Bulletin of the World Health Organization


23 April 2002

The huge and mostly unregulated private health sector in low-income countries raises serious concerns. According to a review in the latest issue of the Bulletin of the World Health Organization, the quality of drugs, advice and care sold privately is often dangerously poor. Especially for major diseases such as tuberculosis, malaria, and sexually transmitted infections, this has "implications not only for the individuals treated but also for disease transmission and the development of drug resistance," the authors say.

The article, by Professor Anne Mills and colleagues in the Health Policy Unit at the London School of Hygiene and Tropical Medicine, shows how the private sector functions, and how it could be influenced in order to help meet national health objectives.

Though it contains extreme diversity, ranging as it does from large commercial companies to shopkeepers and itinerant drug sellers, private enterprise has a strong common characteristic: it needs to sell its services and products profitably. In order to do so it may ignore good technical standards of treatment such as correct drugs and dosages, especially where these are not readily affordable to its customers. For poor people such services are often the only option. In Sierra Leone, for example, the price of purchased drugs was almost a third of the cost of treatment at a public health centre. Private services are often more easily accessible as well, with drugs sold in general shops with convenient opening hours.

People in low-income countries often lack knowledge about effective means of treating and preventing illness and are dependent on providers for information such as an interpretation of their symptoms, the article says. This can make them vulnerable to inadequately qualified practitioners providing care of very poor quality, with little chance of redress when they have been victims of malpractice or negligence.

Direct consumer education could help inform patients about what constitutes good quality care for many common medical procedures. Price information could help patients when they seek providers, and social marketing could prove useful in publicizing such information.

Governments should use a range of approaches when working with private providers rather than relying on single strategies. The improvement of knowledge and skills is a necessary starting point. Most private providers receive no guidance from the public sector on diagnosis and treatment. Consequently, their practices are determined by biased information from pharmaceutical companies. Therefore, the article says, training is central to most approaches. It has improved the diagnosis and counselling practices of informal providers in India, the provision of antimalarials by shopkeepers in Kenya, and the management of diarrhoea and acute respiratory infections by private medical practitioners in Mexico.

Governments should regulate the private sector, but putting regulation into effect has proved extremely difficult, especially in sub-Saharan Africa. For example, at present, many antibiotics and antimalarials, including those most recently released, are readily available from shops and pedlars, encouraging the development of drug resistance. Ways must be found to influence the private sector in favour of public health.

Authors alone are responsible for views expressed in the Bulletin's signed articles, which are not necessarily those of the World Health Organization

For further information, contact Thomson Prentice, Tel. (41 22) 791 4224. Email prenticet@who.int

All WHO Press releases, Fact sheets and Features as well as other information on this subject can be obtained on internet on the WHO home page http://www.who.int