Access cannot be equated simply with supply

EDITOR—Zwi et al in their editorial suggest means by which governments in developing countries should try to harness private providers to improve the health of their citizens.1 A recent article by Whitehead et al, however, points to a medical poverty trap, created by the introduction of user fees for public services and the growth of out of pocket expenses for private services.2 The authors conclude that the main challenge in developing countries is to improve public health services and enable the poorest sections of society to obtain the health care they need.

India has experienced a massive growth in private health provision despite high public investment in health services. Several studies have shown that there is a marked reluctance to use free facilities even among the poorest sections in Indian society. For example, a study of health and …