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 the strategies available to influence both the supply and the demand for private health care. In the final part of the article, the authors focus on the necessary steps to improve the government’s stewardship role vis-à-vis the private sector.

The main findings are:

• The quality of private health provision is often very low, but is popular because it is often very cheap (partial doses of drugs may be sold) and accessible (drugs are sold through widespread retail outlets).
• There is some conflict between the public and private sectors since they may both compete for trained human resources. However, the private sector may support the public sector by promoting public health objectives.
• Social marketing is one means of influencing consumer choice in health care, stimulating demand for effective public health interventions. This can make medical care more affordable since commodities are subsidised, although it is an untargeted measure so there may be substantial leakage to the non-poor.
• The use of vouchers allows consumers to exercise choice over health care, although it also requires a mechanism for determining who qualifies for the subsidy.
• Supply-side initiatives aimed at regulating or encouraging private providers include offering training to such providers, regulation, resourcing providers by furnishing them with packaged drugs, and comprehensive approaches which include all of these interventions. None are without their flaws and some can prove to be very costly.

The implications of this research include:

• Since successful interventions are very resource intensive, careful judgements have to be made concerning the relative return on investment in improving private sector activities, as opposed to strengthening the public sector.
• Although working with the organised formal sector (doctors, nurses etc) is a more feasible point of intervention for governments, the poor may be more prone to use informal providers and therefore are likely to be missed.
• More research is needed into understanding and influencing the behaviour of the private health sectors of developing countries, in order to allow for governments to experiment with alternative strategies.