The role of private providers in maternal and child health and family planning services in...

HEALTH POLICY AND PLANNING; 11(2): 142-155 © Oxford University Press 1996

The role of private providers in maternal and childhealth and family planning services in developingcountriesPETER BERMAN1 AND LAURA ROSE2

1 Harvard School of Public Health, Boston, USA and 2The World Bank, Washington DC, USA

This paper uses data from the Demographic and Health Surveys program (DHS) in 11 countries inAsia, Africa, and Latin America to explore the contribution of private health care providers to popula-tion coverage with a variety of maternal and child health and family planning services. The choiceof countries and services assessed was mainly determined by the availability of data in the differentsurveys. Private providers contribute significantly to family planning services and treatment of children'sinfectious diseases in a number of the countries studied. This is as expected from the predictionsof economic theory, since these goods are less subject to market failures. For the more 'public goods'type services, such as immunization and ante-natal care, their role is much more circumscribed. Twogroups of countries were identified: those with a higher private provision role across many differenttypes of services and those where private provision was limited to only one or two types of theservices studied. The analysis identified the lack of consistent or systematic definitions of privateproviders across countries as well as the absence of data on many key services in most of the DHSsurveys. Given the significance of private provision of public health goods in many countries, the authorspropose much more systematic efforts to measure these variables in the future. This could be includedin future DHS surveys without too much difficulty.

IntroductionThe role of the private sector in providing health careservices in developing countries is of great interestto both international donors and national ministriesof health. It is often assumed that private providerswill be a more efficient and higher quality alternativeto public sector providers and a way to increaseoverall resources available in the health sector(Griffin 1989). However, even descriptive data aboutthe private sector in most developing countries is lack-ing. Because the private sector is not regulated, thereare few official data sources on its size and composi-tion. Research in this area is nascent and encounter-ing numerous methodological problems in definingand characterizing the private sector.1

In addition to the paucity of descriptive data aboutthe size and composition of private health care

providers, we know little about the demand for andutilization of the services they provide. A handful ofhealth care demand studies have been completedusing data from developing countries, however, thesestudies have usually estimated the demand forcurative health services. Recent exceptions areSchwartz et al. (1988) and Alderman and Gertler(1989).

The purpose of this paper is to describe and analyzethe utilization of the private sector for maternal andchild health and family planning services in develop-ing countries. Given that these services are consideredto be priorities by many countries, is there potentialto increase their utilization through the private sec-tor? These questions are best answered by householdsurveys that can determine the availability of differenttypes of providers and the consumer's choice of

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Private provision of MCH and FP services 143

provider. National household surveys are, however,costly undertakings. Therefore, a practical first stepis to analyze existing survey data.

This paper uses data from the Demographic andHealth Surveys program (DHS) to describe andanalyze the role of private health care providers inmeeting the public health needs of women andchildren in developing countries. Using DHS datafrom 11 developing countries, we compare the utili-zation of the private sector with that of the publicsector for tetanus toxoid vaccination, deliveries, treat-ment of diarrhoeal disease, treatment of acuterespiratory infections, and family planning services.

The paper is organized as follows. First, we beginwith a description of the DHS data and the methodsused to categorize providers and to analyze the utiliza-tion rates. Next, we provide an overview of the healthsector in each country, including what is currentlyknown about the size and composition of the privatesector. The results are then presented, organized bytype of health service. We conclude with somegeneral observations on the variations in utilizationof the private sector for public health services be-tween countries and types of service.

Data and methodsThe Demographic and Health Surveys program(DHS), funded by the United States Agency for In-ternational Development, has assisted more than 30countries to implement surveys on population andmaternal and child health since 1985. Data from theDHS surveys include information on fertility andchildhood mortality levels, the use of family plan-ning, attitudes towards fertility and family planning,marital status, breastfeeding, various maternal andchild health indicators, anthropometry, and socio-economic characteristics.

The surveys have large national samples of womenof childbearing age. Generally, these are valid prob-ability samples of the national population, using stratafor rural and urban areas and different regions of acountry (see, for example, Institute for ResourceDevelopment 1987 and 1989). Data on child healthwere collected from all children under the age of five.Table 1 summarizes the characteristics of the 11 DHSsurveys included in this analysis. These countrieswere chosen because the data were sufficiently de-tailed to allow comparisons between the public andthe private sector.

