Quality and cost of medical care however, are not the only issues that call for regulatory mechanisms. There are other aspects of health care as well that are dependent upon adequate regulatory mechanisms. For example even though private sector largely deals with individual clinical care, the medical care inputs it provides overlap with the preventive components of components of comprehensive health care at several levels:

a) The provision of clinical care and therapeutics for diseases, which also come under national disease control or elimination programmes. Here by virtue of participating in treatment – which is the mainstay of prevention of infectious diseases such as tuberculosis, malaria, leprosy, etc. – the private sector contributes to lowering the possibility of disease spread and overlaps with preventive programmes.

b) Since immunisations have now become an expressed need of a significant proportion of people, they seek these services from the private sector. The latter provides it on payment but gets the supply of vaccines free from the government.

c) Health education is a key component of any clinical care and providing patients correct information goes a long way in comprehensive care. Thus, providing patients and their families information about personal protection, duration of treatment, preventive strategies, referral point, etc. is common to both the sectors.

d) Provision of curative care and information to the public during an infectious disease outbreak are important activities for epidemic control that again involve the private sector.

The fourth component of comprehensive care, i.e., nutrition, sanitation, drinking water supplies, housing, etc., in any case falls outside the scope of health service activities and thus requires intersectoral strategies.

It is, therefore, necessary to recognize that the private sector, despite its clinical and individual orientation, cannot absolve itself of its comprehensive care (i.e. preventive) responsibilities. To a contribute to the national efforts of disease control and prevention, it will have to adopt the uniform therapeutic norms and standarised procedures for diagnosis, treatment and follow up set for the control programmes. In addition, establishing channels to enrich national monitoring systems by providing feedback from private providers to these units will contribute to national efforts. There is an urgent need to develop mechanisms that will guide and promote these kinds of coordination and control systems.

Another dimension that needs to be highlighted is the fact that the private sector, despite having primary, secondary and tertiary levels to it, has a very restricted inbuilt referral system of its own. Given is profit orientation, there can be no automatic referral system as higher levels are costlier and often inaccessible. Also, very often private providers continue to treat even though they are not in a position to do justice to the patient. As a result, after primary or secondary private sector providers, a large number of users seek referral to public sector institutions of the next level. This link too needs to be streamlined. The referring practitioners should follow certain practices of providing clinical and laboratory information along with treatment provided. This is essential for ‘comprehensive care’ which demands integration of different levels of care.

These various dimensions of the interface between private and public sector health care need urgent attention and regulatory mechanisms are required to streamline the sharing of responsibility between these two sectors. The next section presents a review of available studies on the characteristics of the private sector at different levels of care.

Present Status of Private Sector

The private sector in India presents a picture of plurality and heterogeneity. It includes a large proportion of individual private practitioners providing mostly primary level curative services of extremely variable quality. These practitioners are located in urban and rural areas in the country. The next level of care is provided by the private nursing homes with bed strengths ranging from 5 to over 100m beds (Jesani: 1993, Bhat: 1993; Baru: 1998). While in most states they are largely an urban phenomenon, in other states, where private sector growth (relative to public sector) is high, they have spread to even peri urban and rural areas. Most of these nursing homes offer general and maternity services and are managed by doctor entrepreneurs (Baru: 1998). Within this category there is a further division between small and large nursing homes, which differ widely in terms of investments, equipment and facilities, range of services offered and quality of care. In fact it is difficult to judge how many of them are capable of providing secondary level care of reasonable standards (Nandraj: 1994). For example in Delhi only around 26 per cent of the nursing homes met the standards laid down by the Delhi Nursing Homes Act. The large majority therefore are not in a position to comply with the minimum standards (Interview with official at Directorate of Health Services, Delhi).

Private sector institutions providing tertiary care constitute roughly 1-2 per cent of the total number of medical care institutions. They are mainly the large hospitals run by trusts, private or public limited enterprises. These are only an urban phenomenon and have been the largest beneficiaries of subsidies given by the government. Their interests are at variance with owners of nursing homes whose scale and nature of operation is much smaller. Given these differences it is important that the State has a differential policy towards the two segments. The norms used for the public sector can be used as the basis for defining the parameters for primary, secondary and tertiary service delivery in the private sector and also arriving at certain minimum standards that need to be adhered to by the different levels. Based on the available studies we make some concrete suggestions.

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