Universal health-care and the private sector

Mauritius has since before independence developed a strong welfare state, where the aim is that all Mauritians shall get not only a minimum of that which is necessary for a decent life, but also a wide range of quality welfare services. This has included a focus on health, and ever since the Titmuss Report, Mauritian governments have aimed to deliver free health-care to all its inhabitants.

An important aim of health-care in a welfare state is that it should be universal. Whilst there is no unanimously agreed definition of ‘universality’ or ‘universal health-care’, I see it as demanding that everyone has equal access to health-care of the same high quality. In other words, it contains three aspects: whether one can access care, the waiting time and the quality of care. ‘Quality of care’ includes clinical quality (the treatment as such), the information and explanations the patient receives from the medical staff, and hygiene and cleanliness. Whilst some argue that Mauritius has universal health-care because everyone can access health-care, I believe the truth to be more complex.

Whilst Mauritius fulfils some of the requirements of universality, it fails to fulfil others. On the positive side, care in the public health-care sector is free of charge at the point of delivery. This means that no-one is barred from attending health-care because they lack money for treatment, which has been the case in other countries. On another positive note, there is wide agreement that the clinical quality offered in the public sector is at least as good as that in the private sector.

However, the most recent available statistics demonstrate that patients in the private sector are more satisfied with the information and explanations they get from their doctors, the cleanliness of facilities and waiting time than patients in the public sector. The first difference might be explained by doctors in the public sector not having enough time for each patient, whilst doctors in private clinics are able to devote more time to each, because they are dealing with fewer of them. As for cleanliness, there have been numerous complaints about cleanliness in public health-care institutions, in some cases partly explained by the privatisation of cleaning services seeing unsatisfactory results. Waiting time for appointments and treatment is also believed to be shorter in the private sector than in the public sector. On the whole, there is therefore reason to maintain that the quality of care is better in the private sector than in the public sector – because of aspects of quality other than clinical quality – and more quickly available.

Has this got any consequences for the universality of health-care? That everyone can access health-care, and that the public sector, which is free at the point of delivery, can deliver clinical care of a relatively high standard, must certainly mean that health-care is universal? I disagree with that claim. Whilst everyone can access public health-care, the health-care that is offered by the private sector is on the whole better and has shorter waiting time.

Therefore, the important question that remains is whether everyone can access health-care in the private sector if they want to. The answer is that they cannot. Most private health-care is relatively expensive, and many Mauritians do not earn enough money to be able to pay for private care. The most recent available statistics indicate that at most 20 per cent of Mauritians are able to pay much for private health-care, and it is unlikely that more than five or ten per cent of Mauritians are able to handle large expenditure levels for it. Some private clinics indeed do not even hide the fact that there are individuals from the upper and upper middle classes that attend them for treatment. It is also important to note that very few Mauritians have health insurance, and most of those who are insured are insured by their employer in a medium- or large-sized business. This means that most Mauritians still have to pay for private health-care with their own money. Most cannot afford that.

Therefore, only those who are better-off can afford to pay for private health-care, which tends to be better and more quickly available than public health-care. Moreover, those who are able to afford the private alternative have also got the opportunity to cherry-pick services, that is, choose which sector and which provider to attend at different times. They can, therefore, attend the private sector when it offers the better health-care and opt for public health-care when it offers an alternative that is better. Those who have the means to choose private health-care, therefore, have the opportunity to always choose the better alternative irrespective of where it can be found. This creates inequality and means that health-care is not universal.

The issues that I have discussed in this article are serious challenges for the Mauritian welfare state and for equality in society. If the Mauritian people believes that those with money should be able to buy better and more quickly available health-care, this may not be a problem. If, however, it believes that everyone, irrespective of their means, should be able to access health-care of the same high quality, the current situation is not satisfactory.

As part of his postgraduate studies at the University of Oxford, Erik Eriksen researched the Mauritian health-care sector with a view to looking into the ways in which the private sector affected universal health-care. This included several months of research and interviews in Mauritius. This article discusses some of his most important findings.

Erik Eriksen, MPhil

Oxford Department of International Development

St Antony’s College – University of Oxford