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Best of both worlds? Public and private sector care for people with diabetes in Trinidad

Private healthcare is increasingly important in middle-income countries. In Trinidad and Tobago the private sector may account for more than a third of total health expenditure. Is patients’ use of private sector care influenced by their health status? Do socio-economic factors act as barriers to access to private care?

Researchers from Kings College London and the Ministry of Health in Trinidad and Tobago investigated the use of private healthcare among people with diabetes. They questioned 2117 patients attending 35 government primary care clinics in Trinidad. They found that private sector care is widely used by these patients and this contributes to inequity in the overall utilisation of healthcare.

Public service provision is advocated as a means to improve equity in healthcare. It is sometimes suggested that public healthcare systems are inefficient, providing badly managed, poor quality services. Private care, it is argued, can provide better quality services more efficiently, although this may compromise equity concerns.

Government health services in Trinidad and Tobago are provided through two large acute hospitals and several small district hospitals as well as a system of primary healthcare centres. Government spending on health was estimated at US$ 103 per capita in 1992. In 1988, the average annual household expenditure on medical goods and services was US$ 248, equally divided between purchases of drugs and medical services. Health insurance coverage remains low, so private care is usually paid for on a fee per item basis.

Choices in healthcare may be influenced by health status, income, education, price, quality of services and waiting and travelling times. Looking at the care reported by diabetic patients, the study found that:

Nearly 60 percent of patients have consulted a private doctor. More than a quarter have seen a private physician for their diabetes and 18 percent regularly use the private healthcare system.
Older patients and those who have been ill with diabetes for a long time are more likely to report having visited a private doctor.
Worse health status is an important reason for seeking private care.
People who live alone or do not have water piped into their homes are less likely to report consulting a private doctor.

The findings of the study have several implications for health policy:

There is considerable unmet demand in the public healthcare sector.
Private healthcare is important for people attending government primary care services in Trinidad and Tobago.
The widespread use of both public and private healthcare by the same patients suggests that they do not see the two settings as equivalent. This behaviour may reduce the disadvantages of each sector, by allowing patients to obtain benefits from each.
The use of private healthcare contributes to inequity even among the poorer groups who use government primary healthcare centres.
Possible solutions to these issues include improving standards of care through increased investment in government primary care services, or (as has been proposed) by moving to an insurance based system of healthcare funding. Either approach is likely to lead to increased utilisation of care.

Source(s):
'Utilisation of private care by public primary care clinic attenders with diabetes: relationship to health status and social factors' by M. Gulliford and D. Mahabir, Social Science and Medicine 53 (2001)

Funded by: Special Trustees of Guy's Hospital, London (in part)

id21 Research Highlight: 23 November 2001

Further Information:
Martin Gulliford
Department of Public Health Sciences
GKT School of Medicine
Kings College London
Capital House
42 Weston Street
London SE1 3QD
UK

Tel: +44 (0)20 7848 6631
Fax: +44 (0)20 7848 6620
Contact the contributor: martin.gulliford@kcl.ac.uk

Kings College London

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