However, as seen in Table 2, even in those countrieswith the best data, the range of data available waslimited. In general, the detail found in the family plan-ning questions was not found in the questions forother types of services. Even within the same coun-try survey, 10 providers might be listed as optionsfor family planning while for diarrhoea, only threewere listed.2 We were unable to use much of theDHS data for this analysis because many countriesonly defined the level of services utilized (pharmacy,doctor, hospital) and not whether the provider wasin the public or private sector.

The basis for classifying providers into public,private, or other was not always obvious or consis-tent. We relied primarily on the classification adoptedby each country when they analyzed the data.3 Forconsistency, we included traditional providers in the'other' category. In only a few cases were traditionalproviders used more than 5% of the time. Schools,churches, family and friends, and others are also in-cluded in the 'other' category. Pharmacies, unlessotherwise specified in the survey, were classifiedas private sector. It was also not possible to dist-inguish between for-profit and not-for-profit privateproviders.

Other variable definitions also raise questions of com-parability between countries. The DHS surveys werederived from a common core questionnaire, modifiedto reflect the specific environment of each country.Some terms such as 'diarrhoea' were left to therespondent to define. Earlier analysis of the DHSsurveys has shown that the accuracy and completenessof reporting diarrhoea varies considerably betweencountries and between socioeconomic groups(Boerma et al. 1991). Systematic differences betweencountries in the probability of reporting an illness,could, of course, affect the reported pattern of ser-vice use as well. Unfortunately, there is no way toknow the direction of such biases, if they exist, onthis analysis.

In order to make our analysis comparable betweencountries, we limited the sample to ever marriedwomen (EMW). Unless otherwise specified, the sub-samples for each type of service analyzed in this paperare defined as follows:

1. TT vaccination: currently pregnant women whoreceived at least one dose of TT during the cur-rent pregnancy;

2. Delivery: all live births in the last five years;



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144 Peter Berman and Laura Rose

Table 1. Summary of DHS surveys* included in analysis

Region/Country Code Year Respondents Sample Size

Bolivia

Colombia

Guatemala

Paraguay

Botswana

Kenya

Sudan

Uganda

Indonesia

Morocco

Tunisia

BOL

COL

GUT

PAR

BOT

KEN

SUD

UGA

IND

MOR

TUN

1989

1990

1987

1990

1988

1988/89

1989/90

1988/89

Asi

1991

1987

1988

Latin America and Caribbean Region*

All women, 15-49 years




African Region



Ever-married women, 15-49 years


Asia and Near East Region




7923

8644

5160

6262

4368

7150

5860

4730

22 909

5982

4184

* Regions as defined by USAID.' See References for publication citations for DHS surveys.

Table 2. Data available by country and type of health service

Country Tetanus toxoidimmunization

Delivery Treatment ofdiarrhoea

Treatment of ARI Family planning

Bolivia

Colombia

Guatemala

Paraguay

Botswana

Kenya

Sudan

Uganda

Indonesia

Morocco

Tunisia

X

X

Latin American and Caribbean Region*

X X X

X

X

African Region


X X

X X

X X

X

X

X

X

X

X

X

X

X

X

X

* Regions as defined by USAID.



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3. Treatment of diarrhoea: all live children under theage of five who had diarrhoea in the last twoweeks and were taken for treatment;

4. Treatment of acute respiratory infections: all livechildren under the age of five who had coughand/or fever in the last two (or four) weeks andwere taken for treatment;

5. Family planning: women currently not pregnantwho are currently using modern contraceptivemethods (in Indonesia, Tunisia, and Morocco forcurrently married women only).

A major limitation of the DHS data is the absenceof substantive indicators of family income. Addi-tionally, there are no data on price or quality of healthcare services, which obviously affect utilization andchoice of provider. Therefore, the analysis thatcan be done is primarily descriptive. When possible,the samples were weighted in order to be represen-tative of the national populations.

