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[afro-nets] Private healthcare in poor countries

  • From: "Massimo Serventi" <Ser20@hotmail.it>
  • Date: Thu, 6 Jan 2011 15:25:35 -0800

Private healthcare began entering developing countries in the 1990s, when healthcare systems of many poor countries were “convinced” to reduce public expenditure and to introduce forms of payments for the users of healthcare services (user fees).


In Nyala (Darfur), where I am working, Private Healthcare (PH) is very popular. Nearly all physicians work privately as well as in the public sector. Within the city public hospital there is a private facility that provides a service of medical advice, a sophisticated laboratory and an X-ray facility with CAT scan service. It is owned by the previous governor of South-Darfur and the same specialists of the state hospital work there.

The “in-Sudan-you-pay-for-everything” trend concerns services that should come free. Pregnant women often pay for their Pregnancy Health Card and iron/folic acid capsules. The baby is nearly always delivered at home (80%), where the well-off have a trained midwife or the less well-off have a TBA. A referral to the central hospital will cost €30, plus the cost of infusions and/or medicines. Children (under five) pay 30 cents per visit, the prescribed drugs must then be purchased. Only vaccinations are free of charge.


For the documentation of this article I searched the Internet under ‘private health care in poor/developing countries’. You can find everything, those who write in favour of it [1,2,3] and those who write against it [4], while others analyse the current situation and refrain from any specific judgment [5].

Some conclusions appear to be fairly shared :

1. PH is clearly expanding in the world. In 2005, 60% of the funds spent on health care in Africa was spent on PH. In China, 5 years after the reforms that opened to PH, vaccination dropped by 50% and diseases such as TB, measles and polio began to spread again. There are also marked inequalities: in Paraguay, 5% of physicians work in the private sector, while in Korea 86%. Costa Rica has the lowest percentage of private beds, while the highest is in Korea. Lebanon, whose private coverage is one of the highest in the world, spends more than twice as much as Sri Lanka on health care but achieves worse results in terms of child and maternal mortality. Chile has a largely private healthcare service and one of the highest rates of births by Caesarean section in the world.

2. Achieving a clear separation between public and private is not easy: there is a lot of intertwining between the two sectors and definite data cannot be achieved. Every year, WHO publishes data on physicians, nurses, paramedics, hospitals and beds in State-owned services, but no figures refer to private services. Many physicians around the world work in both the public and private sector. In general, Latin America has the highest percentage of exclusively private physicians, Africa the lowest.

3. The expansion of PH, of its influence on public healthcare and its implications on people’s health does not seem to attract the interest of observers and policy makers.

4. It appears that PH proliferates in proportion to the economic growth of a country. This applies more to the number of private physicians than to the number of private beds (there are more public beds). The level of urbanization has a positive correlation with the expansion of private healthcare, also due to employed people in cities having some forms of healthcare insurance. The same applies to the level of education and life expectancy: in those societies where these values are higher, private healthcare is more used. And also, countries with low child mortality use private services more. As to physicians, where there is better public healthcare there are fewer private physicians, while the same correlation does not hold true in terms of the number of beds.

5. PH is very much present in outpatient clinics and less in hospital beds, which means that there are many private outpatients services while hospitals are more likely to be public. This is particularly true of Africa.

6. Private Healthcare began propagating in developing countries in the
1990s, when the World Bank and other international organizations stated that the healthcare systems of very many poor countries were a failure, and they were ‘convinced’ to reduce healthcare expenditure (especially by means of draconian cuts of hired staff) and to introduce forms of payments for the users of healthcare services (user-fees). In 2007, the World Bank, together with the Bill&Melinda Gates Foundation and McKinsey^Co produced a report “The Business of Health in Africa: Partnering with the Private Sector to Improve People’s Lives” and announced a plan of investments and loans (1 billion USD) to finance the growth of the private sector in Sub-Saharan African Countries [1].

Arguments in favour were as follows:

• private medicine is already very much developed: excluding it is unconceivable so it must be regulated and involved in the provision of healthcare services

• investments in the ‘private sector’ would bring money also to the poor public coffers

• the private sector offers better results at lower costs: it is less corrupted.

Against these statements it is worth noting Anna Marriott’s from Oxfam[4], who (the only voice against it) countered one by one all points favouring the propagation of the private medicine. Her conclusions are: “The private sector will continue to exist and offer potential benefits that must be capitalized. But there is no doubt that in order to ensure fair and universal access to healthcare treatments, the public sector must play a primary role. The public sector must be supported and given the opportunity to function well: this is the most effective approach to reduce PM proliferation and influence”.

Personal remarks.
Paediatrician with 28 years work experience in 4 African countries (Tanzania, Uganda, Mozambique and Sudan) and 2 Asian countries (Sri Lanka and Afghanistan).

1. PH is very much present in outpatient services, where children are the most numerous patients accounting for more than 50% of visits. The paediatrician is therefore more ‘interested’ by this aspect.

