Introduction Countries around the world are attempting to achieve equitable, successful, transparent health care systems. Major improvements in health care come from controlling communicable and non-communicable diseases, prolonging life expectancy, ensuring availability and equal access to health care for everyone (Buse et al 2012). These might be achieved due to coherently functioning of health systems, which consist of public and private sectors. Providers of health care who operate outside of the public sector are defined as private health sector (Mills et al 2002). It includes private for-profit (commercial) which in its turn categorized as formal: private hospitals, pharmaceutical companies, physicians who operate individually or in small group practices, and as informal for-profit providers: traditional healers, drug shops, unlicensed and unregulated providers; and not-for profit private sector, such as non-governmental organizations(NGOs), civil society, social enterprises, faith-based groups that function at national or international levels (Basu et al 2012). All of them provide a wide range of medical services from diagnostic and laboratory tests to treatment, medical consultations, and sale of medicines (Mills et al 2002). From the late eighties private sector has been actively engaged in health care financing and service delivery after structural adjustment when governments constrained budgets for health expenditures (Buse et al 2012). Since then there is a longstanding debate in global health arena about the appropriate role of public and private sectors in health care delivery in low and middle-income countries (LMIC). The aim of this essay is to evaluate the private sector performance and understand how it may impact on healthcare delivery to achieve improved health systems and equity in health care. This essay will discuss the role of both of formal and informal private sectors as a whole in health care delivery in LMIC followed by a providing an example of successful public-private partnership in Senegal. In many LMIC the role of private sector is huge in terms of service delivery as it is in high-income countries and thus it functions side by side with the public sector. According to the literature, the big proportion of health expenditure in LMIC goes to the private sector (). The evidence says that in Sub-Saharan African countries over 50% of health expenditure in 2005 went to private providers (Sekhri 2009). Also in fragile countries such as India, Afghanistan, and South Asia, about 80% of healthcare was primarily provided by “non-public” sector and most of the services were paid by out of pocket payments (Results for Development 2018; Mundial 2004). World Bank in an assay of 26 African countries found that the majority of sick children from the low-income families were using private sector services (Loh et al 2013). Moreover, these services were provided primarily by informal health sector the quality of that correspondingly can be very low in LMIC (Basu et al 2012). According to Basu et al (2012) when the informal sector was excluded from the term “private sector” the utilization of public health services was higher than the formal private sectors’. For instance, the experience of the low-quailed treatment of diseases such as tuberculosis and sexually transmitted infections provided by the private sector was detected in Siera-Lion, which could lead to the further transfer of these conditions to the national level (Brugha and Zwi 1998; Lonnroth 2000). Regardless of this, the private sector remains popular in both high and low-income countries. A possible reason for this may be that prices in “non-public” sector are usually adjusted to reflect client’s income and are usually easily available. For example, again, in Sierra Leone people prefer to buy drugs instead of going to public hospitals, where costs for (primary care) of particular disease are “putatively” free of charge, but in practice they are three times higher than the price of medicines available in the drug shops, where the poor usually go (Montagu and Goodman 2016; Marriott 2009) and as the Center for Global Development argues they “Want to go” and “will persist to do so” (Harding 2009). In the systematic review of the 102 articles which were analyzing the performance of the both private and public sectors in cohort and cross-sectional studies which were selected through the criteria of WHO’s themes as quality, accountability, accessibility, responsiveness, transparency, regulation, fairness, equity and efficiency, it was revealed that the private sector has a great risk of low-quality care and lack of published data that complicates the evaluation of their performance (Basu et al 2012). The level of patient’s health outcomes in private sector was low comparing to the public sector’ as well as the performance of physicians, but the hospitality to clients and flexible timetable of working hours of private hospitals overlapped the negative aspects of that (Basu et al 2012), this is also might be another reason for popularity of private sector. Furthermore, factors such as the brain-drain as well as the disbalance between demand side and supply, the preference of doctors where to work in a private or public hospitals also influences the private sector’s growth in LMIC. It is stated that the qualified physicians from LMIC prefer to emigrate to and work abroad in high- income countries with the good infrastructure and qualified health care delivery (). In 2000t in developed countries such as Australia, USA, United Kingdom, Canada, Northern Ireland about 30% of personnel in health care delivery services were from LMIC and particularly from India (nearly 60 000) (Nullis-Kapp 2005). This might aggravate the situation of poor performance and low quality of health care in countries of origin of those who emigrate. In an analysis of physician’s migration from Peru, it was revealed that medical practitioners recruited in both public and private activities were less likely to move to other countries for a better life and work experience (Loh et al 2013). Which means that mutually grateful interactions between public and private sectors might produce a better environment for health workers in order to improve the quality of public health services as a whole. Concerning the debate about determining who is the main actor in health care in achieving universal goals, Bennett et al (2005) argued that in order to reach Millennium Development Goals and to address health needs of communities both public and private sectors should operate in a better way by building supply chains and strengthening mutual relationships. In the context of current situation where MDG was expanded and broaden into context of Sustainable Development Goals agenda in which goal#3 is dedicated to health and states “Ensure healthy lives and promote well-being for all at all ages” (Buse and Hawkes 2015) the important thing is not the who “own” the health institutions, but the quality of health services provided and performance of health workers in that institutions. The point is that public and private sectors are inseparable and the quality and performance of the health sector as a whole are needed to be improved to attain public health goals. Following this, countries such as Mexico, China, Africa, Egypt, Papua, New Guinea, South Africa governments actively interact with the private sector in order to advance the infrastructure, to raise the number of trainings and staff trained, to improve the quality and effectiveness of healthcare facilities (Results for Development 2018).
