Safe in their hands? Engaging private providers in the quest for public health goals

Abstract

In many low-income countries, private providers have long been a significant source of health care. (1-3) Private providers include individual practitioners, both formal and informal, working alone and in groups; (4) national and international nongovernmental organizations; and private companies providing health care for employees and their dependants. In some countries, private (or more accurately non-state) practitioners provide over 50% of ambulatory care in rural and urban areas. (5) Despite their importance in delivering services to vulnerable populations, they received only limited attention from policy-makers and researchers until the late 1980s. (6) This neglect--particularly of informal providers--was often reinforced by active opposition from formal professionals. There is growing recognition of their importance, however, and signs of a shift in attitude. While concerns remain about quality, effectiveness and cost, there is also interest in their untapped potential to help meet public health goals. Public sector managers, who are expected to ensure access to care and protect the public, have a duty to understand and engage with these various players. A number of governments have developed policies to define roles and relations with the private health sector, but these can prove difficult to put into practice. Funds for working with private providers are available from many international agencies. A wide range of approaches has evolved to influence consumers, providers and policy-makers. The scope of services targeted ranges from those for specific health priorities (e.g. HIV, tuberculosis, malaria, and reproductive health) to broader packages of essential services. (3,7) Many efforts exist on a relatively small scale, however, and are undocumented. Debate is often still rich in opinion and short on facts. (8) The following key questions remain. * Do private providers help to expand access to care for the hard-to-reach groups? * How can the safety and effectiveness of services be ensured? * Can privately provided services be affordable, cost-effective and genuinely pro-poor? * What does it take to sustain the involvement of private providers? * How can greater mutual understanding and trust be promoted? Two articles in this issue focus on some of these questions from the perspective of tuberculosis. (9,10) The article by Salim et al. (479-484), reports how informal village doctors in Bangladesh (a mix of semi-qualified and unqualified practitioners, drug vendors and traditional practitioners) became a resource in tuberculosis care on a large scale in rural areas. The article by Floyd et al. (437-445), reports on the cost--effectiveness of DOTS by private practitioners in two cities in India. Persuading private providers to deliver care for one disease is arguably easier than getting them involved in a larger bundle of services. Three essential points about what it took to get results are flagged here as they provide food for thought beyond tuberculosis care: organization; incentives, and the role of the public sector. …