Private Sector: Here, and Here to Stay

In this chapter, Dominic Montagu provides the opposite context: exploring what is known about the providers who deliver services in LMICs. As the chapter title states, “Private Sector: Here, and Here to Stay.” Private sector healthcare providers, in all but the most dysfunctional failed states, function within a health system that is measured, regulated, and policed. This chapter sets out, in brief, the ways in which governments think about the private sector, categorize the different parts of it, and regulate it (well or badly). This is, in turn, influenced by clear trends in market functioning, which drive how different components of the private sector function.There are a few rules of thumb which hold true in nearly all countries. Products – medicines, self-administered test kits, and beauty products – are all more likely to be sold by private providers than public providers. These might be shops, drug vendors, patent-medicine sellers, chemists, or pharmacies, depending on the product and the country, but the source will almost invariably be private.Ambulatory care is more likely to be private than public. That’s particularly the case with dentists and non-clinical specialists (psychiatrists, optometrists, etc.), but it is also true for primary care doctors. In most LMICs, most primary care doctors work in solo practices, and while they might have a “day job” in a government facility, most of their time is spent in their private clinics, and most of their income comes from that after-hours private practice.Hospitals, by contrast, are likely to be public in most countries – subsidized by governments, absorbing a large portion of the national health budget, and being a visible indicator of public healthcare assurance. Uncertain regulations and duplicative or complex subsidies (i.e. hospitals sometimes pay for infrastructure from on budget, salaries from a second budget, and consumables from yet a third source) make public services likely to be continued even when questions about their comparative advantages over the private sector exist.In financing and in oversight, government attitudes toward the private sector influence what services are delivered where, to whom, and by whom. The framing of this chapter sets the scene for the following case studies.