Public or private?

 Who is best placed to deliver quality health care services if we want to achieve accessible, good quality health care for all? Public or private providers? There is no easy answer to this question, firstly because defining what is private and what is public is complex. Private providers are heterogeneous, consisting of formal for-profit entities such as independent hospitals, individual care workers working on a self-employed basis, informal entities that may include unlicensed providers, and not-for-profit providers, such as community and social enterprises, non-governmental organisations, civil society etc. In many countries, individual health workers, like doctors, are often self-employed, but hospitals and health centres are mostly (or all) in the hands of the government or run by social, not for profit, organisations. Elsewhere, health services are provided by a mix of for profit and not for profit enterprises and institution, subsidised by the government or otherwise. So, we can’t make a simple distinction between public and private, but we can say that there are some clear structural reasons why for-profit health care and competition do not promote efficiency or quality, and impede universal and equitable access to health care.


There are substantial differences to be made between public or not for profit providers on the one hand and commercial service providers on the other. While the commercial sector’s primary goal is to maximise profits, public health services aim to cater for the population’s basic needs. Public health services are not in a good position to compete, because (in principle) they have to provide services also to the people that have the highest needs and the least purchasing power, e.g. the poor, the disabled, the elderly, the unemployed, migrants; in short, people that have a harder time  in society.
It is often stated that commercial health care providers would be in a position to offer better quality. However, if “quality care” is understood as “offering the best treatment according to the diagnosis, based on evidence and international treatment guidelines”, then this is not necessarily the case.

To guarantee social protection, health systems should promote equity, accessibility, quality and efficiency. People’s wellbeing should always be prioritised. Economic development should be no more than a tool to help achieve human development. Because of the risks for equity in access to quality health care, we oppose the commercialisation of health care services.

Health systems that rely mainly on public provisioning and financing of health care perform better in terms of equitable access. A single public system also seems to perform better in terms of efficiency, while more privatised systems are more fragmented and incur more transaction costs.
Governments need to refrain from committing health services to commercialisation. Additionally, because of the market failures in health care and the proven impact on access to health care, there should be a carve-out for the health system in trade and investment agreements, enabling the state to safeguard health care access. For example, in Peru and Chile higher rates of potentially unnecessary procedures, particularly caesarean sections, were reported in private-for-profit settings after privatisation of obstetric services.

Extract from dossier Health, a commodity, by Campaign of Social Protection for all