|16. Is There a Case for Privatising Reproductive Health? Patchy Evidence and Much Wishful Thinking|
Surprising as it may seem, relevant evidence on differences in quality of care and of other determinants of health-seeking behaviour is hard to come by, even more so regarding reproductive health differentiated into the three segments being considered.
Two important determinants of treatment choices are the costs of health care alternatives (Young 1980) and distance from the health care provider. But regardless of distance to the provider, households in Africa or Asia chose their provider on the basis of the nature of the health problem and expectations of quality of care (Stock 1983, Colson 1971). These often counterbalance the effect of distance. Common wisdom has it that that patients would prefer private providers for reproductive health problems since these are supposed to dispense better quality care. This section reviews the patchy evidence for preference of private providers.
In urban areas, the reason to seek private healthcare is often one of accessibility and convenience. In Thailand, for example, opening hours are a major reason for people to choose private practitioners for ambulatory care. In rural Malaysia private services are more accessible in terms of their operating hours and the flexibility of their clinic schedules. All services are available during opening hours while in the public sector some services, such as ante-natal care, are available only at certain days of the week (Aljunid and Zwi 1997). In Mexico the 32% of women who chose the private sector for ante-natal care do so according to physical accessibility and to economic and organisational reasons (Ramirez et al. 1997). In urban areas the distribution of private providers may be more capillary than that of public services, such as in Dar Es Salaam, where they are geographically more accessible to most people (Wyss et al. 1996). In Egypt, although there are 3700 state family planning outlets, the 63% of women prefer private services, because they consider them more accessible, physically and psychologically (Amin and Lloyd 1998). This greater physical availability of private services may, sometimes, be politically motivated, creating a niche that it is then filled by the private sector, as was the case in South Africa in the 1980s (Frame et al. 1991, Ferrinho et al. 1990, Ferrinho 1995).
Perhaps their most visible comparative advantage of PFP and PNFP providers is their client-friendliness. In Alexandra, South Africa, the staff of a PNFP University Clinic were made to use name tags while on duty to ensure a better rapport with patients (Ferrinho 1995). In Thailand patients almost always know the name of their private doctor, but the treating doctor in public facilities only in one case out of two. When patients feel treated like a client rather than like a number, and they assume that this also translates into better clinical quality. The latter, of course, is prey to asymmetry of information.
Supply induced demand has resulted in an, infrequently mentioned, problem of iatrogenesis. The question of supply induced demand - exemplified in the epidemic of caesarean sections mentioned above - is one of a priori reasons to question the supposed better quality of the private sector, especially in the case of PFP providers. Iatrogenesis is likely to be a real consequence. In Brazil the epidemic of caesarean sections is responsible for a not insignificant proportion of maternal morbidity and mortality (Cecatti, personal communication, May 2000).
Overintervention is compounded by the tendency of PFP providers to specialise and deliver only part of reproductive health packages. This represents a second reason to question the supposed better quality of the private sector. The lack of integration automatically leads to sub-optimal care, as in Brazil, where the separation between fertility control and health care for poor women leads to totally uncontrolled and incorrect use of oral contraceptives, resulting in unwanted pregnancies, illegal abortions and clandestine surgical sterilisation (Giffin 1994).
Infrastructural quality may be better in the private sector than in the public sector. In three districts of Tanzania, for example, infra-structural quality was fair in the voluntary and private dispensaries but tended to be poor in the public ones. The private dispensaries also employed more doctors than the PNFP and the public sectors (Ahmed et al. 1996). But this does not mean that not-public does not always mean better clinical quality, even if one makes abstraction of over-medication and iatrogenesis.
In a large proportion of PNFP consultations care was potentially dangerous or outside established clinical practice. A study in Dar Es Salaam, Tanzania, suggested better clinical performance and interpersonal conduct and overall user satisfaction for PNFP providers as compared to government providers. Despite better performance, however, in a large proportion of PNFP consultations care was potentially dangerous or outside established clinical practice (Kanji et al. 1995). In urban Nigeria curative and preventive STD services provided by formal and informal health sectors were substandard. The informal sector (traditional healers and patent medicine dealers) was particularly problematic, as many of the practitioners in this sector provided inappropriate STD treatment and preventive services. By contrast, the formal treatment sector (private and public doctors, pharmacists and laboratory technologists) provided appropriate STD treatment, but they demonstrated substantial inadequacies in several areas. In particular, the private sector and public doctors lacked appropriate diagnostic tools. Many of these doctors were also not familiar with the appropriate treatment protocols, did not include counselling and contact tracing in their care procedures and lacked adequate channels of referral (Okonofua et al. 1999). In Alexandra, South Africa, many women booking for ante-natal care at a PNFP NGO providing comprehensive PHC, had previously booked at local GP in private cash practices. Most of the GP failed to conduct ante-natal laboratory screening. They kept patients as ante-natal care clients, only to refer them, near term, to the labour unit of the local PNFP provider, without any referral note (Frame et al. 1991, Ferrinho 1995). This type of predatory behaviour by the private for profit practices, is also not conducive to efficiency claims (Ferrinho 1995). Other data from South Africa suggest that PFP-GP offering STD care were providing a low standard of care. STD were a common reason for acute curative care but the management was mostly syndromic, little use was made of diagnostic resources which were readily available, and the therapies chosen were not the most correct considering the local epidemiological profile (Frame et al. 1991, Coetzee et al. 1994, Ferrinho 1995, Schneider et al. 1999 ). In rural Malaysia, in the public sector, new family planning clients were given a physical examination, a cervical smear and contraceptive advice. Oral contraceptives were given only to those below 35 years of age and their blood pressure was checked during follow up. In the private sector new clients were not usually screened and cervical smears were done only at the patients request. Women taking oral contraceptives could buy them without seeing a clinician. Although STD treatment was provided at the private providers, they were not equipped to handle an anaphylactic shock in reaction to administration of an antibiotic (Aljunid & Zwi 1997).
