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Inequalities can result in barriers to good health and unacceptable differences in healthcare. In this blog post, Dominic Montagu, professor of epidemiology and biostatistics at University of California, San Francisco, discusses the research carried out by he and his co-authors, Lauren Suchman and Charlotte Avery Seefeld. Compelled by the importance to better our understanding of the drivers of inequality and the potential changes within health systems that could mitigate inequity.

I began working in international healthcare by accident. I was an architect working in Paris and was hired by a Non-Governmental Organisation, Architectes Sans Frontieres, to design the renovation of a pediatric hospital in Vietnam. Inspired by that, I studied management and public health, and a few years later returned to Vietnam, first as the country director for an organization focused on rural development among the poorest citizens, and later as a researcher at the Population Council. One study on family planning that we did while I was with Pop Council showed that in 1997, only a year or two after private practices were legalized, nearly 1/2 of women in urban areas were getting their family planning from private providers. I wondered why. 

Those experiences led me to my current areas of focus: on private healthcare, on equity and care distribution. My coauthors came to this work with significant experience in the study of quality and access based on US healthcare, on sexual and reproductive health in India and Africa, and on HIV/AIDS services. They have seen in those other locations and fields how inequity in access translates to unacceptable differences in health outcomes. We feel strongly that it is important to better understand drivers of inequity and the potential changes within health systems that could mitigate inequity. 

Disparities in health care choice

First off, many of the disparities are both between wealthy and poor and between urban and rural.  Hospitals, clinics, pharmacies, maternity centers, and laboratories are all more likely to be in urban areas, serving populations that are both numerous and wealthy. So, the poor get worse care and worse access to care than the wealthy, and the rural poor have the double handicap that comes from lacking wealth and population density.  

It is important to recognize that this observed disparity in both availability and choice is the result of both logic (an urban hospital can serve more patients than a rural one) and market economics (if more people go to the urban hospital, maybe it gets electricity, or an updated x-ray, or a full-time Ob/Gyn, while the rural hospital with fewer patients does not).  Recognizing both of the drivers of disparity is important, because while it’s not possible to change the logic of demographics, it absolutely is possible, and should be a priority for governments seeking to serve all citizens well, to work to correct for the inequities caused by market economics. 

When compared to the wealthy, poor people in countries around the world are more likely to fall ill, less likely to seek care when sick, less likely to receive care when they seek it, and less likely to get good quality care if they are treated. The results can be seen in everything from attended delivery rates in Nigeria, to Covid-19 mortality rates in the United States.

The pros and cons of the private sector

There are large questions in the study of health systems about when and how the private sector is a good or bad thing.  When does it complement the public sector, and when does it compete with the public sector? When does it mean more supply, better access to care, and better quality; and when does it mean unregulated care that is exploitative and does nothing to improve health? 

There is evidence that the private sector is entrepreneurial and so often available in the form of drug stores, clinics, or maternity centers, when government facilities are non-existent. There is evidence that private providers in some countries deliver better quality than government providers. And there is matching evidence that fees are high, that quality is variable, and that private providers may serve the poor, but that they are strongly biased towards serving the wealthy. 

All of these issues could be addressed by a mix of quality assurance with providers and so-called third party-payer systems (insurance of some kind) which control prices and make all patients equally attractive to providers. In 2013, a large and complex initiative set out to test an integrated approach to improve both quality and financing issues in Ghana and Kenya. Both countries have strong and widely distributed private health provider coverage and growing national or social health insurance schemes that are open to working with private providers. It seemed a perfect opportunity to study these issues.

Why are patients choosing private providers over public facilities?

The four reasons identified in our study are similar to those found throughout the literature on health seeking behavior:

1.   Convenience – distance, opening hours, wait times. These things matter a lot. In most countries there are more private providers than public, they are less crowded, closer to where people live, and open much longer hours than government facilities. A study in the Kibera slums outside of Nairobi a few years ago found 70 private clinics and only one government clinic.

2.   Efficiency and Predictability – opportunity cost due to travel, waiting times, and lost wages often outweigh the out-of-pocket costs of care. For the poor who cannot lose a day’s wage, the opening hours of many government clinics can be an impossible barrier to seeking care. Knowing that care will be available, knowing that providers will be quick, attentive, and responsive, makes a great difference to many people when they look for care.

3.   Quality – sometimes people go to the private sector for the best clinical quality (Aga Khan Hospital in Nairobi; Apollo Hospitals in New Delhi) but sometimes the private sector is preferred because of ‘perceived quality’: private providers have been well documented to spend more time with patients, ask more questions of them, and be more responsive to their preferences. We note that listening to patients is a part of quality, but that it may not make a difference to clinical outcomes.

4.   Empowerment – Being able to choose where to go matters to patients. A quick trip to a pharmacy for aspirin. A short visit to a nearby private clinic to have a cut looked at. A longer trip to a public hospital for a feverish child to be examined. Choice is a form of empowerment for many patients. 

Note that some of these reasons, in particular predictable clinical quality, are also given as the reasons many patients choose public facilities over private as well. So, there is no one-size-fits all answer, but many factors influence these decisions.

The cost of ‘free’ care

In addition to the attractions noted above I would add that the poor often go without care because of costs: ‘free’ care offered in government clinics may not really be without costs if drugs are not available in government clinics, if the travel is far and expensive, or if the wait times can take a day or more and so the result is lost wages.  

Transforming healthcare

National health insurance, if well-funded and widely implemented, will be the defining change to health care in many, many low and middle-income countries. Whether or not a country has large numbers of private providers is largely based on path-dependency: health systems evolve slowly and if a country – India, Bangladesh, Ghana, Egypt, Brazil – has many private providers, private hospitals, and private specialists today, it will have many private providers, hospitals, and specialists tomorrow. 

Knowing that, the key to achieving Universal Health Coverage for many countries will be to integrate private sources of care into an equitable national delivery system.  A high level of centralized financing of healthcare is the way to make this happen. With national health insurance a central source of financing for all providers, issues of equity, quality, and access can be addressed by the central administration because an effective lever of control will now exist to put forward and insist upon standard rules applicable to all providers. 

National health insurance is key to allowing policy responses that counteract the failings of market-based health care (poor clinical quality, urban bias, excluding large numbers of the poor because private care is un-affordable and public care is in-accessible). The experiences of many OECD countries have shown that when national health insurance systems are strong, high quality and equitable care can be assured whether delivery is private (Belgium, Netherlands), public (UK, Ireland), or evenly split between the two (Germany, Italy).  

Increasing access and equity

Our study shows that facilitating access to private providers as one component of a larger health system can serve the needs of many people, and in particular can increase access and equity. Experiences from Europe and beyond show that an integrated delivery system is in no way antithetical to equity or quality or achieving universal health coverage. Policy makers should be encouraged to advance national health insurance in order to integrate public and private delivery effectively. This can be a viable, effective, highly-popular, way of improving care across the whole health system, serving all income levels and all geographies.

Why publish your article on Gates Open Research?

It matters to all three authors that our work be widely read, be understood to be credible, and be accessible to everyone. Gates Open Research is fast, transparent, and free. For a study on equity, what else could we ask?