Economic and health sector situations inthe study countriesThe countries included in this analysis vary greatlyin both their levels of economic development andthe structure and financing of their health caresystems. Table 3 compares the size, urbanization, in-come, and infant mortality rates of the countries. Withthe exception of Botswana, the African countries areless urbanized and have lower GNPs per capita thanthe countries in the other regions.

With these characteristics, one might expect thatprivate sector utilization would be lower in theAfrican countries - constrained by both supply (in-sufficient population concentration for multipleproviders) and by demand (insufficient resources tospend on health care). Preliminary research by Han-son and Berman (19%), however, suggests that whileincome is an important determinant of total quantityof services provided, it is unrelated to the propor-tion of providers that are private. Data in Table 4 sup-port this finding; while the quantity of physicians andhospital beds per capita is lowest in the African coun-tries and higher in the Latin American countries,the proportion of providers in the# private sector ishigher in Africa for the few countries (physicians -1 country, hospital beds - 2 countries) where dataare available.

Table 3. Basic country indicators

Country

Bolivia

Colombia

Guatemala

Paraguay

Botswana

Kenya

Sudan

Uganda

Indonesia

Morocco

Tunisia

Population(millions)

Percenturban

GNP percapita(US$)

Latin America and Caribbean*

7.3

32.8

9.5

4.4

52

71

40

48

650

1260

930

1270

African Region

1.3

25.0

25.8

16.9

29

24

22

11

Asia and Near East

181.3

25.7

8.2

31

49

55

2530

340

NA

170

Region

610

1030

1500

Infantmortality

rate

83

23

60

35

36

45

84

107

36

43

21

Notes: Data are for 1991NA = data not available

Source: World Bank 1993*These are regions as defined by US AID.

The goal of our analysis was to examine the overalllevel of utilization of the private sector for each ofthe services described above and to compare the levelof use between countries and between services withina country. In addition, we also explored the varia-tion in use of the private sector by selectedsocioeconomic characteristics. The characteristics wechose were place of residence (urban or rural);mother's age (in 5 year groups); mother's education(non, primary, secondary, and higher); and mother'scurrent employment status (working or not working).

While we have little data on the size of the privatesector, Table 5 illustrates that private health expen-diture is significant in most of the countries includedin this analysis. In the Sudan, 85% of total health ex-penditure is estimated to be private expenditure. Theamount of private expenditure as a percentage of totalhealth expenditure was below 40% in only two coun-tries (Kenya and Tunisia). However, little is knownabout what types of services people are purchasingin the private sector. While this analysis has no in-formation on expenditure, it does attempt to describethe extent to which the private sector is used formaternal and child health and family planning service.



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Table 4. Public and private provision of health care in study countries

Country

Bolivia

Colombia

Guatemala

Paraguay

Botswana

Kenya

Sudan

Uganda

Indonesia

Morocco

Tunisia

Notes: a:b:c:d:e:f:

Physicians per 1000 Percentage physicianspop. (88-92)' in private sector

]

0.48

0.87

0.44

0.62

NA

0.14

0.09

0.04

0.14

0.21

0.53

World Bank 1993PAHO 1990Hanson and Berman 1996Delius and Lule 1993Griffin 1992World Bank 1985

Inpatient beds per1000 pop. (85-90)'

Latin America and Caribbean Region

NA

NA

NA

5C

African Region

NA

40°

NA

NA

1.3

1.5

1.7

1.0

NA

1.7

0.9

0.8


6

50f

36C

NA: data not available

0.7

1.2

2.0

Percentage of beds inprivate sector

13"

16e

18b

11"

NA

31C

NA

57"

31C

NA

NA

Table 5. Health care expenditure in study countries

Country Total health expenditure Private expenditureper capita (US $ - 1990) as a percentage of

total

Latin America and Caribbean Region

BoliviaColombiaGuatemalaParaguay

BotswanaKenyaSudanUganda

IndonesiaMoroccoTunisia

25503137

African RegionNA16126

Asia and Near East Region122676

40554357

NA378553

656133

Source: World Bank 1993 NA: data not available

Levels of private sector use: byintervention and by countryThis section summarizes the results of tabulations ofusage patterns of private providers for the differentinterventions covered by the DHS surveys. In addi-tion, we review patterns within countries to deter-mine whether there is a consistent pattern of high orlow use for other services and when private use ishigh or low for some services.

