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Coveney L, Musoke D, Russo G. Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries. Health Policy Plan 2023; 38:1050-1063. [PMID: 37632759 PMCID: PMC10566321 DOI: 10.1093/heapol/czad075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 08/07/2023] [Accepted: 08/15/2023] [Indexed: 08/28/2023] Open
Abstract
Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.
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Affiliation(s)
- Laura Coveney
- The Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, United Kingdom
| | - David Musoke
- School of Public Health, Makerere University, New Mulago Hill Road, Mulango, Kampala, Uganda
| | - Giuliano Russo
- The Wolfson Institute of Population Health, Queen Mary University of London, 58 Turner Street, London E1 2AB, United Kingdom
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Siddiqi S, Aftab W, Venkat Raman A, Soucat A, Alwan A. The role of the private sector in delivering essential packages of health services: lessons from country experiences. BMJ Glob Health 2023; 8:bmjgh-2022-010742. [PMID: 36657810 PMCID: PMC9853132 DOI: 10.1136/bmjgh-2022-010742] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/10/2022] [Indexed: 01/20/2023] Open
Abstract
Many countries are adopting essential packages of health services (EPHS) to implement universal health coverage (UHC), which are mostly financed and delivered by the public sector, while the potential role of the private health sector (PHS) remains untapped. Currently, many low-income and lower middle-income countries (LLMICs) have devised EPHS; however, guidance on translating these packages into quality, accessible and affordable services is limited. This paper explores the role of PHS in achieving UHC, identifies key concerns and presents the experience of the Diseases Control Priorities 3 Country Translation project in Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar. There are key challenges to engagement of the PHS, which include the complexity and heterogeneity of private providers, their operation in isolation of the health system, limitations of population coverage and equity when left to PHS's own choices, and higher overall cost of care for privately delivered services. Irrespective of the strategies employed to involve the PHS in delivering EPHS, it is necessary to identify private providers in terms of their characteristics and contribution, and their response to regulatory tools and incentives. Strategies for regulating private providers include better statutory control to prevent unlicensed practice, self-regulation by professional bodies to maintain standards of practice and accreditation of large private hospitals and chains. Potentially, purchasing delivery of essential services by engaging private providers can be an effective 'regulatory approach' to modify provider behaviour. Despite existing experience, more research is needed to better explore and operationalise the role of PHS in implementing EPHS in LLMICs.
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Affiliation(s)
- Sameen Siddiqi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Wafa Aftab
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - A Venkat Raman
- Faculty of Management Studies, University of Delhi, New Delhi, India
| | - Agnès Soucat
- Division of Health and Social Protection, France Development Agency (AFD), Paris, France
| | - Ala Alwan
- London School of Hygiene & Tropical Medicine, London, UK
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Ravindran TKS, Govender V. Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries. Sex Reprod Health Matters 2020; 28:1779632. [PMID: 32530387 PMCID: PMC7887992 DOI: 10.1080/26410397.2020.1779632] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.
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Affiliation(s)
- T. K. Sundari Ravindran
- Principal Visiting Fellow, United Nations University, International Institute for Global Health, Kuala Lumpur, Malaysia
| | - Veloshnee Govender
- Scientist, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Shamu S, Farirai T, Kuwanda L, Slabbert J, Guloba G, Johnson S, Khupakonke S, Masihleho N, Kamera J, Nkhwashu N. Social franchising of community-based HIV testing and linkage to HIV care and treatment services: an evaluation of a pilot study in Tshwane, South Africa. J Int AIDS Soc 2018; 21:e25216. [PMID: 30569625 PMCID: PMC6300754 DOI: 10.1002/jia2.25216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 11/14/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Although HIV testing services (HTS) have been successfully task-shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small-scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS-managed pilot project compared to the Foundation for Professional Development (FPD) employee-managed HTS programme in testing and linking clients to care. METHODS Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV-prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per-HIV test and received larger payments per-HIV-positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per-counsellor cost of HIV test and linkage to care in the two HTS groups. RESULTS The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first-time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV-positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13). CONCLUSIONS SF HTS was effective in identifying more clients, first-time HIV testers and more HIV-positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD-employee model. We recommend strengthening SFs particularly their linkage to care activities.
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Affiliation(s)
- Simukai Shamu
- Foundation for Professional DevelopmentPretoriaSouth Africa
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Thato Farirai
- Foundation for Professional DevelopmentPretoriaSouth Africa
| | | | - Jean Slabbert
- Foundation for Professional DevelopmentPretoriaSouth Africa
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Benova L, Campbell OMR, Sholkamy H, Ploubidis GB. Socio-economic factors associated with maternal health-seeking behaviours among women from poor households in rural Egypt. Int J Equity Health 2014; 13:111. [PMID: 25424200 PMCID: PMC4247707 DOI: 10.1186/s12939-014-0111-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/03/2014] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Socio-economic inequalities in basic maternal health interventions exist in Egypt, yet little is known about health-seeking of poor households. This paper assesses levels of maternal health-seeking behaviours in women living in poor households in rural Upper Egypt, and compares these to national averages. Secondly, we construct innovative measures of socio-economic resourcefulness among the rural poor in order to examine the association between the resulting variables and the four dimensions of maternal health-seeking behaviour. METHODS We analysed a cross-sectional survey conducted in Assiut and Sohag governorates in 2010-2011 of 2,242 women in households below the poverty line in 65 poorest villages in Egypt. The associations between four latent socio-economic constructs (socio-cultural resourcefulness, economic resourcefulness, dwelling quality and woman's status) and receipt of any antenatal care (ANC), regular ANC (four or more visits), facility delivery and private sector delivery for women's most recent pregnancy in five years preceding survey were assessed using multivariate logistic regression. RESULTS In the sample, 58.5% of women reported using any ANC and 51.1% facility delivery, lower than national coverage (74.2% and 72.4%, respectively). The proportion of ANC users receiving regular ANC was lower (67%) than nationally (91%). Among women delivering in facilities, 18% of women in the poor Upper Egypt sample used private providers (63% nationally). In multivariate analysis, higher economic resourcefulness was associated with higher odds of receiving ANC but with lower odds of facility delivery. Socio-cultural resourcefulness was positively associated with receiving any ANC, regular ANC and facility delivery, whereas it was not associated with private delivery care. Dwelling quality was positively associated with private delivery facility use. Woman's status was not independently associated with any of the four behaviours. CONCLUSIONS Coverage of basic maternal health interventions and utilisation of private providers are lower among rural poor women in Upper Egypt than nationally. Variables capturing socio-cultural resourcefulness and economic resourcefulness were useful predictors of ANC and facility delivery. Further understanding of issues surrounding availability, affordability and quality of maternal health services among the poor is crucial to eliminating inequalities in maternal health coverage in Egypt.
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Affiliation(s)
- Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Oona M R Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Hania Sholkamy
- Social Research Center, American University in Cairo, Cairo, Egypt.
| | - George B Ploubidis
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. .,Centre for Longitudinal Studies, Institute of Education, London, WC1H 0AL, UK.
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Poverty, food security and universal access to sexual and reproductive health services: a call for cross-movement advocacy against neoliberal globalisation. REPRODUCTIVE HEALTH MATTERS 2014; 22:14-27. [DOI: 10.1016/s0968-8080(14)43751-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Freedman LP, Schaaf M. Act global, but think local: accountability at the frontlines. REPRODUCTIVE HEALTH MATTERS 2013; 21:103-12. [DOI: 10.1016/s0968-8080(13)42744-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Beyeler N, York De La Cruz A, Montagu D. The impact of clinical social franchising on health services in low- and middle-income countries: a systematic review. PLoS One 2013; 8:e60669. [PMID: 23637757 PMCID: PMC3634059 DOI: 10.1371/journal.pone.0060669] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 03/01/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access. OBJECTIVES AND METHODS We examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings. RESULTS Of 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes. CONCLUSIONS Our review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system.
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Affiliation(s)
- Naomi Beyeler
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | - Anna York De La Cruz
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
| | - Dominic Montagu
- Global Health Group, University of California San Francisco, San Francisco, California, United States of America
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Gilbert C, Muhit M. Eye conditions and blindness in children: priorities for research, programs, and policy with a focus on childhood cataract. Indian J Ophthalmol 2012; 60:451-5. [PMID: 22944758 PMCID: PMC3491274 DOI: 10.4103/0301-4738.100548] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Accepted: 07/25/2012] [Indexed: 11/23/2022] Open
Abstract
The major causes of blindness in children encompass intrauterine and acquired infectious diseases, teratogens and developmental and molecular genetics, nutritional factors, the consequences of preterm birth, and tumors. A multidisciplinary approach is therefore needed. In terms of the major avoidable causes (i.e., those that can be prevented or treated) the available evidence shows that these vary in importance from country to country, as well as over time. This is because the underlying causes closely reflect socioeconomic development and the social determinants of health, as well as the provision of preventive and therapeutic programs and services from the community through to tertiary levels of care. The control of blindness in children therefore requires not only strategies that reflect the local epidemiology and the needs and priorities of communities, but also a well functioning, accessible health system which operates within an enabling and conducive policy environment. In this article we use cataract in children as an example and make the case for health financing systems that do not lead to 'catastrophic health expenditure' for affected families, and the integration of eye health for children into those elements of the health system that work closely with mothers and their children.
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Affiliation(s)
- Clare Gilbert
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine and Medical Advisor, Sightsavers, UK
| | - Mohammed Muhit
- International Centre for Eye Health, Department of Clinical Research, London School of Hygiene and Tropical Medicine and Medical Advisor, Sightsavers, UK
- Department of Public Health and Life Sciences, University of South Asia, Dhaka, Bangladesh and Child Sight Foundation (CSF), Dhaka, Bangladesh
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