The Public versus Private Debate: Inching Toward the Middle . . .

An exchange in the pages of PLoS Medicine underscores a promising trend in global health: a shift toward more pragmatism and less name-calling on the role of the private sector in developing country health systems.Discussions of the private health sector in developing countries have long been dominated by dogmatism on both sides. For public-sector-purists, the existence and rapid growth of the private sector in the 80s and 90s was a symptom of what was wrong with developing country health systems, and good policies were those that would strengthen the public sector in such a way as to lead to the fading away of the private sector. For the private-sector-believers, the growing private sector revealed the unfixable problems of the public sector, and made it clear that to achieve sectoral goals you’d have to engage the private sector. The public-sector-purists thought the private-sector believers were anti-poor, since they believed only the public sector could look after their interests. The believers though the purists were in denial about the fixable-ness (and pro-poorness) of the public sector.For years, this, rather sterile, debate raged - with relatively little benefit. In the past 2 years, this debate has moved on. Both the purists and the believers have shifted to the middle, with growing consensus on the need to work with the private sector (broadly defined), if not where this ranks in the long list of health policy priorities for developing countriesSigns of the growing pragmatism, and desire for constructive debate include:• an editorial written by two WHO staff, presenting a number of illustrative cases of successful public-private engagement, who concluded

“These cases show that without engaging private providers, poor quality and sometimes harmful care will continue, they show that private providers can help expand access in rural, as well as urban, areas…”

• the very practical position taken by the World Bank in their 2007 Strategy for the health sector which states

“improving HNP(health, nutrition, and population) results requires the Bank to provide sound policy advice to client countries on how to ensure effective regulation to enhance equity and efficiency as well as synergy and collaboration between the private and public sectors to improve access to services for the poor”

• And most recently, the interesting debate in PLoS Medicine (LINK above), which presents a number of growing areas of agreement, and, naturally, some areas where disagreement persist.While there is still much that the two camps disagree on, notably the appropriateness of engaging the for-profit sector, the growing pragmatism is definitely a positive development.