Figures 1-4 present the percentages of respondentsreporting service use who received care from public,private, and other types of providers. These utiliza-tion probabilities are conditional on a prior decisionto use services or seek treatment and may not reflectpotential utilization patterns that might occur iffinancial or informational constraints were removed.

Figure 1 displays the results for source of maternaltetanus toxoid vaccination, which was reported in fivecountries. In all of them more than three-quarters



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100

80

60

40

20

0

100

83.780.6

14.2-16.4 -

95.8

0 0

74.1

BOL GUT BOT SUD UQA

Legend E H Pubflc Private Other

Figure 1 . Source of TT vaccination

of vaccinations were obtained from public providers.Only Uganda reported significant private provisionof this service, at 20%. This may reflect a lack ofpublic sector provision after the years of civil unrestin that country.

Data on use of pre-natal care was only available forMorocco and Tunisia. They reported 48.2% and 25%use of private providers respectively for that service,not an insignificant level.

The survey questions concerning deliveries mainlyidentified the location of the delivery in terms ofpublic or private clinics and hospitals or home

delivery. However, this information does not providea firm indication of who attended the delivery andwhether they did so in a public or private capacity.For example, it is possible that a private physicianor midwife would attend delivery in a public hospital.A publicly employed provider might also attend ina private facility in a private practice role. A publicor a private provider could attend a home birth. Mostof the home births were probably attended by tradi-tional birth attendants, who are generally privatepractitioners although they may receive government-financed training and supplies. In Indonesia, homebirths might also be attended by publicly employedmidwives, though they might frequently do this ina private capacity, receiving fee-for-service payment.

Figure 2 indicates that, in three of the four countriesproviding data on deliveries, home births accountedfor more than 60% of all live births reported in thelast five years. Facility-based births dominated onlyin Tunisia, where public facilities accounted for morethan 60% of the total. Thus, it is likely that privateproviders are the dominant source of birth attendancein these countries.

The data on treatment of diarrhoea vary substantiallyin detail from country to country. For example, inIndonesia, 12 alternative sources of diarrhoea treat-ment were noted, including four levels of governmentprovider (village health worker through to hospital),7 types of private providers ranging from drug shopsto private hospitals, and other. In contrast, for Kenyaand Uganda, the question listed only private doctor,

100

80

60

40

20

79

I 76J

1 eas

27.4

10.4u 9.1 11.5

0.4

31.7

I0.2

BOL IND MOR TUN

Legend E M I Pubflc EZ3 Private Home Other

Figure 2. Place of delivery



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100

80

60

40

20

94.2

513

-775-70.8

505

-I18. _ _

i 4 9 -3

232

BOL GUT PAR BOT SUD IND MOR TUN

Legend E x j l Public Private Other

Figure 3a. Source of treatment for diarrhoea

100

80

60

£ 40"o

20

98.4 ng

555"

37.1-

54.4

IIP

1.1.

533

22J2


Legend E H Public K52 Private Other

Figure 3b. Source of treatment for ARI

hospital/clinic, and other, making it impossible toidentify private providers (these data were not used).Figure 3 shows the breakdown of sources of treat-ment for diarrhoea in terms of public, private, andother types of providers. It is likely that 'other'includes private providers as well, although probablythose with lesser qualifications.

The results from the 8 countries are split. In fourcountries: Botswana, Sudan, Morocco, and Tunisia,public providers account for more than 60% of thetreated diarrhoea cases, with Botswana close to100%. In Bolivia, public providers account for just

over half the cases, 52%. In the other three coun-tries, Guatemala, Paraguay, and Indonesia, privatepractitioners and other account for more than 60%.

The questions on source of treatment for childhoodacute respiratory infections were similar to those fordiarrhoea and are also presented in Figure 3. Dataon public and private sector treatments were onlyavailable for five countries, all of which had infor-mation on diarrhoea as well. The patterns were fairlysimilar. In Botswana and Sudan public providers weredominant. In Bolivia, just over half (56%) of treatedARI was taken to public providers. In Paraguay and



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Indonesia private providers were a more frequentsource of treatment.

