Range of services in private and public health care institutions

Private forprofit HCIs tend to more readily offer certain services and shy away from others. This may mean that there are healthcare services where the private forprofit HCIs have a comparative advantage. In addition, forprofit health care institutions (HCIs) may cream skim best paying patients by focusing on most profitable services. Restricting the range of available services is one form of cream-skimming. Experience from industrialised countries suggests that forprofit HCIs cater to more defined demands like ambulatory care, surgery, and maternity services. Findings earlier studies in AP and from this study are consistent with the experience from industrialised countries. We found, for example, that availability of clinical services in hospitals was more or less similar between private and public sector. But the later provided in addition other services related to various public health programmes.

The study also revealed that private HCIs are quick to enter into the diagnostic services provision. All primarily diagnostic facilities in the study sample were private forprofit institutions. Similarly, ambulatory care very readily appears in the private forprofit sector, mostly by way of proprietary physician practice facilities. The proprietary physician practice facilities may have a distinct comparative advantage in provision of ambulatory care, by locating nearer to client locations, more compatible timings and better interpersonal care. Experience from industrialised countries also supports the general preference for proprietary physician practitioners as far as ambulatory care is concerned. Household survey data on health seeking behaviour in India shows higher preference for private HCIs for ambulatory care. Some of the factors giving a comparative advantage to private proprietary HCIs for ambulatory care are obvious. Since these are usually small in size ranging from solo clinics to small hospitals, they have the required locational flexibility to site nearer to their clientele. Distance is an important consideration for accessing of services from health care facilities and more so for ambulatory care. Another clear advantage of proprietary HCIs is their flexible timing, which again is an important consideration for accessing ambulatory medical care. Thus it would appear that private forprofit HCIs have a distinct comparative advantage for delivering ambulatory medical care.

There is some evidence of cream-skimming. For big hospitals, there appears to be no restriction in availability of public health services between private and public HCIs. Rate of participation in national programmes drops to around 30% in case of small hospitals and around 20% in case of private clinics. Polio and family planning programs are exceptions. More than 60% of small hospitals in the private sector reported to have participated in these programs. Rate of participation of private clinics in polio control program is around 30%. It would appear that big hospitals would play some role in National Health Programmes to broaden the scope of their services and in response to expectations of their clients. Participation by clinics and small private hospitals would appear to be determined by the interest of respective owner managers and effectiveness of the concerned programmes to involve the private sector. The higher rates of participation by private clinics and small hospitals in Polio and Family Welfare programmes would appear to have been due to specific efforts by these programmes to involve the private sector.

An important finding from the data on the range of available services is about failure of rational planning process in the public HCIs. The range of services available in a cross section of private health care institutions would be a result of two factors, namely the range of skills that doctors have to offer and demand for various services. On the other hand, we would normally expect the public sector to offer a smaller but more consistent range, if they were implementing something like an essential clinical package. We found that the range of clinical service available in public sector health care institutions in AP is not very different from that of in the private sector. It appears that in the matter of general clinical services both private and public sectors operate alike. Availability of clinical services in public sector appears to be determined by what doctors working in public sector have to offer. This is mainly because the personnel policy does not yet adequately define the cadre strength of doctors by specialty.