[e-drug] Private health care in developing countries

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E-drug: Private health care in developing countries 
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[Published as fair use. HH]

BMJ 2001;323:463-464 (1 September 2001)

Editorials
Private health care in developing countries 
If it is to work, it must start from what users need 

Private healthcare provision is growing in low and middle income
countries.1,2 The poor, as well as the rich, often seek health care
from private providers, including for conditions of public health
importance such as malaria, tuberculosis, and sexually transmitted
infections.3,4,5  The reasons cited by users include better and
more flexible access, shorter waiting, greater confidentiality, and
greater sensitivity to user needs.1,6 International policymakers are
currently recommending greater use of private providers7,8,9 on
the grounds that they offer consumers greater choice; increase
competition in the healthcare market; and remove state
responsibility for service provision, thereby encouraging its role as
regulator and guarantor. We should, however, be concerned. When
examined, the quality of care offered by many private providers is
poor.1,2,10  Furthermore, poor people spend a greater proportion
of their income on health care (private or public) than do the rich,
often using less qualified or totally untrained private providers. We
have recommended three objectives in relation to the private
provision of care for conditions of public health importance:
widening access, improving quality, and ensuring non-exploitative
prices.11  None of these will be simple to achieve; and multifaceted
interventions, involving policymakers, providers, and users will be
required.12  Increasingly service users (or "consumers") are being
highlighted as the key to driving improvements to achieve these
goals. Their role has, however, been little evaluated in developing
countries.11 

Community education strategies 
In the poorest countries most people who use private providers pay
directly for services, drugs, and other health commodities. In
theory, community education strategies could help people
recognise, demand, and obtain higher quality care and know what
they might expect to pay for it. The influence of users is likely to be
greater where popular political involvement, advocacy and
consumer organisations, an active media, and higher levels of
education are present. Working through representative community
organisations is likely to be more effective than placing the onus on
individuals to negotiate better quality care. Community education is
a core element of social marketing strategies to stimulate demand
and increase population coverage of products with public health
benefits, such as oral rehydration therapy, contraceptives, and
insecticide treated mosquito nets. This needs to be combined with
measures to ensure access, affordability, and supply. Though users
can identify what constitutes for them a good quality service, there
is limited evidence that they can assess the technical quality of
services. Users expect providers to act in their best interests,
although this trust is often misplaced. Expectations that community
advocates or increased user knowledge and confidence are enough
to improve the quality of services are unrealistic, however, in
relation to the appropriateness, quality, and availability of drugs and
diagnostic tests, and even more so for more complex clinical
services. 

In the case of commodities with a public health benefit such as
insecticide treated mosquito nets and contraceptives, information
about product quality can be conveyed through a product brand,
reinforced through use and experience. With more complex
products such as correctly packaged doses of drugs for the
syndromic management of malaria and sexually transmitted
infections, users rely on some third party to guarantee technical
quality.

Accreditation schemes 
In relation to a package of services, accreditation schemes may
monitor the services offered by providers against agreed quality
standards, in exchange for which such services are promoted to
potential service users. High levels of capability are required of
accrediting bodies, however, and this strategy may not be feasible
in many settings, especially when there are large numbers and
different types of single providers and where resources are highly
constrained. Such schemes are more practicable, and usually more
politically acceptable, when working with qualified private providers
organised into professional bodies. 

With respect to the cost of health care, information on regulated
prices for essential drugs has been communicated directly to users
in several countries (Philippines, Colombia, Argentina, India, and
Pakistan) with variable success. This strategy is hindered by
currency fluctuations, uncontrolled drug markets, and weak state
regulation. Price controls on a limited set of essential drugs and for
generics are likely to be more feasible than price controls for
branded products or for services. 