Figure 4 presents the results for source of family plan-ning services. Since this was one of the core ques-tions of the DHS, data are available for all countrieswe reviewed. They follow a predictable pattern. Forthe Latin American countries, non-government pro-viders are the dominant source of family planning ser-vices, over 60% in all cases. This may be explainedby the fact that many Latin American governmentshave been reluctant to promote or provide familyplanning services given the political influence of theCatholic Church, which opposes such programmes.In these countries, it may fall to not-for-profitproviders to supply this 'public good'. In contrast,in much of Africa, the Middle East, and Asia familyplanning has been predominantly a government ini-tiative. In these countries, a large non-governmentprovision role was reported from Uganda and Sudan(47% and 42% of users respectively), with Kenya andIndonesia reporting somewhat less private provision.

Overall, the results support expected patterns. Forthe more 'public goods' type of service (those withimportant market failures on the demand side suchas immunization), private providers play a minor rolein most countries reviewed. These public goods areservices for which private demand would be expectedto be weak, at least at the advent of making the ser-vice or technology available. This corresponds with

limited private supply of such services, hence lowreported levels of actual private provision.

In contrast, the treatment of symptomatic and com-mon illness is a major source of private demand forhealth care - in fact one of the major functions ofmost private providers, including those without for-mal medical qualifications. For such services, privateprovision is more common. We should expect to findsimilar results for services treating many commondiseases, including those which are the focus of in-tensive public health campaigns, such as tuberculosisand malaria.

Attendance at deliveries presents a more complexcase. There is significant private demand for birthattendance, although it may not be for modern clinicalskill. There is also significant public provision, in theform of medical and midwife personnel. Governmentalso intervenes to modify private provision in termsof training and supplies for traditional birth atten-dants. Unfortunately, the DHS data do not permit anassessment of the relative roles of different public andprivate providers in birth attendance. They do,however, indicate strongly that the main venue ofsuch provision is the home.

Another way of looking at the DHS data would bein terms of patterns within countries. Is a low or highdegree of private service provision consistent acrossdifferent types of services or is the private provision

100

BOL COL GUT PAR BOT KEN SUD UGA IND MOR TUN

Legend EH21 PubBc Private Other

Figure 4. Source of family planning services



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role more haphazard? Data were available for 8 coun-tries with at least three different types of servicesreported: one country had five services, five coun-tries had four services, and two countries had threeservices. For simplicity, the data were presented asthe proportion of service use at all non-governmentproviders, i.e. combining private and 'other'.

Figures 5 and 6 present results for two groups ofcountries, those with fairly consistent levels of privateprovision across the different services for which datawere available (Group I) and those with substantialvariation across services (Group II). In Group I,Botswana and Tunisia both report low levels of non-government service use across all the services

Proportion of service use In private and othernon-public sectors: Sudan

100

80

60

40

201

Diarrhoea ARI FP

Proportion of service use in private and othernon-public sectors: Botswana

100

Proportion of service use in private and othernon-public sectors: Tunisia

100 r

PNC DEL Diarrhoea

Proportion of service use In private and othernon-public sectors: Paraguay

TT Diarrhoea ARI FP

Figure 5. Variation in private

Diarrhoea ARI

provision across countries - Group 1

Proportion of service use In private and othernon-public sectors: Morocco

100

Proportion of service use in private and othernon-public sectors: Bolivia

100

PNC DEL Diarrhoea

Proportion of service use In private and otherrton-pubBc sectors: Indonesia

100

Proportion of service use in private and othernon-pubOc sectors: Guatemala

100

DEL Diarrhoea ARI FP

Figure 6. Variation in private

Diarrhoea FPprovision across countries - Group 2



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estimated. In contrast, Paraguay reports fairly highlevels of non-government service use.

In Group II (Figure 6) there is substantial variation.Indonesia reports a high level of public provision forfamily planning, but not for other services (NB: inthese figures deliveries are presented for type of loca-tion not type of provider, as discussed above). InBolivia, TT immunization is predominantly govern-ment provided, treatment of childhood illness hassignificant private sector provision, and family plan-ning is largely privately provided. Guatemala also hasa high level of public provision for TT immuniza-tion, but much lower levels for diarrhoea treatmentand family planning services.

