This is a continuation of my last post. In that post, I tried to show in general just how complicated the public vs private debate could get. In this post, I use the healthcare sector to illustrate the nuances of the private vs public debate.
Generally, this debate has been divided between those seeking universal state-based healthcare availability and those advocating for the private sector to provide care in areas where the public sector has typically failed. Private sector advocates have pointed to evidence that the “private sector is the main provider,” as many impoverished patients prefer to seek care at private clinics. They have suggested that the private sector may be more efficient and responsive to patient needs because of market competition, which they indicate should overcome government inefficiency and corruption. In contrast, public sector advocates have highlighted inequities in access to health care resulting from the inability of the poor to pay for private services. They have noted that private markets often fail to deliver public health goods including preventative services (a “market failure”), and lack coordinated planning with public health systems, required to curb epidemics.
This post highlights the major insights gleaned from a systematic review of comparative performance of private and public healthcare systems in low and middle-income countries conducted by researchers based at western academic and health institutions. It is important to point out that studies comparing the performance of private and public sectors are difficult to implement, for several reasons. Healthcare services are not universally dichotomized between public and private providers, as some practitioners participate in both state-based and privately owned healthcare delivery systems, and many systems are dually funded or informal.
The healthcare systems were evaluated using WHO criteria of:
- accessibility and responsiveness
- quality
- outcomes
- accountability, transparency, and regulation
- fairness and equity
- efficiency
Out of the 102 relevant studies included in their comparative analysis, one-third of studies were conducted in Africa and a third in Southeast Asia (Indonesia, Philippines, Cambodia, Myanmar, Malaysia, Thailand, Laos, Singapore, Vietnam).
This systematic review did not support previous views that private sector delivery of health care in low- and middle-income settings is more efficient, accountable, or effective than public sector delivery; however, the public sector appears frequently to lack timeliness and hospitality towards patients. Each system has its strengths and weaknesses, but importantly, in both sectors, there were financial barriers to care, and each had poor accountability and transparency. This systematic review highlights a limited and poor-quality evidence base regarding the comparative performance of the two systems. Private sector healthcare systems tended to lack published data by which to evaluate their performance, had greater risks of low-quality care, and served higher socio-economic groups, whereas the public sector tended to be less responsive to patients and lacked availability of supplies. Contrary to prevailing assumptions, the private sector appeared to have lower efficiency than the public sector, resulting from higher drug costs, perverse incentives for unnecessary testing and treatment, greater risks of complications, and weak regulation. Both public and private sector systems had poor accountability and transparency. Within all WHO health system themes, study findings varied considerably across countries and by the methods employed.
Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients.
Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers.
When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. However, there were three exceptions: Namibia, Tanzania, and Zambia, where private sectors are majority providers even when only licensed personnel are counted.
Financial barriers to care, such as user fees were reported for both public and private systems. User fees are health payments charged at the point of accessing health care services.
The analysis found that private outpatient clinics often had better drug supplies and responsiveness than public clinics.
Women living in rural Nigeria also reported preferring private obstetric services to public services because doctors were more frequently present at the time of patient presentation.
In Nigeria, public providers were significantly more likely to use rapid malaria diagnostics and to use the recommended combination therapies than private providers.
Poor adherence to guidelines in prescription practices, including sub-therapeutic dosing, by private sector providers has been associated with a rise in drug-resistant malaria in Nigeria. Failure to provide oral rehydration salts, and prescribing of unnecessary antibiotics were more likely to occur among private than public providers although there were exceptions.
Higher rates of potentially unnecessary procedures, particularly cesarean sections (C-sections), were also reported at private than at public settings.
Reports from Africa and Laos suggest ineffective and sometimes harmful pharmaceuticals are being distributed in the private sector.
Surveys of patients’ perceptions of care quality were mixed. Two survey-based studies suggested that patients perceived higher quality among private practitioners, possibly due to frequent prescribing of medications and more time spent with patients.
Public sector provision was associated with higher rates of treatment success for tuberculosis and HIV as well as vaccination. For example, in Pakistan, a matched cohort study in Karachi found that public sector tuberculosis care resulted in an 85% higher treatment success rate than private sector care. In Thailand, patients seeking care in private institutions had significantly lower treatment success rates for tuberculosis, which was attributed to a three to five times greater likelihood of being prescribed non-WHO-recommended regimens than in the public sector. In South Korea, tuberculosis treatment success rates were 51.8% in private clinics as opposed to 79.7% in public clinics, with only 26.2% of patients in private clinics receiving the recommended therapy, and over 40% receiving an inappropriately short duration of therapy. Similarly higher rates of treatment failure were observed for private than public system patients on antiretroviral therapy for HIV in Botswana. In India, an analysis of over 120,000 households, adjusted for demographic and socioeconomic factors, found that children receiving private health services were less likely to receive measles vaccinations. Similar findings were reported from Cambodia.
