Prohibit, Constrain, Encourage, or Purchase: How Should We Engage with the Private Health-Care Sector?

This chapter, originally published in The Lancet and titled “Prohibit, Constrain, Encourage, or Purchase: How Should We Engage with the Private Health-Care Sector?” sets out a framework for understanding how governments and donor agencies can, and should, work with or regulate the private sector. Authors Dominic Montagu and Catherine Goodman set out the context of the private for-profit sector’s prominence in healthcare delivery, concerns about its failures to deliver social benefit, and the resulting search for interventions to improve the sector’s functioning. From that starting point, the chapter reviews the evidence for the effectiveness and limitations of such private sector interventions in LMICs and sets out a framework for defining the focus of different interventions.While few robust assessments are available, some conclusions are possible. Prohibiting the private sector is very unlikely to succeed, and regulatory approaches face persistent challenges in many LMICs. Attention is therefore turning to interventions that encourage private providers to improve quality and coverage (while advancing their financial interests), such as social marketing, social franchising, vouchers, and contracting.Evidence about the effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate for generalizations. While interventions have been effective in many instances, for example, in addressing a number of specific, focused problems related to cost, access, efficiency, and quality on a restricted scale, challenges remain concerning scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage.