Private for Profit and Private non for Profit

Not until the 1990s was it possible to discuss these problems in other terms than thatcherite or statist ideological statements. However, there is no such thing as a pure dichotomy between public and private sector. A first step that has helped was the public/private mix framework of the early 1990s (Table 1), that distinguished the functions of provision and financing of care.

Table 1. The 1990’s framework for analysing the public/private mix

A further distinction has to do with the mission of the non-state health care provision organisations (Giusti et al. 1997). Some have an administrative stewardship and/or institutional identity that results in a social perspective: non-discrimination, population-basis, guidance by government policy, non-lucrative goals, social advocacy (Box 1). These are what one indicates by “NGOs” strictu sensu. Others have profit as their raison d’être, rather than an agenda of public service. These are what one indicates by private sector strictu sensu.

The distinction is not always clear-cut (Van Lerberghe et al. 1997) and often a matter of judgement. In Dar Es Salaam, Tanzania, for example, a number of such NGOs providing reproductive health services are owned by private entrepreneurs whose affiliation with religious groups allows them to register as voluntary, and to benefit from favourable tax concessions. For all due purposes they function as for-profit organisations, NGO status notwithstanding (Kanji et al. 1995).

The blurring of the distinction between for-profit and non-for-profit is compounded by the different hats worn by individual providers. Private and non-governmental providers include large numbers of (on- or off-duty) government officials. This results in formal or informal sharing of human (Asiimwe et al. 1997, Ferrinho et al. 1998, Backström et al. 1997, Roenen et al. 1997, Damasceno et al. 2000, Mcpake et al. 2000), pharmaceutical (Asiimwe et al. 1997) and other resources between different “sectors” of health care provision, including, sometimes, “traditional” health care (Adam et al. 1997, Backström et al. 1997). Whether regulated and controlled or not officially acknowledged and “wild”, passive privatisation over the last decades has changed the picture of health care provision.

Even if it is difficult to make, this distinction has such consequences for service delivery that it is necessary to specify what we talk about. In this paper we use the terminology of private-for-profit (PFP) and private-non-for-profit (PNFP) organisations to distinguish those for whom profit is a dominant raison d’être from those for whom the accent is on delivering a service to the public. PFP then corresponds to the entrepreneurial private sector strictu sensu, and PNFP to what commonly goes under the label of NGOs, and may include family planning institutions, medical associations, universities and research institutions, solidarity groups, religious, international or locally based welfare groups, unions, professional associations and the proliferation of organisations in rather small communities.