Studies comparing pre- and post-privatization outcomes tended to find worse health system performance associated with rapid and extensive healthcare privatization initiatives in Latin American countries. However, a slower pace of privatization of health care services did not appear to correlate with a substantial worsening in patient outcomes among Latin American countries.
On Accountability, Transparency, and Regulation, data tended to be unavailable from the private sector. No papers were found to describe any systematic collection of outcome data from entirely private sector sources. One recent independent review of Ghana’s private sector referred to the private sector as a “black box,” with a dearth of information on delivery practices and outcomes. Tuberculosis and malaria case notification to the public health system was particularly poor among private sector providers as compared to public providers in a number of countries.
Several reports observed significant public spending being used to regulate the private sector in order to improve patient care quality, particularly in African countries, and with limited effectiveness.
Financial barriers to care, particularly user fees, were reported to be prevalent in both private and public systems. A World Bank study in Ghana concluded that there was no systematic evidence indicating whether user fees in the public sector were different than in the private sector however, the data presented showed that out-of-pocket user fees for patients were highest for private not-for-profit, lowest for public, and intermediate for private self-financed providers. Hence, the conclusions of the report appear to be disputed by the data within the report.
Several studies suggested that the process of privatizing existing public services increased inequalities in the distribution of services. Analyses of the Tanzanian and Chilean health systems found that privatization led to many clinics being built in areas with less need, whereas prior to privatization government clinics had opened in underserved areas and made greater improvements in expanding population coverage of health services.
Privatization in China was statistically related to a rise in out-of-pocket expenditures, such that by 2001, half of Chinese surveyed reported that they had forgone health care in the previous year due to costs; out-of-pocket expenses accounted for 58% of healthcare spending in 2002 compared with 20% in 1978 when privatization began.
One survey-based study using Demographic Health Survey data from 34 sub-Saharan African countries found that privatization was associated with increased access, and reduced disparities in access between rich and poor.
Several reports observed higher prescription drug costs in the private sector for equivalent clinical diagnoses. Tanzanian private facilities typically used more brand-name oral hypoglycemic agents, but even generic medications were five times higher in price.
There is also evidence that the process of privatization is associated with increased drug costs. A study of the Malaysian health system found that increasing privatization of health services was associated with increased medicine prices and decreased stability of prices.
Healthcare costs in Colombia rose significantly following privatization reform in 1993. It was estimated that in Mexico, Brazil, and South Africa, unnecessary C-sections increased delivery-related health costs in the private sector by at least 10-fold.
Several studies found that poor reporting of diseases in the private sector impeded public sector control of communicable diseases.
The review showed that some findings in low- and middle-income countries mirrored existing evidence from high-income countries. For example, the lack of data from private sector groups was similar to the situation in the UK, where the privately run Independent Sector Treatment Centres were unable to provide healthcare performance data when required. However, the evidence also indicates that contextual factors modify the relationships we have observed, so that it is not straightforward to transpose health system evidence from high-income countries to low- and middle-income countries. Importantly, we observed that regulatory conditions interact with the effectiveness of public and private sector provision, but in low- and middle-income countries regulatory capacity is much weaker.
Overall, the data describing the performance of public and private systems remains highly limited and poor in quality, suggesting that further investigations should more systematically make data available to track the performance of both public and private care systems before further judgments are made concerning their relative merits and risks.
This study was published in 2012 by researchers from the following institutions:
- Department of Medicine, University of California (San Francisco), USA
- Division of General Internal Medicine, San Francisco General Hospital, USA
- Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
- Division of Infectious Diseases, Massachusetts General Hospital, USA
- Tri-Institutional MD-PhD Program, Weill Cornell Medical College/Rockefeller University/Sloan-Kettering Institute, USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Harvard Medical School, USA
- Department of Sociology, Cambridge University, UK
The period covered in the study is from 1 January 1980 to 31 August 2011.
BEFORE YOU GO: Please share this post with as many people as possible and please check out my book, Why Africa is not rich like America and Europe on Amazon. Thank you
Bibliography
- Basu, Sanjay et al. June 2012 ‘Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review’ PLoS Medicine