Firm-level perspectives on public sector engagement with private healthcare providers: survey evidence from Ghana and Kenya

From paper to practice: an exploratory study of policy making and implementation in alternative forms of healthcare public-private partnership in Ghana

There has been growing advocacy for public-private partnership (PPP) in healthcare in both policy and academic circles over the last 3 decades. However, our understanding of the tensions between the policy cycle and critical organisational trade-offs that characterise alternative forms of healthcare PPPs remains limited. In this paper, we use Walt and Gilson's policy analysis triangle to explore the policy and practice of two alternative models of healthcare PPPs-autonomous and integrative partnerships-at the sub-national level in Ghana, a typical case of a polycentric health management structure. The study is a sequential exploratory qualitative design, consisting of review of four policy documents and in-depth interviews with 13 key informants, comprising health managers from the regional and district health directorates, and medical directors of selected private health facilities. Our findings reveal that in spite of the natural potential of integrative PPP models to present a relatively stronger policy capacity to the private partner than autonomous models, the capacity of sub-national level public-private actors to participate in policy making and implementation remains very limited across both models. We further find that effective policy making and implementation requires significant governance attention to building the policy capacity of actors across vertical and horizontal levels of the partnership, regardless of the model of engagement. We suggest that this is achievable through instrumental multistakeholderism in PPP policy, planning and management. The paper contributes to developing understanding of the policy and practice of healthcare PPP in polycentric institutional settings.

Proposed business and franchising models for primary care in Kenya

Purpose

The purpose of this paper is to present proposed solutions and interventions to some of the major barriers to providing adequate access to healthcare in Kenya. Specific business models are proposed to improve access to quality healthcare in low- and middle-income countries. Finally, strategies are developed for the retail clinic concept (RCC).

Design/methodology/approach

Google Scholar, PubMed and EBSCOhost were among the databases used to collect articles relevant to the purpose in Kenya. Various governmental and news articles were collected from Google searches. Relevant business models from other sectors were considered for potential application to healthcare and the retail clinic concept.

Findings

After a review of current methodologies and approaches to business and franchising models in various settings, the most relevant models are proposed as solutions to improving quality healthcare in Kenya through the RCC. For example, authors reviewed physician recruitment strategies, insurance plans and community engagement. The paper is informed by existing literature and reports as well as key informants.

Research limitations/implications

This paper lacks primary data collection within Kenya and is limited to a brief scoping review of literature. The findings provide effective strategies for various business and franchising models in healthcare.

Originality/value

The assembling of relevant information specific to Kenya and potential business models provides effective means of improving health delivery through business and franchising, focusing on innovative approaches and models that have proven effective in other settings.

From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance

BACKGROUND

Private practitioners are the preferred first point of care in a majority of low and middle-income countries and in this position, best placed for the surveillance of diseases. However their contribution to routine surveillance data is marginal. This systematic review aims to explore evidence with regards to the role, contribution, and involvement of private practitioners in routine disease data notification. We examined the factors that determine the inclusion of, and the participation thereof of private practitioners in disease surveillance activities.

METHODS

Literature search was conducted using the PubMed, Web of Knowledge, WHOLIS, and WHO-IRIS databases to identify peer-reviewed and gray full-text documents in English with no limits for year of publication or study design. Forty manuscripts were reviewed.

RESULTS

The current participation of private practitioners in disease surveillance efforts is appalling. The main barriers to their participation are inadequate knowledge leading to unsatisfactory attitudes and misperceptions that influence their practices. Complicated reporting mechanisms with unclear guidelines, along with unsatisfactory attitudes on behalf of the government and surveillance program managers also contribute to the underreporting of cases. Infrastructural barriers especially the availability of computers and skilled human resources are critical to improving private sector participation in routine disease surveillance.

CONCLUSION

The issues identified are similar to those for underreporting within the Integrated infectious Disease Surveillance and Response systems (IDSR) which collects data mainly from public healthcare facilities. We recommend that surveillance program officers should provide periodic training, supportive supervision and offer regular feedback to the practitioners from both public as well as private sectors in order to improve case notification. Governments need to take leadership and foster collaborative partnerships between the public and private sectors and most importantly exercise regulatory authority where needed.

