The ability of public and private sectors to contribute to more equitable population coverage
It is clear that the private for-profit sector concentrates on providing urban-based care, especially as it expands into the upper levels of the health system. In South Africa, 45 per cent of public hospital beds and 63 per cent of private hospital beds are in metropolitan areas (Price et al. 1993). In Nepal, 100 per cent of private for-profit hospital beds are in the more urbanized Central and Western regions compared to 67 per cent of government hospital beds (Olsen and Gurung 1993). In Ghana, 53 per cent of private hospitals and clinics are in the two main cities of the country and one-third of maternity clinics are in Accra (Adusei and Dakpallah 1993). In Papua New Guinea, the private sector accounts for only 9 per cent of health expenditure overall, but approximately 30 per cent of outpatient attendances in Port Moresby (Thomason 1993). In Thailand, it is noted that private facilities are highly concentrated in urban areas (Nitayarumphong and Tangcharoensathien 1994) and even when the rural population use hospitals in urban areas they are far more likely to use public hospitals than the urban population (Pan-narunothai and Mills, this volume). In contrast, mission facilities in Zambia serve rural populations far more than the public sector to the extent of having only 12.5 per cent of beds in the three most urbanized provinces which account for 46 per cent of the country’s population (Berman et al. 1995a). This is not always the case for mission facilities in other countries. For example, in addition to the concentration of for-profit hospitals in Nepal mentioned above, 92 per cent of mission hospital beds are also in the more urbanized Central and Western regions (Olsen and Gurung 1993).
It is often assumed that the private sector serves upper-income groups only but this is not uniformly the case. The formal private sector does seem to rely on upper-income groups for its initial growth but, as it grows further, relies on being able to capture middle- and lower-income group markets. The small private sector in Papua New Guinea is predominantly used by upper-income groups but a significant proportion of users (9 per cent) have more moderate incomes (Thomason 1993). Rannan-Eliya (1996) suggests that the process by which the private sector grew in Sri Lanka involved the increasing desertion of the public sector by higher-income groups in response to perceptions of quality of care differences between the two sectors. In Bombay, where the private sector has overtaken the public sector in size, Yesudian (1993) notes no class gradient in the users of services from different sectors. More disaggregated analysis may well have revealed differences, however. Lower-income groups are first able to purchase private health services at lower levels of the system. Thaver (1996) describes the phenomenon of private for-profit providers whose services are exclusively oriented to poor slum-dwellers in Pakistan. Nitayarumphong and Tangcharoensathien (1993) show that in Thailand, farmers and miners use private hospitals very little (for 1.1 per cent of illness episodes), private doctors somewhat more often (6.7 per cent) but mainly self-treat (57.8 per cent) which often involves use of drug shops. About 30 per cent of the lowest income decile use drug shops whereas only 18 per cent of the highest income decile do so. Price et al. (1993) also distinguish between the types of private health services purchased by different income groups in South Africa. Middle- and upper-income groups are enrolled in medical aid schemes which entide them to private health care at all levels of the system. Poorer black consumers make out-of-pocket payments for private medical care at primary level but use the public sector for specialist hospital services.
In pattern I type of health systems where the formal private for-profit sector has hardly yet developed, the users of unqualified and unregistered private doctors and pharmacists who often rely on undercutting the public sector in cost terms, and on lack of information about the quality of their products, are more likely to be poorer groups. However, the poorest and least powerful groups may still fail to access services at all. For example, Feldman (1983) argues that the costs of the public and private, qualified and unqualified, allopathic providers of rural Bangladesh lead to the exclusion of rural women.
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