Private care and public health: do vaccination and prenatal care rates differ between users of private versus public sector care in India?

Health Services Research, Dec, 2004 by David H. Howard, Kakoli Roy

Governments in developing countries such as India spend the majority of their health care budgets on direct public provision of care. Though public services are offered free of charge, most patients, including those from the lowest income groups, seek ambulatory care in the private sector. In recent years, governments and donor organizations have reassessed their traditional emphasis on the public sector, and, in recognition of its inability to achieve universal access and equity in financing as well as the complementary nature of the public and private sectors, gradually sought to shift responsibilities to private hospitals, clinics, and physicians (Bennett, McPake, and Mills 1997; Peters et al. 2002).

While private providers may be more responsive to patient demand, many observers are concerned about the ability of private sector physicians to provide public health services (Brugha and Zwi 1998; McPake 1997; Newell 2002). Private providers often lack the expertise and facilities to deliver high quality preventive services (Mills et al. 2002). Vaccines, in particular, require proper handling and storage, and private providers may fail to keep vaccines adequately refrigerated (Aljunid and Zwi 1997). On the demand side, patients' willingness to pay for preventive services will not reflect the positive externalities associated with reduced transmission of infectious diseases and decreased use of tertiary care in the public sector. Hence, private providers face suboptimal incentives to provide preventive care.

Another potential problem with the private sector vis-a-vis public health is that use of private versus public facilities may be associated with "missed opportunities" for vaccination and prenatal care. Narrowly defined, a "missed opportunity" occurs when an individual eligible for such care visits a health care facility for curative services and does not receive concurrent preventive services (Szilagyi and Rodewald 1996). Eliminating missed opportunities is a major goal of the "integrated management of childhood illness" approach to primary care promoted by the World Health Organization and other aid agencies (Nicoll 2000), based on the belief that targeting persons already in contact with the health care system represents a cost effective method of increasing immunization rates and use of prenatal services (Khan, Saha, and Ahmed 2000; Patwari and Raina 2002). Some analysts have dismissed concerns about missed opportunities as a rationale for public provision of curative medical care (for example, Peters et al. 2002), but hard evidence is lacking.

The purpose of this study is to compare rates of vaccination and prenatal care between children and women who use private care for curative services and those who use public care for curative services. We do not measure missed opportunities for vaccination directly. More than 90 percent of vaccinations are provided by public facilities in India/Peters et al. 2002), so there is little doubt that the proportion of visits in which previously unvaccinated patients receive vaccinations is higher in public facilities. Instead, our approach is to compare vaccination and prenatal care rates overall, regardless of the facility type at which they were received. Just because private providers are less likely to administer vaccines does not mean that their patients are less likely to be vaccinated. Patients who use private care for curative services always have the option of obtaining preventive services from the public sector. That said, there are still reasons to suspect that use of private care for curative services may be associated with decreased use of public health services overall. Persons who regularly use private care may lack established relationships with public providers, and private providers may be less likely to exhort their patients to obtain preventive care.

THE INDIAN HEALTH CARE SYSTEM

As in most other developing countries, the Indian health system is comprised of a mix of public and private providers. The large public health infrastructure, financed out of general tax revenues, operates largely through primary health centers. Administrative decisions are made primarily at the state level, though some states have decentralized managerial functions to local bodies. Public clinics do not charge for professional services, but patients must pay for the facility and supply costs associated with treatment (for example, drugs, diagnostics, supplies, and inpatient lodging). The availability of public clinics varies greatly between states and regions within states, and for some patients travel costs are prohibitive.

At independence in 1947, the private sector comprised only a small share of clinics and hospitals. Since then, the number of private providers has grown rapidly. According to recent estimates, between 80 and 85 percent of physicians are employed in the private sector and 80 percent of outpatient visits in India are to private clinics/Peters et al. 2002). There is tremendous variation in terms of the size of facilities, the range of services offered, and the expertise of physicians. Most clinics are for-profit, and though physicians have formal training in Western medicine, they may also prescribe traditional Indian healing therapies.