Active use of market mechanisms such as contracting public-private sectors.
Governments try to achieve universal health coverage to meet expectations of citizens and look for partners among civil society organizations, NGOs, partnerships with businesses to share expertise, to mitigate the risks of ambitious outcomes. One example is “informed push distribution model” (IPM) in Senegal for providing contraceptives and other reproductive technologies (Daff et al 2014). Before that Senegal was using the standard method for delivering health care, medicines, and other technologies with centralized medical stores. 140 of health facilities were recipients of materials from the central store which was in government hands and it turned out that this was not an efficient way to do it, as stock-outs run at about 80% on average. When women went to facilities to get an implanted contraceptive or just a get a pill or other technologies they needed for contraception or family planning chances were 4 out of 5 times just would not be able to get what they needed. Through the partnership that involves government as the leaders but also involved Merck for mother’s, the Gates Foundation intra health international Imperial Health Sciences and some other partners as well they were able to transform to supply chain for reproductive commodities in Senegal fairly short order and by outstanding the supply to third party logistics providers like imperial Health sciences and using that they called a ‘mobile warehouse’ that was a software that enabled people to go to health facilities in the most rural areas check what was needed and send that information back immediately to a central database; within 6 months stock out rate went from 80% to 2% and it also saved about third of the costs distributing these products so that outsourcing was successful because the government was able to put together this partnership with complementary skills and resources from private sector (). It was successful also due to right contract management facilities and accreditation of the providers who they want to expand this system to other countries in Africa ().
Because of the current proliferation of market failure, in terms of financing and provision of health care, the careful regulation of private sector is needed. Montagu (2016) points out that for the most of LMIC it is a challenge to interact with the private sector practitioners to achieve improved health care system. For the response to market failures in LMIC he illustrated a model of the four approaches such as the activation of prohibition and constrain through the statutory controls, self-regulation, and accreditation; as well as the encouragement of training and quality improved and purchase of vouchers and contracting. These approaches are designed to restrict system failures in terms of informational asymmetry between consumers and providers; provision of unnecessary care; poor quality and safety of healthcare as well as ignorance of preventative measures of communicable diseases, or reduction of antimicrobial resistance by private sector providers, because they merely don’t pursue additional benefits for a society as it is not valued in markets. “Market failure” they usually overcharge for the services provided, prescribe expensive medicines and unnecessary test for a diagnosis or promise “magic” cure for those in need with the only goal of profit (Montagu, Goodman 2016, 1-2).
Although the prominence of the private sector is driven by profit in LMIC’s health-care delivery is doubtful, and prohibitions of that seems to be almost impossible, but careful interventions for regulation to improve the quality provided are needed.
The private sector as a part of health systems has resources and expertise that can help with global health problems and also helps to have a healthier world. The latter in its turn is important for business because this means that people will have the ability to take an advantage of educational opportunities, be productive in their jobs means that countries develop and are able to move beyond the cycles of poverty and political instability. A healthier population is the wealthier population, because they contribute to the empowerment of the countries every day.
In LMIC, people from the poorest areas have limited access to primary health care as the result of poverty, insufficient demand side and weak health care delivery services of the countries. The fail of adequate health care delivery supply pushes the poor toward the private sector usage. Therefore, the role of private sector is enormous in LMIC, because the major proportion of health expenditure comes from this sector and they are accountable for the delivery of health services as just the public sector. This essay concludes by saying that there is an indisputable role for private sector in improving human health and health systems. However, to achieve better health care delivery for all more well-structured and organized public-private partnerships are needed to be built.