Elderly man receiving free Diabetic tests. Is the quality of our public healthcare adequate? Health sector reform initiatives announced recently by South Asian governments include permissions to foreign providers of medical care, leasing spare capacity in public facilities to private practitioners, encouraging private health insurance and offering concessional loans to private practitioners to practice in rural areas.

Among SAARC countries, India has the largest private sector and is an exporter of tertiary corporate health care to others in the region. The growth of the private sector is varied across the four largest countries.

While Bangladesh, Pakistan and Sri Lanka have a small presence of institutions at secondary and tertiary levels, India has a fairly large private sector at these levels, marked by regional variations.

Urban middle classes use private facilities more than government facilities, while the urban poor utilise the facilities of government hospitals where accessible.

In rural areas the use of private doctors is slightly more than that of private hospitals. For minor illnesses, simple herbal preparations and analgesics are much used. For chronic ailments, there is greater resort to traditional healers and ayurvedic practitioners.

The consequences of rapid privatisation during the 1980s and 1990s have been highly significant in Bangladesh, India, and Pakistan. The private sector has drawn middle and upper income groups away from public services.

Medical officers and professionals within the state health sector often practice privately.

In Bangladesh and Pakistan the private sector has been largely unregulated compared to Sri Lanka and has grown in a haphazard and uncontrolled manner. No effort has been made to regulate government doctors practicing privately. In Bangladesh, there was a steady growth of public institutions and manpower until the late seventies.

While there has been some expansion of facilities since then, many hospitals have been built, declines in investment have resulted in an overall shortage of facilities, personnel and supplies.

As far as training of doctors and paramedical personnel was concerned, the state started encouraging the establishment of private medical colleges.

Those trained in private colleges have been more interested in finding jobs in the private sector, reflecting trends seen in other countries.

Recent trends continue to show a shift in the appointment and training of medical personnel. Several states within India have tried to overcome the shortage of personnel in rural areas by appointing doctors on a contract basis.

There remains however a shortage of paramedical workers due to lack of growth in training and recruitment.

One solution to this impasse is to introduce cross-training of existing workers or to encourage community health workers on a voluntary basis with a small honorarium.

Health sector reform in South Asia not only presents certain common trends but also variations in the four largest SAARC countries.

Soon after independence the governments of these states had committed themselves to investing and building a welfare state governed by principles of equity and social justice.

With the exception of Sri Lanka which managed to build a universal and free welfare service, the others did not make the required investments in the welfare sector, especially health.

The global recession during the late seventies had an adverse impact on public spending and this resulted either in cutbacks or stagnation in investments in healthcare, particularly in the public sector.

The shift of policy in favour of privatisation within already highly iniquitous societies like ours in South Asia, is bound to marginalise access for poorer sections of society, which constitute around 30%-60% of the population.

The principles of universality have been gradually undermined with upper and middle income groups moving away from public provisioning, leaving the poor who use public services often ignored.

Indirect costs for even publicly provided services are increasing and there is evidence that a significant section of the population may not be able to afford even these services.

Equity concerns are very important at this juncture for health policy. Concern for public health should derive not only from concern about the impact of growth in market-based for-profit health care, but also from the national need to reduce differentials in the provision of health services.

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