These results do not suggest a universal pattern ofpublic and private roles. In some countries public pro-vision dominates the more public goods, while privateproviders remain important for a wide range ofprivately demanded services. However, country-specific institutional factors also influence public andprivate roles, so that public or private providers mightstep in to fill market gaps left, for various reasons,by the other party.

The role of individual and householdfactors in preference for private providersAs noted above, the DHS collect data on a varietyof individual demographic and socioeconomic

characteristics. Most of these apply to the main DHSrespondents, mothers and women of child-bearingages. Sex of the child is also available for servicesprovided to children. In terms of demographicmeasures, we analyzed women's age and child's sex.Household socioeconomic status is not well measuredin the DHS. No direct measures of economic statusare available, such as income, expenditure, or sub-stantial measures of household assets. Socioeconomicfactors must therefore be represented by associatedmeasures. We selected women's education, women'sreported employment status (a dichotomous variableof working or not), and urban or rural location ofresidence as those most likely to reflect behaviouraland socioeconomic differences, based on experiencewith other surveys. While we recognize that theseare crude measures, particularly on the householdeconomics side, they provide some useful insights.

Table 6 summarizes the association of these variableswith the probability of use of private providers forthe different interventions. The table indicateswhether consistent relationships appear across all thecountries reporting results for each type of interven-tion. Overall, urban residence, higher levels of educa-tion, and formal employment are positively associatedin varying degrees with use of private sector servicesfor all the interventions reviewed. This correspondswell with the general observation that private servicesupply is greater in urban areas and more likely toreach those of higher socioeconomic status. Theseassociations, however, do not indicate that private

Table 6. Effect of demographic and socioeconomic individual variables on probability of private provider use

Tetanus Toxoid

Place of delivery(private facility)

Diarrhoeatreatment

ARI treatment

Family planning

# of countriesreporting

4

4

8

5

11

Demographic variables

Mother's age

No effect

Higher in mid child-bearing ages

No effect

No effect

No effect

Child sex

NA

NA

No effect

Slightly higher forfemales in Latin America

NA

Socioeconomic

Mother working Mother's education

Africa (2) + +Latin America (2) —

+ +

+ +

+ (small difference) +

+ +

Notes: NA means measure not applicable.' + ' signifies variable positively associated with probability of private provider use.'No effect' means no systematic effect discemable across countries reporting. Effect might be present in individual countries, see text.



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service provision is insignificant in rural areas or forhouseholds with women with less schooling, whichmay make up a large portion of the high-risk groupstargeted for interventions like diarrhoeal disease con-trol. As discussed above, the importance of thesefindings will vary with the overall level of privateprovision, which is greater for those 'non-public'goods for which there is substantial private demand.This is particularly important for the treatment inter-ventions relating to childhood illnesses: diarrhoea andARI. Each of the interventions will be discussed inturn in the following paragraphs.

TT immunization is mainly provided by the publicsector. The limited non-government provision showssome evidence of bias towards urban households withbetter educated mothers, although this is probablynot of great significance in the overall coverage ofhigh-risk groups with TT vaccine (Berman et al. 1989provides evidence from Indonesia of how effective-ness of TT immunization may increase with bettercoverage of rural women with lower levels ofeducation.)

Analysis of delivery services focuses on deliveriesdone in private facilities, since we cannot identifypublic or private provision in those reported as homedeliveries. Private facility deliveries made up between4% and 11% of all deliveries reported in the fourcountries and were biased towards urban areas andbetter educated mothers. The only association foundbetween private sector use and women's age was forplace of delivery, with women in the middle child-bearing ages (25-34) being more likely to use privatefacilities. This may include associations with income(younger women may be poorer on average) andparity.