District decision-making for health in low-income settings: a qualitative study in Uttar Pradesh, India, on engaging the private health sector in sharing health-related data

Health information systems are an important planning and monitoring tool for public health services, but may lack information from the private health sector. In this fourth article in a series on district decision-making for health, we assessed the extent of maternal, newborn and child health (MNCH)-related data sharing between the private and public sectors in two districts of Uttar Pradesh, India; analysed barriers to data sharing; and identified key inputs required for data sharing. Between March 2013 and August 2014, we conducted 74 key informant interviews at national, state and district levels. Respondents were stakeholders from national, state and district health departments, professional associations, non-governmental programmes and private commercial health facilities with 3–200 beds. Qualitative data were analysed using a framework based on a priori and emerging themes. Private facilities registered for ultrasounds and abortions submitted standardized records on these services, which is compulsory under Indian laws. Data sharing for other services was weak, but most facilities maintained basic records related to institutional deliveries and newborns. Public health facilities in blocks collected these data from a few private facilities using different methods. The major barriers to data sharing included the public sector’s non-standardized data collection and utilization systems for MNCH and lack of communication and follow up with private facilities. Private facilities feared information disclosure and the additional burden of reporting, but were willing to share data if asked officially, provided the process was simple and they were assured of confidentiality. Unregistered facilities, managed by providers without a biomedical qualification, also conducted institutional deliveries, but were outside any reporting loops. Our findings suggest that even without legislation, the public sector could set up an effective MNCH data sharing strategy with private registered facilities by developing a standardized and simple system with consistent communication and follow up.

Linkages between public and non-government sectors in healthcare: A case study from Uttar Pradesh, India

Effective utilisation of collaborative non-governmental organisation (NGO)-public health system linkages in pluralistic health systems of developing countries can substantially improve equity and quality of services. This study explores level and types of linkages between public health sector and NGOs in Uttar Pradesh (UP), an underprivileged state of India, using a social science model for the first time. It also identifies gaps and challenges for effective linkage. Two NGOs were selected as case studies. Data collection included semi-structured in-depth interviews with senior staff and review of records and reporting formats. Formal linkages of NGOs with the public health system related to registration, participation in district level meetings, workforce linkages and sharing information on government-supported programmes. Challenges included limited data sharing, participation in planning and limited monitoring of regulatory compliances. Linkage between public health system and NGOs in UP was moderate, marked by frequent interaction and some reciprocity in information and resource flows, but weak participation in policy and planning. The type of linkage could be described as 'complementarity', entailing information and resource sharing but not joint action. Stronger linkage is required for sustained and systematic collaboration, with joint planning, implementation and evaluation.

Does stewardship make a difference in the quality of care? Evidence from clinics and pharmacies in Kenya and Ghana

OBJECTIVE

To measure level and variation of healthcare quality provided by different types of healthcare facilities in Ghana and Kenya and which factors (including levels of government engagement with small private providers) are associated with improved quality.

DESIGN

Provider knowledge was assessed through responses to clinical vignettes. Associations between performance on vignettes and facility characteristics, provider characteristics and self-reported interaction with government were examined using descriptive statistics and multivariate regressions.

SETTING

Survey of 300 healthcare facilities each in Ghana and Kenya including hospitals, clinics, nursing homes, pharmacies and chemical shops. Private facilities were oversampled.

PARTICIPANTS

Person who generally saw the most patients at each facility.

MAIN OUTCOME MEASURE(S)

Percent of items answered correctly, measured against clinical practice guidelines and World Health Organization's protocol.

RESULTS

Overall, average quality was low. Over 90% of facilities performed less than half of necessary items. Incorrect antibiotic use was frequent. Some evidence of positive association between government stewardship and quality among clinics, with the greatest effect (7% points increase, P = 0.03) for clinics reporting interactions with government across all six stewardship elements. No analogous association was found for pharmacies. No significant effect for any of the stewardship elements individually, nor according to type of engagement.

CONCLUSIONS

Government stewardship appears to have some cumulative association with quality for clinics, suggesting that comprehensive engagement with providers may influence quality. However, our research indicates that continued medical education (CME) by itself is not associated with improved care.

Comparative performance of public and private sector delivery of BCG vaccination: evidence from Sub-Saharan Africa

BACKGROUND

The private sector is an important source of health care in the developing world. However, there is limited evidence on how private providers compare to public providers, particularly for preventive services such as immunizations. We used data from Sub-Saharan Africa (SSA) to assess public-private differences in Bacillus Calmette-Guérin (BCG) vaccine delivery.

METHODS AND FINDINGS

We used demographic and health surveys from 102,629 children aged 0-59 months from 29 countries across SSA to measure differences in BCG status for children born at private versus public health facilities (BCG is recommended at birth). We used a probit model to estimate public-private differences in BCG delivery, while controlling for key confounders. Next, we estimated how differences in BCG status evolved over time for children born at private versus public facilities. Finally, we estimated heterogeneity in public-private differences based on wealth and rural-urban residency. We found that children born at a private facility were 7.1 percentage points less likely to receive BCG vaccine in the same month as birth than children born at a public facility (95% CI 6.3-8.0; p<0.001). Most of this difference was driven by for-profit private providers (as opposed to NGOs) where the BCG provision rate was 10.0 percentage points less than public providers (95% CI 9.0-11.2; p<0.001) compared to only 2.4 percentage points for NGOs (95% CI 1.0-3. 8; p<0.01). Moreover, children born at private for-profit facilities remained less likely to be vaccinated up to 59 months after birth. Finally, public-private differences were more pronounced for poorer children and children in rural areas.

