Tracey Koehlmoos: The tide is turning for the private sector in developing countries

Tracey KoehlmoosYou cannot live in Dhaka, where I live and work, without seeing the necessity of the private sector for health. The private sector provides the overwhelming majority of outpatient curative care, while the public sector is used for a larger proportion of hospital deliveries and preventive care. For example, about 90% of care for children with acute respiratory infection (ARI) or diarrhoea is obtained from the private sector. [4,5] This is partly because of the lack of qualified providers in rural areas [6,7] a problem that is compounded by unfilled vacancies in a large number of staff positions. It is also because the essential services package provided by the public sector does not cover non-communicable diseases and has no health workers trained in management of non-communicable diseases. For these health issues, people routinely turn to the private sector, unlicensed providers, and traditional healers for treatment.

Before the release of a debate paper on the need to engage the private sector that appeared in PLoS Medicine in 2008, [1] I received the firm and well meaning advice: “It is fine for the Richards [Smith and Feachem] to speak with such bravado, but you are junior and have to be careful.”  Possibly risking a bad reputation,  I pressed on with the debate piece. When Oxfam published its inflammatory, anti private sector piece in the BMJ (2009) saying that “Aid money is wasted on the private healthcare programmes in poor countries [2]”  I realised that I could not sit silently and wrote back twice. [2,3]

For years, if the private sector was mentioned in terms of its potential inclusion in meeting the health needs of the poor in low and middle income countries, there would be great debate and righteous outrage from the anti private sector set, who loomed large and influential.  We were seen as rebels against the massive, layered public sector structures built along the “Health for All” vision laid forth in Alma Ata, or worse as not looking out for the needs of the poor. 

However, I have the growing sense that the staunch anti private sector movement might be going out with the tide. It has been changing for a while now and perhaps in a large part this was an inevitability caused by the rapidly approaching, ambitious objectives set forth by the Millennium Development Goals. [8,9,10]

However, there are two or three recent events that drive the point home for me.

My first awakening to this shift was during the First Global Symposium on Health Systems Research held in Montreux in November 2010. Dominic Montagu, the father of social franchising research, hosted a fish bowl session on “The Scale and Scope of Private Contributions to Health Systems.” [11] The room was seriously packed—and I arrived late enough to miss the mingling that takes place before such sessions; however, I could see that some of the usual suspects from the anti private sector crowd were in attendance. I expected fireworks; however, I was surprised that not once during the session did someone question the need to include the private sector in health systems.  There was not a heated debate, there were no accusations, just a genuine discussion by a room full of interested people about how to move on with the business of doing this rationally.

Most recently, Richard Smith published a news article about the World Health Organization’s global forum on meeting the challenges of non-communicable diseases. [12]  In the article Smith points out that Margaret Chan, WHO’s Director General, has given her benediction to include the private sector in the coming battle to develop health systems capable of preventing and treating non-communicable diseases. She says that governments must continue to be the decision makers but that the private sector should be heard but charged them to “walk the talk.”  It is really a “new WHO.”

To those against the private sector, the fall back argument has always been, “There is no evidence.” [1]  However, an excellent new review comparing the quality of private and public ambulatory care in developing countries was recently published in PLoS Medicine [13]. The review was conducted by some of the top systematic reviewers. In addition to the actual findings, such as that the private sector is more likely to have drugs available and be more responsive and possibly client centred and the quality of care in the public and private sectors are equally poor, the review sets forth guidance on which directions can be taken to develop future evidence.  There are other systematic reviews of private sector interventions that are equally prescriptive [14] in terms of identifying the gaps in knowledge and identifying how to  fill them.

Now that we’ve been more or less given “permission” to press ahead with including the private sector, perhaps we can de-camp and move forward toward developing the tools to strengthen health systems so that they can incorporate all players within a country or region to the benefit of the poor.
1. Smith R, Feachem R, Feachem N, Koehlmoos T, Kinlaw H (2008) We must engage the private sector to improve healthcare in low income countries, in Hanson K, Gilson L, Goodman C, Mills A, Smith R, et al. Is Private Health Care the Answer to the Health Problems of the World’s Poor? PLoS Medicine, 5 (11)  doi:10.1371/journal.pmed. Available at:

2. Montagu D, Feachem R, Feachem N, Koehlmoos T, Kinlaw H, Smith R (2009) Oxfam must shed its ideological bias to be taken seriously [Letter to the editor: Aid money is wasted on private healthcare programmes in poor countries, says Oxfam] BMJ; 338: 667.

3. Koehlmoos T (2009) No cost healthcare for the poor, shibboleths should not detract from reality. [Rapid Response: Aid money is wasted on private healthcare programme in poor countries, says Oxfam] BMJ.8 July

4. World Bank (2003). Bangladesh Private Sector Assessment for Health, Nutrition and Population (HNP) in Bangladesh. Report No. 20075-BD

5. Larson CP, Saha UR, Islam R, Roy N (2006) Childhood diarrhoea management practices in Bangladesh: private sector dominance and continued inequities in care. International Journal of Epidemiology. 36(6): 1430-1439.

6. Mahmood S, Iqbal M, Hannifi S, Wahed T, Bhuiya A (2010). Are “village doctors” in Bangladesh a blessing or a curse? BMC International Health and Human Rights. 10 (18).

7. Bhuiya A. (Ed). (2009). Health for the Rural Masses. Monograph No. 8. Dhaka: ICDDR,B.

8.  Bennett S, Hanson K, Kadama P, Montagu D (2005) Working with the Non-State Sector to Achieve Public Health Goals. Making Health Systems Work: Working Paper No. 2. WHO.

9. Working with the Non-State Sector to Achieve Public Health Goals Consualtion on Priorities and Actions. (2006) Chateau de Penthes, Pregny, Geneva 20-21 February 2006. Background paper.

10.  UN Millennium Development Project (2005)

11. Montagu D (2010) The Scale and Scope of the Private Sector for Health Systems. Session hosted at First Global Symposium for Health Systems Research. Montreux, Switzerland.  Slides available at:

12. Smith R (2011) Moscow meeting marks “beginning of a different WHO,” says Director General. BMJ 2011;342:d2766

13. Berendes S, Heywood P, Oliver S, Garner P (2011) Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies. PLoS Med 8(4): e1000433. doi:10.1371/journal.pmed.1000433

14. Koehlmoos T, Gazi R, Hossain S, Zaman K (2009) Effect of social franchising on access to and
quality of health services in low- and middle-income countries. Cochrane Database of Systematic Reviews, Issue 1.

Tracey Koehlmoos is programme head for health and family planning systems at ICDDR,B and adjunct professor at the James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh.