2011 Supplement of Health Policy and Planning

“There is a growing acknowledgment that health system development for improved health and health care must include private actors. Researchers are gradually filling the gaps in knowledge necessary for this inclusion. These articles illustrate that private health sector research has moved beyond classifying and counting providers and users into assessment of mechanisms for harnessing the private sector and identifying conditions for their successful application.”

A Supplement of Health Policy and Planning was published as a result of the 2009 Symposium. The eight papers in the Supplement are open access and provide further details on the presentations that were given.

Moving towards in-depth knowledge on the private health sector in low- and middle-income countries

posted Sep 2, 2012, 1:38 PM by Jeff Knezovich

Birger C Forsberg, Dominic Montagu and Jesper Sundewall

The past two decades have seen a steady growth in attention to the private sector role within the overall health systems of low- and middle-income countries. Since the 1990s researchers have worked to call attention to the previously unrecognized scale of private medical services in the developing world (Berman and Rose 1996; Brugha and Zwi 1998;Hanson and Berman 1998; Preker et al. 2000; Uplekar 2000; Berman 2001; Mills et al. 2002; Harding and Preker 2003). As cross-country datasets have become available, the evidence has become increasingly clear that the private sector plays a major role in financing and provision of care in low- and middle-income countries (LMICs) (Zwi et al. 2001; Haet al. 2002; Liu et al. 2006; Konde-Lule et al. 2010). In parallel, a half-dozen multi-centre projects supporting research on the private sector in LMICs have been implemented (De Costa and Diwan 2007; Access Health International, n.d.; PSP, n.d.; PSP-One, n.d.; Results for Development Institute, n.d.). Evidence and analysis has also pointed to the challenges and opportunities that the private sector poses to health and health sector development (Lonnroth et al. 1998; Lonnroth et al. 2001; Travis and Cassels 2006).

The result of this growth in evidence is a general acknowledgement of the private sector and acceptance of its existence and important role in health care for many people in low- and middle-income countries. Consequently, the focus in research and policy development has moved from measurement to nuanced assessment of policy options and interventions for engagement of the private sector in public policy goal attainment (Montagu 2002; De Costa et al. 2008; Dimovska 2009; Lagomarsino 2009;Kangwana et al. 2011).

Role of the private sector in the provision of immunization services in low- and middle-income countries

posted Sep 2, 2012, 1:37 PM by Jeff Knezovich

Ann Levin and Miloud Kaddar

The authors conducted a literature review on the role of the private sector in low- and middle-income countries. The review indicated that relatively few studies have researched the role of the private sector in immunization service delivery in these countries. The studies suggest that the private sector is playing different roles and functions according to economic development levels, the governance structure and the general presence of the private sector in the health sector. In some countries, generally low-income countries, the private for-profit sector is contributing to immunization service delivery and helping to improve access to traditional EPI vaccines. In other countries, particularly middle-income countries, the private for-profit sector often acts to facilitate early adoption of new vaccines and technologies before introduction and generalization by the public sector.

The not-for-profit sector plays an important role in extending access to traditional EPI vaccines, particularly in low-income countries. Not-for-profit facilities are situated in rural as well as urban areas and are more likely to be coordinated with public services than the private for-profit sector. Although numerous studies on non-governmental organizations (NGOs) suggest that the extent of NGO provision of immunization services in low- and middle-income countries is substantial, the contribution of this sector is poorly documented, leading to a lack of recognition of its role at national and global levels.

Studies on quality of immunization service provision at private health facilities suggest that it is sometimes inadequate and needs to be monitored. Although some articles on public–private collaboration exist, little was found on the extent to which governments are effectively interacting with and regulating the private sector.

The review revealed many geographical and thematic gaps in the literature on the role and regulation of the private sector in the delivery of immunization services in low- and middle-income countries.

