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?
Public-Private Mix
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.
This paper, Prepared and Presented at the 'Making Services Work for Poor People' World Development Report (WDR) 2003/04 Workshop, puts forward three arguments. First our understanding of the health sector is handicapped by trying to fit it into language and concepts which do not adequately capture its changing realities and the political economies within which health sectors are embedded. Second, this has disposed to putting forward decontextualised, and thus largely normative solutions, such as “regulation,” to the problem of improving service delivery in poorly performing environments. Third, approaches need to move beyond the dualism of public versus private and work creatively with messy and sometimes contradictory realities. It concludes with a discussion of how this analysis can be applied to a major international intervention set up to benefit the poor – the Global Fund for HIV/AIDS, TB and Malaria.
Many low and middle-income countries (LMICs) have experienced changes in the provision of healthcare services. Services are now provided by a variety of sources under market conditions. In response to this shift, how have the roles of healthcare providers changed? How have households adapted to these changes in order to meet their health needs? What should governments do to provide good healthcare in these conditions? Research by the UK's Institute of Development Studies highlights that over the last few decades there have been profound changes in the ways that health goods are produced and consumed in LMICs. This change is due to economic and political factors, such as crises in public sector financing and governance, that have reduced governments’ capacity to fund infrastructure, supplies and salaries and competently manage healthcare. The result in many countries is that it is difficult to maintain the distinction between public and private in the health sector.
This paper from Reproductive Health Matters looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented.
As the economic burden of HIV/AIDS increases in sub-Saharan Africa, allocation of the burden among levels and sectors of society is changing. The private sector has more scope to avoid the economic burden of AIDS than governments, households, or nongovernmental organisations, and the burden is being systematically shifted away from the private sector. The article suggests that the shift in the economic burden of AIDS is a predictable response by business to which a deliberate public policy response is needed. Countries should make explicit decisions about each sector's responsibilities if a socially desirable allocation is to be achieved.
This article produced by Social Watch analyses the impact of privatisation of health, education and basic infrastructure. It follows the United Nations Commission on Human Rights (UNCHR) report that urges WTO member nations to consider the human rights implications of liberalising trade in services, especially health, education and water. Social Watch is an international NGO watchdog network monitoring poverty eradication and gender equality.
In the current environment of shrinking global and domestic resources for health care, there is an overwhelming pressure to achieve financial sustainability in the health sectors of developing countries. Within this context, there seems to be increasing acceptance of the view that individuals need to contribute to some of the costs of public health care through charges such as user fees and other cost-recovery mechanisms. This paper looks at the implications of user fees for women's utilization of health care services, based on selected studies in Africa. Lack of access to resources and inequitable decision-making power mean that when poor women face out-of-pocket costs such as user fees when seeking health care, the cost of care may become out of reach. Even though many poor women may be exempt from fees, there is little incentive for providers to apply exemptions, as they too are constrained by restrictive economic and health service conditions. If user fees and other out-of-pocket costs are to be retained in resource-poor settings, there is a need to demonstrate how they can be successfully and equitably implemented. The lack of hard evidence on the impact of user fees on women's health outcomes and reproductive health service utilization reminds us of the urgent need to examine how women cope with health care costs and what trade-offs they make in order to pay for health care.
The World Bank and International Monetary Fund favour healthcare user fees. User fees offer revenue and may decrease inappropriate care. However, user fees may deter needed care, especially in vulnerable populations. A cross-sectional analysis of healthcare utilization in a large Zambian hospital was conducted for children 3-6 years of age during a one-month observation period. Trends suggest female children may be less likely to present for care when user fees are imposed. This paper concludes that user fees appear to decrease differentially utilization of inpatient care for female children in rural Zambia.
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.