Academic journal article Bulletin of the World Health Organization

What Can Be Done about the Private Health Sector in Low-Income Countries? * (Public Health Reviews)

Academic journal article Bulletin of the World Health Organization

What Can Be Done about the Private Health Sector in Low-Income Countries? * (Public Health Reviews)

Article excerpt


In recent years there has been a considerable growth of interest in the activities of providers in the private health sector in low-income countries, and in how policy-makers might best capitalize on the accessibility and popularity of this sector (1-3). However, the evidence is limited as to which approaches work best. There have been many references to social marketing, accreditation, franchising and contracting, but much of the experience is documented only in the unpublished literature or has been gained in relatively small projects (4, 5). The aim of the present paper is to consider how the activities of the private health sector in low-income countries can be influenced so that they help to meet national health objectives.

Characteristics of the private health sector in low-income countries

The private health sector may be defined as comprising all providers who exist outside the public sector, whether their aim is philanthropic or commercial, and whose aim is to treat illness or prevent disease. They include large and small commercial companies, groups of professionals such as doctors, national and international nongovernmental organizations, and individual providers and shopkeepers. The services they provide include hospitals, nursing and maternity homes, clinics run by doctors, nurses, midwives and paramedical workers, diagnostic facilities, e.g. laboratories and radiology units, and the sale of drugs from pharmacies and unqualified static and itinerant drug sellers, including general stores.

In practice there is a considerable overlap between the public and private sectors (6). Staff employed in the public sector may also practise privately, either on their own account or working for owners of private facilities. This may be legal or may not be strictly legal or controlled. Public hospitals may operate their own private wards and manage the income from them, or may allow work for private gain on their premises, as when doctors admit private patients and are paid directly by them. If public services become heavily dependent on fee income, as, for example, in China (7), there may be little to distinguish them from private enterprises that operate in the interest of their owners rather than in that of the general public.

The private sector represents a resource that is available and used even in the poorest countries and among lower income groups (g). For example, the majority of malaria episodes in sub-Saharan Africa are initially treated by private providers, mainly through the purchase of drugs from shops and peddlers (9, 10). For some diseases of high priority, e.g. malaria, tuberculosis and sexually transmitted infections in the many countries where the public infrastructure is limited, prevention and treatment cannot be substantially scaled up without considering how best to make use of contacts with the private sector.

However, the effectiveness of private services is often very low. Poor treatment practices have been reported for diseases such as tuberculosis (11, 12) and sexually transmitted infections (5, 13), with implications not only for the individuals treated but also for disease transmission and the development of drug resistance. Why, then, are private services so popular? One reason is that they are often cheap because they are adjusted to the purchasing power of the client, as when partial doses of drugs are sold. In Sierra Leone, for example, the price of purchased drugs was almost a third of the cost of treatment at a public health centre (14). Another reason for the popularity of private services is that they are often accessible: drugs are sold through general retail outlets with convenient opening hours.

The use of the more expensive private services, or treatment for chronic conditions, can result in households being unable to afford other vital requirements. Over 10% of the income of the poorest quintile of the population is often spent on medical care, as found in a study in Sierra Leone (14). …

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