sector emerged as providing overwhelmingly higher quality services than another and, overall, rural sites performed on par in quality with the urban sites. However, the findings revealed less than optimal counseling practices across the sectors.

Who profits? Private healthcare - opportunity or risk?

As evidence about the importance of the private sector in healthcare delivery accumulates, emphasis is being placed on better understanding the opportunities and risks it creates. Private providers are often key sources of treatment for diseases of public health importance, such as malaria, sexually transmitted infections (STIs) and tuberculosis (TB). They are also an important source of care for poor people, who may use private providers nearly as much as better-off groups. But there are concerns about their quality and affordability.

WHO R&D financing committee approved with controversial industry expert
Saez C: Intellectual Property Watch, 22 January 2011

A compromise was struck at the World Health Organization (WHO) Executive Board meeting, held from 17-25 January 2011, allowing a Swiss pharmaceutical industry representative to sit on a committee selecting proposals for research and development (R&D) financing for neglected diseases, despite the fact that he is author of one of the proposals. In light of the fact that a predecessor working group fell prey to allegations of conflict of interest and lack of transparency, WHO added special safeguards to prevent undue influence, but questions remain for some about conflict of interest. The compromise was reached in the margins of the meeting after developed countries threatened to subject other committee appointees to scrutiny. Developing countries, including those with burgeoning generics industries also have candidates on the 21-member expert committee, though none is considered as directly positioned to benefit from the outcome. Critics say the Swiss private sector proposal could be worth billions of dollars to developed country brand-name pharmaceutical companies. Thailand raised concerns about the proposed expert and Brazil argued that equity in global health was at stake.

WHO reform: opening the floodgates to the private sector?
Richter J: Third World Resurgence 298/299, 20-23, 2015

The author presents in this paper how in the name of 'reform', against a backdrop of a funding crisis, a greater collaboration between WHO and big business is being justified. She provides a historical overview of the process which began in 1992 with the drive for UN 'reforms', naming it as a euphemism for the neoliberal restructuring of the world body. Both the idea of attracting more funding from private foundations and the commercial sector and the notion of dealing with global health and nutrition matters through multi-stakeholder approaches are argued to carry major risks to WHO's role as the highest authority in international public health. Even though the regular World Health Forum is abandoned at the moment, the notion of greater involvement of the private sector as legitimate 'stakeholders' in public health affairs is not. She calls for an urgent reflection on whether this path should be pursued, noting that the 'privatisation' of public agencies and spaces increases the reliance on private sector funding, as well as inviting profit-motivated actors into public decision-making forums, and sometimes removing specific public issues from the public sphere altogether. This is seen to be the opposite of ensuring financial independence of public institutions and safeguarding and enlarging of spaces for public debate.