Introduction

In many developing countries, and particularly in Africa, maternal health care was not particularly high on the list of public health priorities in the first three quarters of the XXth century. “For many years colonial medicine had but few obstetrical problems to resolve” (Amy 1992). That did not mean there were no problems, but these were grossly underestimated and disregarded (De Brouwere & Van Lerberghe 1998). Maternal health care most often was a mere sideline in childcare programmes (Rosenfield & Maine 1985), and essentially provided in the clinics and maternities of missions, foundations and charitable voluntary groups. In contrast, maternal health care today has become a priority of its own in a context of reproductive health.

Perhaps more important, it has become a legitimate and explicit concern of many governments. This is in line with the emphasis on the development of the government-owned health services after the colonial period. The various crises developing countries underwent have led to conspicuous failures of governments to provide good coverage with care of adequate quality (Van Lerberghe 1993, Van Lerberghe & De Brouwere 2000). This has paved the way for appeals to “privatisation”. Privatisation has, for two decades, been a major item on the agenda of structural adjustment programmes in poor countries (Alubo 1990, Evans 1995). The World Bank, the World Health Organization and the United Nations Population Fund, all participated in developing recommendations on the role of the private sector in general and in reproductive health care provision (World Bank 1993, UNFPA 1999a & UNFPA 1999b): governments had failed, as the Safe Motherhood Programme pointed out, to address maternal health effectively.

Current conventional wisdom is nicely summed up in a paper in the World Report on Women’s Health 2000, a special issue of the International Journal of Gynecology & Obstetrics. Following the observation that programme approaches after the Cairo Conference on Population and Development in 1994 has shifted from largely government provision to “significant involvement of non-governmental organisations including the private sector”, the paper states that "NGOs have proven their capability to complement the efforts of government and to implement innovative approaches. NGOs have the following special advantages: flexibility of operations, relevance to the broader context of development, ability to innovate, and effectiveness at the grassroots for targeting services to disadvantaged groups, such as the poor" (Edouard et al. 2000).

There are a number of more or less explicit assumptions that provide a seemingly “rational” basis for the largely ideological blanket appeals to complement or substitute the provision of maternal health care by governmental services with services offered by “private” “non-governmental” providers and organisations.

First, private services are said to capture a significant and growing share of the service delivery market for maternal health care.

Second, they are assumed to provide their clients with more accessible and better services in terms of quality, effectiveness and efficiency.

Third, by doing so they are said to complement government services resulting in a more comprehensive and equitable distribution of the uptake of services.

This paper reviews the evidence-basis of these assumptions. Before doing so, however, it is necessary to revisit the notions of “private sector” and “non-governmental organisations”. Putting both in the same bag obscures the whole debate on privatisation, the supposed advantages of the latter becoming justification for the deregulation of the former.