A country's regulatory and legislative framework underpins the
state's approach to working with private providers. Too often,
especially in the poorest countries, the framework is inadequate,
dealing with only the most basic requirements, such as practice
entry and facility registration. In particular, users' access to
effective and affordable redress through administrative and judicial
channels is often inadequate. The oversight role of health
professional councils may also be limited. Conversely, in some
circumstances lowering regulatory barriers may help: for example,
the availability and use of contraceptives have improved through
lowering regulatory and import barriers to product availability
(Zimbabwe), relaxing advertising restrictions (Pakistan), and
broadening the types of private providers who can administer
injectable contraceptives (Egypt). 

Free services for target groups 
The way in which services are financed may offer mechanisms for
limiting costs to service users and could be used to promote quality
of care. Free services for specific target groups such as pregnant
women, children, and commercial sex workers and for priority
services such as tuberculosis, sexually transmitted infections, and
family planning deserve consideration. Fee exemption schemes,
especially if targeted to particular groups, are costly to administer
and may be difficult to scale up to national level. The most powerful
levers operate where medical aid schemes and insurers influence
the prescribing habits and services provided by private providers by
specifying what diagnostic tests and drug treatments must be
offered if the provider is to be paid. However, insurance schemes
usually cover a minority of the population in many poor countries. 
The potential of these strategies will depend on the context and the
capabilities of various stakeholders, especially the state. The
poorest countries, with impoverished populations and many
untrained and unregulated providers, face the biggest obstacles,
especially given their weak public sectors. Principles that should
govern state collaboration with private providers include recognising
that access to quality and affordable health care is a right; that
ensuring access for poor people is a policy priority; and that the
mechanisms to enhance influence of users should be promoted.11 

Anthony B Zwi, senior lecturer in health policy and epidemiology.
(anthony.zwi@lshtm.ac.uk)

Ruairi Brugha, senior lecturer in public health.
Health Policy Unit, London School of Hygiene and Tropical
Medicine, London WC1E 7HT (Ruairi.brugha@lshtm.ac.uk)

Elizabeth Smith, private sector specialist. 
Options Consultancy Services, London W1P 5RT
(e.smith@options.co.uk)


1. Aljunid S. The role of private medical practitioners and their
interactions with public health services in Asian countries. Health
Policy and Planning 1995; 10: 333-349.

2. Swan M, Zwi A. Private practitioners and public health: close the
gap or increase the distance. London: London School of Hygiene
and Tropical Medicine, 1997. 

3. McCombie SC. Treatment seeking for malaria: a review of recent
research. Soc Sci Med 1996; 43: 933-945.

4. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P. After
health sector reform, whither lung health? Int J Tuberculosis Lung
Dis 1998; 2: 324-329.

5. Brugha R, Zwi A. Sexually transmitted disease control in
developing countries: the challenge of involving the private sector.
Sex Trans Inf 1999; 75: 283-285. 

6. L?nnroth K, Tran T-U, Thuong LM, Quy HT, Diwan V. Can I
afford free treatment? Perceived consequences of health care
provider choices among people with tuberculosis in Ho Chi Minh
City, Vietnam. Soc Sci Med 2001; 52: 935-948. 

7. World Bank. World Development Report 1993, Investing in
health. Washington: World Bank, 1993. 

8. World Health Organisation. The World Health Report 2000.
Health Systems: improving performance. Geneva: World Health
Organisation, 1999. 

9. Preker AS, Harding A, Travis P. "Make or buy" decisions in the
production of health care goods and services: new insights from
institutional economics and organizational theory. Bull World Health
Org 2000; 78: 779-790. 

10. Kamat VR. Private practitioners and their role in the resurgence
of malaria in Mumbai (Bombay) and Navi Mumbai (New Bombay),
India: serving the affected or aiding an epidemic? Soc Sci Med
2001; 52: 885-909. 

11. Smith E, Brugha R, Zwi A. Working with private sector
providers for better health care, an introductory guide. London:
Options and LSHTM, 2001.

12. Brugha R, Zwi A. Improving the quality of privately provided
public health care in low and middle income countries: challenges
and strategies. Health Policy and Planning 1998; 13: 107-120. 

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