CONCLUSIONS

The for-profit private sector performed substantially worse than the public sector in providing BCG vaccine to newborns, resulting in a longer duration of vulnerability to tuberculosis. This disparity was greater for poorer children and children in rural areas.

Private sector provision of oral rehydration therapy for child diarrhea in sub-Saharan Africa

Although diarrheal mortality is cheaply preventable with oral rehydration therapy (ORT), over 700,000 children die of diarrhea annually and many health providers fail to treat diarrheal cases with ORT. Provision of ORT may differ between for-profit and public providers. This study used Demographic and Health Survey data from 19,059 children across 29 countries in sub-Saharan Africa from 2003 to 2011 to measure differences in child diarrhea treatment between private for-profit and public health providers. Differences in treatment provision were estimated using probit regression models controlling for key confounders. For-profit providers were 15% points less likely to provide ORT (95% confidence interval [CI] 13-17) than public providers and 12% points more likely to provide other treatments (95% CI 10-15). These disparities in ORT provision were more pronounced for poorer children in rural areas. As private healthcare in sub-Saharan Africa continues to expand, interventions to increase private sector provision of ORT should be explored.

Stakeholder Perceptions of a Pharmacy-Initiated Tuberculosis Referral Program in Cambodia, 2005-2012

Intensifying detection of tuberculosis (TB) symptomatic patients is a priority for Cambodia’s National Tuberculosis Program, in a country where two-thirds of the population has latent TB infection. In 2005, the National Tuberculosis Program initiated a public-private mix (PPM) collaborative program with external and local stakeholders to identify and refer persons with TB symptoms from private sector pharmacies to public sector clinics for diagnosis and treatment. This qualitative study conducted in-depth interviews with organizational stakeholders to assess their perceptions of PPM program collaboration and its sustainability in the long term. Results showed that stakeholders perceived that collaboration and efficient management had contributed to positive program performance. However, stakeholders expressed anxiety over program sustainability should external resources be reduced. Recent developments in pharmacy undergraduate education and recognition of pharmacy providers’ contribution to public health interventions may challenge PPM stakeholders to shift the paradigm from dependence on external agencies to confidence in local expertise and infrastructure.

For-profit sector immunization service provision: does low provision create a barrier to take-up?

Achievement of the health-related Millennium Development Goals is dependent on increasing take-up of preventive public health services (PHSs) in developing countries. Poor country governments often lack the resources to provide optimal access to preventive services and a great deal of attention is being directed towards the private sector to fill this void. In many developing countries, the private sector already plays a large role in health care. However, the for-profit private sector has little incentive to provide PHSs. The lack of provision of services by the for-profit sector may create a barrier to take-up of these services. In this study, we use data from a census of health facilities combined with data from community and provider surveys from Kenya to analyse whether the private for-profit sector has lower provision rates of child immunization services, and subsequently whether this creates a barrier that results in lower immunization take-up. We show that only 34% of for-profit facilities provide immunizations and that in areas with a larger share of for-profit providers, children are more likely to have no immunization coverage. Our model predicts that the odds of a child receiving no immunization coverage are 4.8 times higher in areas where all health facilities are for-profit compared to areas with no for-profit facilities. This indicates that a policy of engagement with the private for-profit sector aimed at increasing provision of immunization services may be an effective strategy for increasing take-up.

Healthy firms: constraints to growth among private health sector facilities in Ghana and Kenya

Background

Health outcomes in developing countries continue to lag the developed world, and many countries are not on target to meet the Millennium Development Goals. The private health sector provides much of the care in many developing countries (e.g., approximately 50 percent in Sub-Saharan Africa), but private providers are often poorly integrated into the health system. Efforts to improve health systems performance will need to include the private sector and increase its contributions to national health goals. However, the literature on constraints private health care providers face is limited.

Methodology/Principal Findings

We analyze data from a survey of private health facilities in Kenya and Ghana to evaluate growth constraints facing private providers. A significant portion of facilities (Ghana: 62 percent; Kenya: 40 percent) report limited access to finance as the most significant barrier they face; only a small minority of facilities report using formal credit institutions to finance day to day operations (Ghana: 6 percent; Kenya: 11 percent). Other important barriers include corruption, crime, limited demand for goods and services, and poor public infrastructure. Most facilities have paper-based rather than electronic systems for patient records (Ghana: 30 percent; Kenya: 22 percent), accounting (Ghana: 45 percent; Kenya: 27 percent), and inventory control (Ghana: 41 percent; Kenya: 24 percent). A majority of clinics in both countries report undertaking activities to improve provider skills and to monitor the level and quality of care they provide. However, only a minority of pharmacies report undertaking such activities.

Conclusions/Significance

The results suggest that improved access to finance and improving business processes especially among pharmacies would support improved contributions by private health facilities. These strategies might be complementary if providers are more able to take advantage of increased access to finance when they have the business processes in place for operating a successful business and health facility.