|16. Is There a Case for Privatising Reproductive Health? Patchy Evidence and Much Wishful Thinking|
|A Large and Growing Share of the Market|
The first assumption has it that private providers capture a significant and growing share of the service delivery market for maternal health care, and ensure an important part of the uptake of services. This is certainly correct for health care in general. For a sample of 40 developing countries, a sample average of 55% of physicians worked in the private sector and a sample average of 28% of health care beds were private beds (21% private for profit) (Hanson & Berman, 1998). In Asia, for example, the percentage of private hospital beds ranges from 22 to 77% in six countries, and their share is growing (Newbrander & Moser 1997). The assumption is probably also basically correct for maternal health care. Nevertheless, actual documentation supporting this statement is scanty and patchy. There are wide differences between and within countries. Also, much depends on what maternal or reproductive health activities one considers: overall the market share is smaller for inpatient than for ambulatory care, and limited for preventive and public health services (Hanson & Berman 1998).
Box 1. Setting up gender-sensitive practices (Doyal 1996)
At the heart of all feminist critiques of medicine is the recognition that women lack power in health care institutions, limiting their ability to determine priorities and allocation of scarce resources. In this context, in some countries women have set up their own health centres.
In Britain very few services have been created outside the mainstream. This reflects in part the limited market for private care when it is available in the National Health Service without direct cost. But there is also a political reluctance to offer services that many women could not afford to buy. In the United States, the 1970s and early 1980s saw a proliferation of womens health centres offering reproductive care and a range of other services. Womens health centres have been most successful in Australia. This reflects the priority they have been given within the Australian Womens health movement and their subsequent incorporation into the National Womens Health Policy. Though the women involved continue to grapple with the contradictions inherent in any attempt to use state funding for radical initiatives, health centres in Australia do offer important examples of gender-sensitive practice for other health care providers.
In developing countries, womens health centres are not an alternative to the formal system of health care but very often the only option for care. The Bangladesh Womens Health Coalition now runs ten projects providing both reproductive and general health services for women and children. In Peru, Centro Flora Tristan and Vaso de Leche have worked together to create an integrated health service for women living in Lima. In Brazil, an alliance between the Ministry of Health and activists in the Womens Movement led to the creation of the Comprehensive Program for Womens Health Care. In Colombia, women have been able to go to a stage further with the implementation of a national women and health policy.
Moreover, the few data available usually fail to distinguish between PFP and PNFP. For example, the analysis of the data from the 1988-90 Demographic and Health Surveys programme in 11 countries could only classify providers in public, private (including pharmacies) or others (traditional healers, schools, churches, families and friends). Even so, there were large variations: in Morocco and Tunisia 48,2% and 25% of ante-natal care was private, but only 4,6% and 4,2% of delivery care (76,5% and 31,7% were home based). Private sector providers were the source of family planning in 7% of cases in Botswana, 21% in Morocco, 22% in Tunisia, 28% in Kenya, 36% in Sudan and 44% in Uganda (Berman & Rose 1996).