The two treatment interventions, diarrhoea and ARI,showed high levels of government provision in theAfrican (Botswana and Sudan) and Middle Eastern(Tunisia and Morocco) countries reporting. Theformer may reflect lack of supply, while the lattermay be better interpreted as the result of moresystematic public provision policies. Non-governmentprovision was dominant in Indonesia, Bolivia,Paraguay, and Guatemala. Across all these countriesthere was a general tendency for private provisionto be more prevalent in urban areas and forhouseholds with employed and better educatedmothers. However, the differences were not thatlarge, as shown in Figures 7 and 8. In other words,private provision of these services is substantial evenfor rural and lower socioeconomic group households

Diarrhoea treatment by place of residence100

80

60%

40

20

02 E


Legend Rural Urban

Diarrhoea treatment by mother's education

100

80

60%

40

20

0

- - 1 ~ /<•

f

it

f\

Si

•

/

\

\

\

\

\

s


Legend ^ None E Primary [ ^ 3 Secondary ^ Higher

100

80

60%

40

20

0

Diarrhoea treatment by whether mother works

fa


Legend Working Not working

Figure 7. Percentage treatment of diarrhoea in private sectorby place of residence, mother's level of education, and mother'swork status.



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100

80

60

40

20

0

ARI treatment by place of residence


and may merit more attention in developing interven-

PBOL PAR BOT SUD IND

Legend Rural Urban

100

80

60

X>

40

20

0

ARI treatment by mother's education

::;

BOL PAR BOT SUD IND

Legend ^ None | Primary £ - 3 Higher

100

80

60

40

20

0

ARI treatment by whether mother works

BOL PAR BOT SUD IND

Legend Working | J § Not working

Figure 8. Percentage treatment of ARI in private sector by placeof residence, mother's level of education, and mother's work status

tion programmes.

For family planning services, the pattern of publicand private provision shows strong regional variation,with private provision dominant in Latin Americaand public provision dominant in the other countries.Although the levels of use differ, the association ofprivate sector use with urban residence, female educa-tion, and employment is positive and similar acrossall the countries. We found no systematic link acrosscountries between private sector use and type of con-traceptive provided.

Conclusions

Using the available DHS data from 11 developingcountries, we analyzed the role of the private sectorin meeting the needs for maternal and child health andfamily planning. These services are considered to bepriorities by most countries, however, little is knownabout where women seek these services for them-selves and for their children. As many countries movetoward a larger role for the private sector in the pro-vision of health care services, they must address therealistic potential for the private sector to providethese public health services. A first step in this pro-cess is to determine the extent to which these servicesare currently provided by the private sector.

This analysis has shown that, overall, private sectoruse reflects expected patterns: lower for the more'public' goods with significant demand side marketfailures such as immunization and family planning,and higher for more private goods such as treatmentof childhood diseases. In some countries, particularlythose in Latin America, and Indonesia, the levels ofprivate sector utilization are quite high; often morethan half of the treatments for diarrhoea and ARI areprovided in the private sector. In contrast, vaccina-tions continue to be provided almost entirely by thepublic sector. An insufficient number of countries haddata on deliveries or prenatal care for us to drawmany conclusions.

These patterns may be significantly modified bycountry-specific conditions, affecting both demandand supply. For example, in Latin America, the lowerlevel of state action in family planning has resultedin a dominance of private provision for that service.In Africa, constraints to both private demand andsupply related to general economic conditions may



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limit private provision, even of illness treatments.Where incomes permit, for example in Botswana, orTunisia and Morocco, policies to assure public pro-vision of service also significantly affect the public-private mix of provision.

Also, private provision is not monolithic. In manycountries it includes a sizeable not-for-profit sectoras well as unqualified providers. Not-for-profitprivate providers may view provision of 'publicgoods' as part of their mission. Not all private pro-viders may contribute to service provision of highsocial priority. Unfortunately, the level of detailavailable in the DHS surveys did not permit analysisof this issue.

Does the evidence suggest private provision may bea significant factor in the priority public sector healthand population agenda? The answer from this reviewis a qualified yes. To the extent that primary curativeinterventions offer potential for cost-effective healthimprovements, it is likely that private providers arean important source of services in many countries.However, based on the DHS data we can onlydescribe use patterns for two childhood diseases.More data are needed on significant adult and repro-ductive and health morbidities. For the more 'public'goods of immunization and antenatal care, the limitedevidence suggests the role of private providers re-mains small. In family planning, private provisionis significant in some countries, depending on localconditions.

