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Monday, 9 July 2012

Private or Public, which providers perform better?

Whether to use private sector in the face of poorly functioning, ineffective and inefficient public sector to improve equitable access to quality healthcare for the poor has been a matter of intense debate in recent times. Proponents of private providers (e.g., World Bank) would argue that the poor in the low and middle income countries (LMICs) are in any way using private sector providers in greater proportion than the public sector providers for a number of reasons (such as distance to health facilities, long waiting time, rude behaviour of the providers and poor-quality care). In their definition, they would include all types of providers under the sun who are not ‘state providers’ and include the large army of drug shop attendants, village doctors and other informal sector providers. On the other hand, proponents of public sector would argue that, driven by profit motive, private sector does not provide services (such as immunization, family planning etc.) which is not profitable, and makes the cost of services high through irrational use of diagnostics and medicines. According to them, a strong public health system financed through payroll or taxes, that such a system is more equitable, and produce better health outcome. Still others would argue that both have their strengths and weaknesses, and for an optimum system, both are needed.

In a recent systematic review of the performances of Private and Public healthcare systems in LMICs, it did not found private sector ‘usually more efficient, accountable or medically effective than the public sector’. The review examined 100+ articles on the issue in different LMICs following stringent criteria. It examined six thematic areas WHO health system framework e.g., access and responsiveness; quality; outcomes; accountability, transparency and regulation; fairness and equity; and efficiency.

On the first issue, it found that both affluent and poor households accessed more care from private than public sources, only if the private sector includes drug shops and other informal providers. When these are excluded and only qualified registeres providers are included, the scenario is reversed i.e., more care is accessed from public sector providers. However, the performance of the private sector was better in terms of ‘responsiveness’ such as lesser waiting time, more time in examining the patient, explanation of the illness, courtesy of the staff, and more availability of drugs.

In quality of care, the private providers lacked behind. The private providers were found to be less knowledgeable, less diagnostic accuracy and adherence to standard protocol for treatment. Irrational use of drugs such as antibiotics was more common among them. Higher rates of treatment completion was found in case of public providers (e.g., in case of TB) while higher treatment failures was found with the private providers. Interestingly, data on accountability, transparency and regulation for the private providers was not available. While exploring  fairness and equity, the ‘inverse care law’ was found to persist in case of the private providers: they were found to cater to the need of the affluent more than that of the poor.

Overall, the study concluded that there doesn’t exists enough evidence to say that the performance of private providers is better than public providers.

Source: Basu et al. Comparative performance of private and public healthcare system in lower and middle-income countries: A Systematic review. PLos Medicine 2012;9(6):e1001244.

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