Private providers operating in a public logic: what could that mean in practice?

The presentation I made at this conference was precisely based on the central argument of our paper published in 1997: i.e. the analysis that a distinction between public and private health care providers along the lines of their administrative identity is not necessarily the most relevant one in every context. A more appropriate distinction could be made according to the values that guide providers in their action and the nature of the care they eventually provide to people. In the Giusti paper, five general criteria are presented to define what such a “public-oriented” service could be: i) a social perspective ii) non-discrimination iii) population-based iv) government policy guided; and v) non-lucrative goals.

Public doesn’t mean public oriented

This discussion refers to a reality that I, as a Belgian citizen, perceive in my country. The huge majority of the Belgian health care providers, certainly at the level of the first line (general practitioners), are not civil servants but self-employed health workers working on a solo basis or in small multidisciplinary teams. The huge majority of them are remunerated on a fee-for-service basis in a (regulated) environment where the amount of the fees charged to the patients, and the level of their reimbursement by the Belgian social health insurance system, are negotiated on a yearly basis by the federal government, the different health insurance funds and the representatives of the health care providers. Most of the Belgian health care providers are thus not “public” in the traditional sense of the word. But in many instances, they aim for and succeed in delivering a service to their patients that is consistent with the spirit of a public-oriented service. The same holds for most of the faith-based hospitals operating in sub-Saharan Africa. On the other hand, it is not because a health facility is publicly owned - i.e. by the government - that it therefore automatically offers a service to people that matches the definition of a “public orientation”.

Urgent need of validated indicators

Hence it is relevant to classify providers according to the logic that guides their action and not according to their administrative identity. A limitation, however, of this sort of classification is that it remains conceptual and broad: it does not necessarily offer a practical operational tool that could be used by policy makers and health system managers to „assess“ providers. Consequently, there is an urgent need to design a comprehensive set of validated indicators that would help interested parties to actually appreciate this public-oriented orientation of providers. For instance, one of the five criteria proposed by Giusti is non-discrimination. But how does one assess this in the field? What indicators could be developed to actually measure whether and to what extent there is no discrimination of patients? There is thus a need for measurable criteria and, perhaps, this should lead to some composite score where different criteria could have a different weight. Research into this matter is required.

Let me conclude with a call for more pragmatism, and less ideology, in the public-private debate. Let us concentrate on the results we wish to reach, now and in the future. The way to achieve these results may and will differ from setting to setting. A productive public-private collaboration implies a willingness from the private sector to respect national policy guidelines and to integrate its action in national plans. From the side of the government, it implies political will to accept the existence of a pluralistic healthcare delivery environment, but a fruitful public-private collaboration also requires an adequate institutional capacity for the government, and for the Ministry of Health in particular, to play its stewardship role and to regulate the action of the different health care providers operating on the national territory.

* Bart Criel is a medical doctor by training. In the 80's he worked for 7 years as a medical officer at district level in the former Zaire, now Democratic Republic of Congo. He obtained an MSc in Community Health in Developing Countries in London (LSHTM) in 1989. In 1990 he joined the Public Health Department of the Institute of Tropical Medicine in Antwerp, Belgium. In that position he is involved in a variety of activities in the field of training and research. In 1998 he obtained a PhD at the Free University of Brussels on the subject of „district-based health insurance in sub-Saharan Africa“. He currently occupies the position of senior lecturer at the ITM. For many years he has been active in the management of Medicus Mundi Belgium. He still represents MMB in the executive board of Medicus Mundi International (MMI) in which he also takes part as a public health advisor. In addition to his academic and NGO-commitments, he has taken up a political mandate in his home municipality in Belgium where he is in charge of the social assistance policies. www.itg.be/itg/, www.medicusmundi.org/, BCriel@itg.be.