Should the private sector play a greater role in delivering health care in low-income countries?

A provocative debate in this week's PLoS Medicine examines whether the private sector should step up its involvement in delivering health care in low-income countries.

These countries suffer a disproportionate burden of disease, and often struggle with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial.

Richard Smith (Ovations Chronic Disease Initiative, London, UK) and colleagues argue that in the developing world "the private sector's role in health care should be strengthened and more closely aligned with the public interest." They discuss evidence showing that "private contractors can operate on a large scale, be more cost effective than government-provided services, and increase coverage in poor and remote areas." The authors argue the case for supporting public-private partnerships for health system strengthening. Improving health care for the world's poor, they say, "means harnessing everyone's capacity, not just that of governments."

But Kara Hanson (London School of Hygiene and Tropical Medicine, UK) and colleagues argue that "there is no alternative to strengthening the public role in the health system." Even where private services are low cost, they say, they are not necessarily affordable - even short bouts of illness can have a catastrophic impact on welfare when households are poor. There is no evidence, say Hanson and colleagues, that private risk sharing schemes such as commercial insurance can reach the poorest groups. Public financing of health care, they say, "can help achieve protection both against the cost of care and also against loss of income caused by illness."