The analysis that is possible with existing DHS datais very elementary and omits many importantvariables. For example, without information on thequality of public and private services, one cannotdetermine whether high levels of private use enhancethe overall coverage with priority services or areinstead a detriment to health. National data on theoverall supply of private services are generally lack-ing, making it impossible to determine the relativeimportance of private sector use in national healthcare systems, and the composition of private pro-viders in terms of qualifications and whether they arefor-profit or not-for-profit.

Price variables for providers and important individualand household characteristics such as income andperceptions of quality also limit our ability to explaindifferent patterns of public and private sector use. Thedescriptive analysis we have done is suggestive ofbehavioural factors operating on both the supply and

demand side, but is insufficient to evaluate it or torecommend appropriate actions. It would be impor-tant in the design of public interventions to under-stand how health care markets for priority servicesoperate. Are public and private providers mainlysubstitutes, or are there important complementaritieswhich could be exploited?

A further constraint has been the limited and ad hocinclusion of health-related questions in the DHS.Although the DHS is the most significant global effortto date to study maternal and child health servicescross-nationally, health-related questions have beenapplied unevenly. This limits the potential for com-parative analyses. The difficulty is compounded byinadequate definitions of key terms, such as that for'public' and 'private' provider and different types ofprovider within these categories.

There is growing recognition internationally thatprivately provided health care is widespread andsignificant in reaching the general population, in-cluding the poor and those at risk for many priorityproblems. Privately provided services should con-tribute more to national health goals - especiallywhere national resources are limited and private pro-viders already comprise an acceptable source of ser-vices to much of the population. Wise policies toderive more benefit from these national resources re-quire better understanding of what private providersprovide, to whom, and_at what level of quality, priceand cost. The DHS can make an important contribu-tion to this knowledge. Further analysis of the existingsurveys is certainly needed, along with improvementof future surveys.

Endnotes1 Many of these issues are discussed in Berman and Rannan-

Eliya (1993).2 The 1989 DHS survey for Kenya, for instance, lists the

following providers as family planning options: governmenthospital, government health centre, Family Planning Associationof Kenya, mobile clinic, field educator, pharmacy/shop, privatehospital, mission hospital/dispensary, employer's clinic, privatedoctor, traditional healer, friends/relatives, and other. Fourprovider opcions were included for diarrhoea: private doctor,hospital/clinic, traditional healer, and other.

3 In nearly all countries, the data on family planning wererecorded into public, private, and other categories. It was possibleto work backwards and determine which providers were codedas public, and which were coded as private. We then assumed thesame classification for the other types of services. While this givesus consistency within a country, we cannot be sure of theconsistency between countries.



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AcknowledgementsMuch of the data analysis in this report was done by GustavoAngeles and Oleh Wolowyna of the Research Triangle Institute,North Carolina, USA. In addition, we benefited greatly from DrWolowyna's expertise in survey design and familiarity with DHSsurvey data. Financial support for this work was provided byUSATD through the Data for Decision Making Project, CooperativeAgreement No. DPE-5991-A-00-1052-00.

BiographiesPeter A Berman, MSc, PhD, is Associate Professor of Interna-tional Health Economics (Population and International Health) andDirector of the Data for Decision Making Project. His researchinterests include health sector reform in developing countries andeconomic assessment of health policies and programmes. He hasconsulted to the World Bank, USAID, UNICEF, and the AsianDevelopment Bank in various African and Asian countries. Hewas a Ford Foundation Program Officer in India from 1987 to1991, and prior to that, a UNICEF Project Officer in Indonesia,1973 to 1977.

Laura Rose, BA, MSc, SD (Candidate), is particularly interestedin health economics and international health care financing. Hercurrent research includes comparative health financing systems,health care simulation modelling, decentralization, and health in-surance in developing countries. Since 1991 she has held the posi-tion of Health Economist on the Cyprus Project which is part ofthe Program in Health Care Financing at Harvard University.She has consulted and led investigations for the Hinduja HarvardProgramme for Community Health in Bombay, India, and forUNICEF, Amman, Jordan. She is currently an economist at TheWorld Bank, Washington, DC.

Correspondence: Harvard University School of Public Health, Deptof Population and International Health, 677 Huntingdon Ave., Bldg1-1210, Boston, MA 02115, USA.



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