April 1997 Insights Issue #22

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Optimising the public/private mix

In many countries, the ‘for-profit’ private sector is an important source of family planning and STI services. Clients often prefer to consult privately, reasoning that private providers offer more sensitive and confidential care, are often more geographically accessible, and offer shorter waiting with more convenient consultation times. In addition, service users may be able to choose the provider on the basis of gender and other characteristics such as cultural background, religion and ethnicity, which can be important in seeking FP and STI care.

On the other hand, there are clear problems associated with private sector provision. There is some evidence that poor quality private sector treatment of STIs contributes to antibiotic resistance. Private providers may have little incentive to engage in health promotion and preventive activities. Although it has been argued that pressure on the public sector can be eased, allowing greater targetting of the poor and vunerable, promotion of the private sector may instead be used as a way of shifting the burden of health care financing further on to public sector service users. Where user charges have been introduced for STI services, they have had a deterrent effect, particularly on women, who may lack access to household cash, and on the poor and marginalised, who may be at highest risk of contracting and transmitting STIs. A weakened public sector may also reduce competition, leading to higher private sector service charges. Finally, growth of the private sector may reduce demands for protecting public sector services, particularly from the otherwise vocal middle class.

Yes budgetary constraints suggest that the private sector will have to expand, especially given the withdrawal of donor subsidies for FP services in many countries. The policy environment will need to facilitate appropriate interactions between the public and private sectors. Mechanisms to monitor and assure quality of care in the private sector will need to be established and policy makers must sustain and reinforce public sector capacity to provide efficient, equitable and effective services. One possible approach is to establish ‘managed networks’ of providers which are able to draw together a range of providers, including the public sector and some parts of the private sector, to meet common objectives (e.g. improvements in service coverage, quality and access) while also encouraging providers to improve further upon what they have to offer.