Private health care in developing countries

Editor—Zwi et al in their editorial suggest means by which governments in developing countries should try to harness private providers to improve the health of their citizens.¹ A recent article by Whitehead et al, however, points to a medical poverty trap, created by the introduction of user fees for public services and the growth of out of pocket expenses for private services.² The authors conclude that the main challenge in developing countries is to improve public health services and enable the poorest sections of society to obtain the health care they need.

India has experienced a massive growth in private health provision despite high public investment in health services. Several studies have shown that there is a marked reluctance to use free facilities even among the poorest sections in Indian society. For example, a study of health and health care among scheduled castes showed that 38% sought private medical help when their children became ill, compared with 28% for government health facilities.³ Another study, which focused on the urban poor in Calcutta, concluded that public health facilities were used for emergency purposes but there was a preference for private practitioners for all other types of care.³ The implication of these studies is that access cannot be equated simply with supply but is dependent on locational, economic, and social access, as well as the quality of the services themselves.

At the same time as trying to make public services more responsive it is vital that resources are used efficiently in areas that maximise health improvement. At present, in India, over half of the health budget is spent on secondary and tertiary curative services, whereas better health outcomes could be achieved by investing in preventive measures. The emphasis on private healthcare provision may serve to distort these priorities even further.