Non-state sector private providers of health services dominate health systems of low-income countries. The poor are likely to use informal, illegally practising private providers. Yet, the quality of these services tends to be very low. How can health service delivery be improved in the non-state sector? Can the informal sector be brought into an overall public policy net?
In addressing these questions, this paper from the DFID November 2002 retreat reviews what is known about how health service delivery might be improved in the non-state sector. After pointing out what the non-state sector in low income countries consists of, and why it should be of concern to policy makers, the paper reviews interventions on demand and supply, as well as approaches which seek to restructure market relationships. Training and investment in a stronger formal sector, both private and public, and restructuring the market so as to strengthen the purchasing and regulation functions of government, may displace the informal sector, but this is likely to be a very long term process.
In many countries, the boundaries between state and non-state actors are blurred, since the same individuals may work in both, and public premises may be used for private gain. While some providers offer services of good quality, many are of poor quality, especially at the more informal end of the market, and deal inadequately with diseases of public health importance. This situation results form the interaction of consumers and providers. Other findings are:
- There is a fair amount of experience in working with the non- state sector in low-income countries to improve performance but very little information on how to influence consumer behaviour and the restructuring of the market
- Social marketing and targeted distribution vouchers are two approaches that can be used to support consumers. Yet, evidence is lacking in other measures to influence consumers in their interactions with the healthcare marketplace
- From the supply side, enabling and reinforcing strategies (for example, combining patient education with interventions to improve provider knowledge and skills) are more effective than those focusing only on providers
- Using less well qualified providers and drug retailers in government-approved programmes requires building stakeholder support to overcome or neutralise the opposition of powerful professional organisations
- Training and investment in a stronger formal sector and restructuring the market so as to strengthen the purchasing and regulation functions of government may displace the informal sector, but this is likely to be a very long-term process.
Policy implications include the need to:
- Consider combining a range of approaches in working with private providers, rather than relying on single strategies
- Regulate the non- state sector both in the sense of legislating and administering formal rules, and also by intervening to alter the incentives available to private sector institutions and thereby their activities and performance outcomes
- Make judgements on the relative return to investment in improving non-state sector activities as opposed to investment in a strengthened public sector
- Identify products that can safely be delivered through the retail sector
- Develop targeted programmes involving a package of social marketing, provider training, product packaging and subsidies, consumer information, and monitoring.