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Predicting performance in contracting of basic health care to NGOs: experience from large-scale contracting in Uttar Pradesh, India

posted Sep 2, 2012, 1:36 PM by Jeff Knezovich

Anna Heard, Maya Kant Awasthi, Jabir Ali, Neena Shukla, and Birger C Forsberg

Escalating costs and increasing pressure to improve health services have driven a trend toward contracting with the private sector to provide traditionally state-run services. Such contracting is seen as an opportunity to combine theorized advantages of contracting with the efficiency of the private sector. There is still a limited understanding of the preconditions for successful use of contracting and the resources needed for their appropriate use and sustainability. This study assesses the large-scale contracting of 294 non-governmental organizations (NGOs) for delivery of basic health services in Uttar Pradesh, a state with almost 170 million in India. Due to high rates of discontinuation or non-renewal of contracts based on poor performance in the project, a better method for selecting partners was requested. Data on characteristics of the NGOs (intake data) and performance/outcome monitoring indicators were combined to identify correlations. The results showed that NGOs selected were generally small but well-established, had implemented at least two large projects, and had more non-health experience than health experience. Bivariate regressions of outcome score on each input variable showed that training experience, proposal quality and having ‘health’ contained in the objectives of the organization were statistically significant predictors of good performance. Factors relating to financial capacity, staff qualification, previous experience with health or non-health projects, and age of establishment were not. A combined training plus proposal score was highly predictive of outcome score (β = 1.37, P < 0.001). The combined score was found to be a much better predictor of outcome scores than a total score used to select NGOs (β = 0.073, P = 0.539). The study provides valuable information from large-scale contracting. Conclusions on criteria for selecting NGOs for providing basic health care could guide other governments choosing to contract for such services.

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Comparison of trust in public vs private health care providers in rural Cambodia

posted Sep 2, 2012, 1:35 PM by Jeff Knezovich

Sachiko Ozawa and Damian G Walker

How trust in providers affects health care-seeking behaviour is not well understood. Focus groups and household surveys were conducted in Cambodia to examine how villagers describe their trust in public and private providers, and to assess whether a difference exists in provider trust levels. Our findings suggest the reasons for trusting public and private providers differ, and that villagers’ trust in and relationship with providers is one of the important considerations affecting where they seek care. People believed that public providers were ‘honest’ and ‘sincere’, did not ‘bad mouth people’ and explained the ‘status of [the] disease’. Villagers trusted public providers for their skills and abilities, and for an effective referral system. In contrast, respondents noted that seeing private providers was ‘comfortable and easy’, that they ‘come to our home’ and patients can ‘owe [them] some money’. Private providers were trusted for being very friendly and approachable, extremely thorough and careful, and easy to contact. Among those who sought care in the past 30 days, trust in the health care provider was listed as the fifth and second most important consideration for choosing public or private providers, respectively. This study illustrates the importance of trust as a unique concept that can affect people’s choice of health care providers in a low-income country.

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Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia

posted Sep 2, 2012, 1:33 PM by Jeff Knezovich

Bruno Meessen, Maryam Bigdeli, Kannarath Chheng, Kristof Decoster, Por Ir, Chean Men, and Wim Van Damme

In spite of all efforts to build national health services, health systems of many low-income countries are today highly pluralistic. Households use a vast range of public and private health care providers, many of whom are not controlled by national health authorities. Experts have called on Ministries of Health to re-establish themselves as stewards of the entire health system. Modern stewardship will require national and decentralized health authorities to have an overall view of their pluralistic health system, especially of the components outside the public sector. Little guidance has been provided so far on how to develop such a view. In this paper, we explore whether household surveys could be a source of information. The study builds on secondary data analysis of a household survey carried out in three health districts in rural Cambodia and of two national surveys. Cambodia is indeed an interesting case, as massive efforts by donors in favour of the public sector go hand in hand with a dominant role of the private sector in the provision of health care services. The study confirms that the health care sector in Cambodia is now highly pluralistic, and that the great majority of health seeking behaviour takes place outside the public health system. Our analysis of the survey also shows that the disaffection of the population with public health facilities varies across places, socio-economic groups and health problems. We illustrate how such knowledge could allow stewards to better identify challenges for existing or future health policies. We argue that a whole research programme on the composition of pluralistic health systems still needs to be developed. We identify some challenges and opportunities.

