Private-public mix in woman and child health in low-income countries: an analysis of demographic and health surveys

Abstract

Achieving the maternal and child health Millennium Development Goals (MDGs 4 and 5) is still a grand challenge to several low-income countries (LIC). An analysis of the most recent (2001-2006) Demographic and Health Survey (DHS) plus an adjacent prior wave (1995-2000) reveals a wide variation in the role of private sector on health care for women in reproductive ages and children under five in 19 LIC in sub-Saharan Africa (SSA) and six LIC in South and Southeast Asia (SA/SEA). Health providers or facilities sought by women in the nationally representative households for four care tracers: modern contraception, birth delivery, and child diarrhea and fever/cough treatments were grouped hierarchically into three major sources: informal, formal private, and public sectors. Eight of 19 LIC in SSA and two of six in SA/SEA had over 50% share of family planning services provided by the private sector, mostly through the formal providers or facilities. The private sector was even more dominant on delivery, especially by the informal care. In Vietnam (2002), however, public sector dominated these health markets for women. The informal sector very prevailed on the family planning in Cameroon (2004) and on the delivery care in Ethiopia (2005) and Bangladesh (2004), whereas Indonesia (2002) had the top share of both services by the formal private sector. The informal sector is most prevalent for the treatments of child illnesses similarly between diarrhea and fever/cough, whereby Chad (2004) and Mali (2001) were the informal champions. Vietnam, Nepal (2006) and Uganda (2006) experienced a minimal role of the informal sector for both diarrhea and fever/cough, whereas in Mozambique (2003) treatments by the public sector dominated. India (2005) was the formal private champion for these two diseases. Comparison between the two DHS waves (approximately 5-6 years apart) shed light on an expanding (or shrinking) trend in this private-public trade off on woman and child health for some countries. For observable geographic and economic gaps, the formal private sector typically tended to favor urban or wealthier population over their rural or poorer counterparts. For the family planning services, public sector was relied heavily by the rural or poorer subgroups in most countries (except in Mozambique and Mali). Unfortunately, the public sector was found in favor of the better off on the delivery care in all countries. This DHS analysis found a mixed result on the geographic and economic gaps in the child treatments. Chad and Mali were the two LIC showing a consistent pattern that both formal private and public sectors favored the better off, whereas Vietnam was an example of LIC where the worse off depended largely on the public sector for the treatments of both illnesses. An ecological analysis linking the country’s private-public mix to population health outcome has found a consistent correlation of under-five mortality positively with the informal treatment share (correlation coefficient, r=0.44 and 0.54) but negatively with the formal private treatment share (r=-0.55 and -0.70) for fever/cough and diarrhea, respectively. However, both baseline illness prevalence (r=0.58 and 0.70) and overall treatment coverage (r=-0.29 and -0.63) also showed an expected outcome correlation. Other country-level variations, including national income, out-of-pocket health spending, and governance performance were also taken into perspective for further policy recommendation.