2. PH is not ‘neutral’: in other words, it is better if it is available
since more care does not hurt anyone. In fact, since it is connected to profit, an outpatient clinic for children must prescribe more to justify to the mother the cost of the service and to receive money from the sale of drugs and laboratory exams (which are often sold in the same outpatient clinic). This applies also to the ‘religious’ outpatient clinics that only request a minimum payment (because they can often get medicines free of charge) but which must always prescribe a drug. In any case, the mother had to pay for a ‘disease’ that perhaps might have been ‘treated’ by means of simple, cheap remedies such as rehydrating salts (diarrhoea), drops of water in the nose (rhinitis), Paracetamol syrup (viral fevers, the most frequent) or simple food recommendations. Prescribing and selling expensive drugs (antibiotics) to children that do not need them is like depriving their mothers of money they could spend on food, and this is even worse in those places where the most frequent cause of death is child malnutrition.

3. Profit making, and also ‘missionary-for charity’, PH drains healthcare staff from the reservoir of the State Healthcare Service (HS), that is , it deprives the health service of valid people, often taking them away from country areas which are poorly served. This development also affects staff hired by international NGOs: WHO recently drafted a code of behaviour with the aim of regulating this issue and reduce the drainage of healthcare staff from State-owned facilities [6].

4. The goals regarding healthcare (MDGs) can be achieved without the action of PH. Child mortality has and is being decreased by actions that do not pertain strictly to healthcare and treatment (vaccinations, public hygiene, water, nutrition, healthcare education). Mortality among babies and the benefits of safe pregnancy and delivery and the early identification of the first signs of sepsis in the newborn, certainly do not get any help from the private sector. Private fac ilities for safe deliveries are almost always in the cities and they serve the richer classes in the population. Pregnancy monitoring, family planning, prevention of sexual diseases including AIDS, TB treatment and control, distribution of treated mosquito nets are all actions that pertain to the public domain. True, malaria treatment and prevention also gain benefit from drugs and mosquito nets sold on streets.

5. Private pharmacies appeared years ago in the cities, and now they are expanding into the outskirts: they are a safe source of income. They must be subject to government rules but in fact they work in full ‘autonomy’ and ‘deregulation’. Given their constantly increasing number, we can be certain that there are no pharmacists behind the counter. They are filled with all sorts of drugs (whose quality is uncertain and rarely ascertained) and OTC products. In Afghanistan, the outpatient clinic has a pharmacy attached: first they prescribe the medicines and then they sell them. OTC products are of all sorts, from herbal teas to carbonated waters for babies with colic to ‘tonics and appetite stimulators’ for children (very popular in India). The world production of useful drugs for poor countries has not yielded any positive results so far [7]. Here in Nyala, in the very many private pharmacies, products to lose weight (!), sachets of seaweed salt and pills, multivitamins and ‘tonics’ are displayed prominently (and therefore used). These ‘drugs carry along with them’ other ‘luxury’ products, for example formula milks which in Afghanistan are easily prescribed at the first sign of a problem with breast feeding. UNICEF initiatives: ‘exclusive breast feeding for 6 months’ and ‘breast feeding for 2 years’ lose their meaning in cities where formula milks are sold and any type of OTC drugs ‘useful’ for the child’s health.

6. Non profit hospitals are the most popular form of private sector in Africa. The mission expressed by these hospitals is peculiar: offer services to poor people that they do not get from public facilities. In fact many of them have become private clinics where every service is paid, including paediatric visits and deliveries. One example is the Aga Khan hospitals. Many others have gone from initial support from Europe that would have allowed them to keep fees fairly low, to a gradual fund reduction. To survive, many centres have been obliged to raise their fees, make patients pay all sorts of services and finally select patients on the basis of their income. Attempts to pay overheads by means of good quality specialist clinics failed: in reality it is sufficient that the specialist (usually a European) returns home for the specialist clinic to be closed down.


PH exists and is expanding, in the wake of global liberalism that permeates the whole world, including poor countries. The World Bank that triggered this process years ago is now reconsidering it [8]. PH has almost no influence in achieving the MDGs and PHC values [9]. I believe it cannot be regulated and/or involved in a process of global and fair healthcare; the aim of achieving profit results in an implicit conflict of interests: more health for people (today) means less money (tomorrow). Hence the absolute lack of any type of prevention supported by PM. Children and pregnant women, who are the most vulnerable population groups, are also the least ‘treated’ by PH. Or rather, …. children are treated, but badly, without respecting WHO guidelines, with drug abuse and misuse. Types of healthcare insurance are in their early stages and only relate to very narrow bands of the population who are already privileged. Farmers, who account for 70-80% of Africa’s population, certainly do not have healthcare insurance. Methods of contracting out, that is, assigning PHC services, or service packages to local NGOs, are interesting: in Afghanistan I saw them function well, though my experience was limited.

Massimo Serventi, paediatrician.