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Making health markets work better for poor people: the case of informal providers

posted Sep 2, 2012, 1:32 PM by Jeff Knezovich

Gerald Bloom, Hilary Standing, Henry Lucas, Abbas Bhuiya, Oladimeji Oladepo, and David H Peters

There has been a dramatic spread of market relationships in many low- and middle-income countries. This spread has been much faster than the development of the institutional arrangements to influence the performance of health service providers. In many countries poor people obtain a large proportion of their outpatient medical care and drugs from informal providers working outside a regulatory framework, with deleterious consequences in terms of the safety and efficacy of treatment and its cost. Interventions that focus only on improving the knowledge of these providers have had limited impact. There is a considerable amount of experience in other sectors with interventions for improving the performance of markets that poor people use. This paper applies lessons from this experience to the issue of informal providers, drawing on the findings of studies in Bangladesh and Nigeria. These studies analyse the markets for informal health care services in terms of the sources of health-related knowledge for the providers, the livelihood strategies of these providers and the institutional arrangements within which they build and maintain their reputation. The paper concludes that there is a need to build a systematic understanding of these markets to support collaboration between key actors in building institutional arrangements that provide incentives for better performance.

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The principal-agent problems in health care: evidence from prescribing patterns of private providers in Vietnam

posted Sep 2, 2012, 1:26 PM by Jeff Knezovich

Ha Nguyen

The principal-agent problem in health care asserts that providers, being the imperfect agents of patients, will act to maximize their profits at the expense of the patients’ interests. This problem applies especially where professional regulations are lacking and incentives exist to directly link providers’ actions to their profits, such as a fee-for-service payment system. The current analysis tests for the existence of the principal-agent problem in the private health market in Vietnam by examining the prescribing patterns of private providers. I show that: (1) private providers were able to induce demand by prescribing more drugs than public providers for a similar illness and patient profile; (2) private providers were significantly more likely to prescribe injection drugs to gain trust among the patients; and (3) patients’ education as a source of information and empowerment has enabled them to mitigate the demand inducement by the providers. The hypotheses are supported with evidence from the Vietnam National Health Survey 2001–02, the first and, so far, only comprehensive health survey in the country.

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Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?

posted Sep 2, 2012, 1:25 PM by Jeff Knezovich

Nirali M Shah, Wenjuan Wang and David M Bishai

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific.

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The private sector role in HIV/AIDS in the context of an expanded global response: expenditure trends in five sub-Saharan African countries

posted Sep 2, 2012, 1:23 PM by Jeff Knezovich   [ updated Sep 2, 2012, 1:23 PM ]

Sara Sulzbach, Susna De and Wenjuan Wang

Global financing for the HIV response has reached unprecedented levels in recent years. Over US$10 billion were mobilized in 2007, an effort credited with saving the lives of millions of people living with HIV (PLHIV). A relatively unexamined aspect of the global HIV response is the role of the private sector in financing HIV/AIDS services. As the nature of the response evolves from emergency relief to long-term sustainability, understanding current and potential contributions from the private sector is critical. This paper examines trends in private sector financing, management and resource consumption related to HIV/AIDS in five sub-Saharan African countries, with a particular emphasis on the effects of recently scaled-up donor funding on private sector contributions. We analysed National Health Accounts HIV/AIDS subaccount data for Kenya, Malawi, Rwanda, Tanzania and Zambia between 2002 and 2006. HIV subaccounts provide comparable data on the flow of HIV/AIDS funding from source to use. Findings indicate that private sector contributions decreased in all countries except Tanzania. With regards to managing HIV/AIDS funds, non-governmental organizations are increasingly controlling the largest share of resources relative to other stakeholders, whereas private for-profit entities are managing fewer HIV/AIDS resources since the donor influx. The majority of HIV/AIDS funds were spent in the public sector, although a considerable amount was spent at private facilities, largely fuelled by out-of-pocket (OOP) payments. On the whole, OOP spending by PLHIV decreased over the 4-year period, with the exception of Malawi, demonstrating that PLHIV have increased access to free or subsidized HIV/AIDS services. Our findings suggest that the influx of donor funding has led to decreased private contributions for HIV/AIDS. The reduction in private sector investment and engagement raises concerns about the sustainability of HIV/AIDS programmes over the long term, particularly in light of current global economic crisis and emerging competing priorities.

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