The claim for greater efficiency is not based on empirical evidence. This claim often merely refers to a higher efficiency per output unit, not per outcome unit. For example, contracted hospitals in South Africa have lower production costs than district public sector hospitals for caesarean sections and normal deliveries. But this was associated with higher perinatal mortality and more avoidable factors in the contractor hospitals than in the public sector hospitals (Broomberg et al. 1997). At times, one definitely gets the impression that efficiency is defined, not in terms of getting most value for money, but in terms of the possibility of running a service on basis of cost-recovery. For example, Potts and Walsh organisations such as FEMAP in Mexico and Marie Stopes International in Asia, Africa, and Latin America, are developing comprehensive clinics for family planning, maternal and child health, the running costs of which can be wholly or largely recovered from user fees. Such clinics still require capital for start-up costs, but they have great potential, and non-governmental and international donors should explore provision of the needed capital as a cost-effective way of fulfilling the government mission to take services to the poor (Potts & Walsh 1999). Apart from the fact that this affirmation still needs to be explored [in three Tanzanian districts, for example, PFP dispensaries had a lower output of treated outpatients than PNFP and public dispensaries, although their equipment was superior (Ahmed et al. 1996) this defines cost-effectiveness in terms of shifting the burden to the client.]
Obviously resources make a difference. An under-funded public service without drugs, equipment and adequately trained and paid staff will not provide as a good a service as a well capitalised private one. In Bolivia, injectables are only available in the private sector and access to public sector provided tubal ligation is difficult: this obviously drains people away from the public facilities (WHO 1998).
If resources are adequate and the range of services comprehensive, the quality and efficiency comparison hinges on the (visible) productivity and client-friendliness of the staff, and on the (invisible, at least to the patient) justification of the care. Some of the evidence presented above justifies a cautious claim that PFP providers may be less efficient than PNFP or public providers, in as much as they can shift the risk and the consequences of their inefficiency to the client. On the other hand, the evidence does not allow for conclusions regarding the efficiency of PNFP providers. But it is not the public or non-public nature of service provision that makes the difference in quality and efficiency.
The complementing assumption: of filling gaps, occupying niches and poaching.
The third assumption underlying the calls for privatisation is that by ensuring uptake of services PFP and PNFP providers complement government services and ensure a more comprehensive and equitable distribution of the uptake of services.
The word complementarity is seductive. The private sector would indeed contribute most to equity in situations where public and private sectors are complementary. The public sector would act as the first mover and choose its level of investment in the health sector. The private sector would then observe the level of public investment and would invest to meet the residual demand. This in turn would allow the public sector to make the most of its limited resources, whilst still responding to its political responsibility of delivering care to its population (Hanson & Berman 1998). Such a planners heaven assumes a rational, wise and well-meaning private sector, that makes the public agenda its own. This ignores institutional logic and conflicts of interest.
The empirical evidence suggests a scenario of substitution rather than complementary (Hanson & Berman 1998). In the best of cases this means filling the void left by failing public services. In South Africa, for example, private cash practices and PNFP services tend to emerge in areas of State neglect, namely the large sprawling peri-urban squatter areas (Ferrinho 1995) where, many times, they were the only providers of reproductive health care. Often, however, it becomes a reality of competition and poaching.
A two-tier health care system is emerging. This is true in some African countries, as for example in Tanzania, with private care for the wealthy and public services for the poor (Wyss et al 1996). The poor are more sensitive to price than the wealthy (Gertler et al. 1987). All this would not be so bad if this allowed the State to redirect its resources and the poor could then get good health care at an accessible price. In actual fact this happens only seldom. Quality in public services does not improve readily, and the price of health care in public facilities is not so low as to compensate for the perceived differences in quality.
Although, in some countries like Kenya (Mbugua et al. 1995) and South Africa (Ferrinho 1995) antenatal services and family planning services are exempted, reforms have almost systematically introduced user fees for many health services, including reproductive health services. It is known that user fees may force low-income users out of the public health care system and even out of the modern health care system (Yoder 1989). For example, in Tanzania (Demographic and Health Survey 1991 and 1996) and Kenya (Mbugua et al. 1995), deliveries in health facilities dropped by at least 12% after cost-sharing measures were implemented. These fees, and most of all the informal charges demanded by health workers for delivery care, like in Uganda (Asiimwe et al. 1997), take away the main perceived comparative advantage of public services, their low price. One consequence is a shift of patients to commercial self-treatment. In Gaza reproductive health problems (infertility, urogenital problems and contraception) are the third most common (the first for women) reason for purchases in private pharmacies (Beckerleg et al. 1999). In some African and Asian countries unprescribed purchase of STD treatment in private pharmacies is quite common (Kloos et al. 1988, Crabbe et al. 1998, Okonofua et al. 1999, Phalla et al. 1998).
Some see difficulties of accessing the public sector as a necessary stimulus to ensure that the PFP sector gets more involved into the provision of reproductive health care. For example, encouraging commercial family planning services for people who are able to pay is said to be one way to improve services for those who cannot pay, releasing public resources to be used more effectively to serve lower-income clients (Anonymous 1994). Unfortunately, there is no hard evidence that this is a normal course of events, certainly not without a proactive policy.