The perils and possibilities of the private health sector .pdf

Nom original: The perils and possibilities of the private health sector.pdf
Titre: The perils and possibilities of the private health sector
Auteur: Richard Horton

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The perils and possibilities of the private health sector
health coverage firmly in mind, ensuring that whatever
mix of public and private health provision exists in a
particular setting meets that goal. What we do know
is that the public and private sectors cannot be seen
as mutually exclusive entities within a health system.
Each depends upon the other, and the performance of
one is often intimately linked to the performance of
the other. Public and private sectors therefore should
be viewed as entwined elements of a whole health
system, and managed as such.
So far, ways to improve provision of health care
by the private sector have been limited to banning,
regulation, subsidy, and purchase of services, as
outlined by Dominic Montagu and colleagues.3
Banning or heavily regulating the private sector are
certainly policy options. But neither may be feasible
nor fully practical in countries with weak governments
or weak governmental institutions. Moreover, there
is no ideal prescription for the perfect mix of public
and private health-care provision. Every country is
different, and each country’s government will have to
make choices to manage its public and private sectors
with the overall objective of universal health coverage
in mind.
Finally, McPake and Hanson4 discuss the importance
of designing policies to govern the private sector.
They emphasise that governments should choose
policies to cover the performance of the sector as
a whole and not the individual parts. Inevitably, Published online June 26, 2016

Published Online
June 26, 2016
See Online/Series
S0140-6736(16)30242-2, and

Godong/BSIP/Science Photo Library

Few issues provoke as much disagreement, even
anger, as the question of the private sector’s role in
delivering health care. Supporting a contribution by
the private health sector towards achieving the goal
of universal health coverage is seen as a betrayal of
public welfare by many critics. For those of us brought
up with (or trained within) a publicly financed health
system (such as the UK’s National Health Service),
private provision of health care may be anathema.
Very often, we will rail against private providers—
the profit they make from the sick, the catastrophic
health expenditures they may cause, or the latitude
they enjoy to exploit the poor in systems where
government regulation is weak or non-existent. But,
as Kara Hanson, Barbara McPake, and their colleagues
set out in this Lancet Series on the private sector
in health, these simplistic views may hinder rather
than help our understanding about what the private
sector is and how it can best contribute to broad
health goals.1–4
The private sector in health care is not going away.
Indeed, it has a large and expanding part to play in the
health systems of all low-income and middle-income
nations. Provision of private health care varies greatly
between and within countries, as does the quality of
that care. Private health care ranges from the most
basic care offered by travelling merchants selling
medicines to highly commercialised hospital care.
The task of those concerned with health should be to
subject the private sector to scrutiny—description,
analysis, and evaluation. What this Series makes
abundantly and disappointingly clear is that the
evidence on which to make wise policy decisions
concerning the private sector is often weak or absent.
That situation must change.
Maureen Mackintosh and colleagues1 argue that a
good-quality and accessible public sector system will
lead to a private health system with similarly desirable
characteristics. Research so far has usually compared
provision of care by the private sector with that of the
public sector, which might be misleading, according
to Rosemary Morgan and colleagues.2 Our collective
goal should not be to arrive at some settled ideological
position either for or against the private sector.
Instead, we should keep the objective of universal



policies will reflect the ability of governments to pay
for services and provide the necessary capacity to do
so. But as systems evolve towards universal health
coverage the private sector could provide services that
are publicly funded.
This Series concludes that perhaps the best option
available to governments is to identify incentives to
encourage private health providers to change their
behaviour, making equity and quality more important
measures of success, while addressing the dangers of
an often predatory corporate health sector. Our hope
is that the UHC: markets, profit, and the public good
Series disentangles opinion from evidence. We hope
these papers clarify what we mean when we speak of
private health providers. And we hope they provide
practical guidance for practitioners and policy makers
(and perhaps even users) about how to optimise the


interaction of public and private sectors to ensure that
they do deliver healthy lives for all by 2030.
Richard Horton, Stephanie Clark
The Lancet, London EC2Y 5AS, UK
The Lancet is currently owned by the RELX Group, a private sector provider of
information and analytic services to professionals, including health
professionals, and businesses.




Mackintosh M, Channon A, Karan A, Selvaraj S, Zhao H, Cavagnero E. What is
the private sector? Understanding private provision in the health systems of
low-income and middle-income countries. Lancet 2016; published online
June 26.
Morgan R, Ensor T, Waters H. Performance of private sector health care:
implications for universal health coverage. Lancet 2016; published online
June 26.
Montagu D, Goodman C. Prohibit, constrain, encourage, or purchase:
how should we engage with the private health-care sector? Lancet 2016;
published online June 26.
McPake B, Hanson K. Managing the public–private mix to achieve universal
health coverage. Lancet 2016; published online June 26. http://dx.doi.
org/10.1016/S0140-6736(16)00344-5. Published online June 26, 2016

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