Factors influencing private health providers' technical quality of care for acute respiratory infections among under-five children in rural West Bengal,India

In many developing countries, private health practitioners provide a significant portion of curative care for diseases which are of public health importance. Currently, health sector reform efforts in these countries are fostering increased participation of private providers in the delivery of health services, including those of public health importance. Guaranteeing good technical quality of care is critical to the process. However, little is known about private providers' technical quality of care (disease management practices) and the factors influencing these services. The purpose of this study was to contribute information on this topic.The study was conducted among private providers in rural West Bengal, India and focused on providers' disease management practices for acute respiratory infections (ARI) among under-five children. World Health Organization (WHO) guidelines for ARI case management were used as the expected standard of care. Observations of patient-provider encounters and interviews with the providers and mothers were the main sources of data.The study found that private health providers in rural West Bengal have inadequate technical quality of care. The problem was related both to low levels of performance (limited potential) and inconsistency in performance (within-provider variation). Limited potential for good technical quality for ARI among the providers was related to lack of knowledge (technical incompetence). One of the important factors influencing within-provider variation was patient load. Since rural private providers operate on a fee-for-service payment system, there are incentives related to seeing many patients. The study concluded that to bring about sustainable improvements in private providers' ARI disease management practices, training programs and interventions that improved compliance were necessary.     

Efficiency and quality in the public and private sectors in Senegal

It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access.     

'Where is the public health sector?' Public and private sector healthcare provision in Madhya Pradesh, India

OBJECTIVE: This paper aims to empirically demonstrate the size and composition of the private health care sector in one of India's largest provinces, Madhya Pradesh. METHODOLOGY: It is based on a field survey of all health care providers in Madhya Pradesh (60.4 million in 52,117 villages and 394 towns). Seventy-five percent of the population is rural and 37% live below poverty line. This survey was done as part of the development of a health management information system. FINDINGS: The distribution of health care providers in the province with regard to sector of work (public/private), rural-urban location, qualification, commercial orientation and institutional set-up are described. Of the 24,807 qualified doctors mapped in the survey, 18,757 (75.6%) work in the private sector. Fifteen thousand one hundred forty-two (80%) of these private physicians work in urban areas. The 72.1% (67793) of all qualified paramedical staff work in the private sector, mostly in rural areas. CONCLUSION: The paper empirically demonstrates the dominant heterogeneous private health sector and the overall the disparity in healthcare provision in rural and urban areas. It argues for a new role for the public health sector, one of constructive oversight over the entire health sector (public and private) balanced with direct provision of services where necessary. It emphasizes the need to build strong public private partnerships to ensure equitable access to healthcare for all.     

Household utilization and expenditure on private and public health services in Vietnam

The private provision of health services in Vietnam was legalized in 1989 as one of the country's means to mobilize resources and improve efficiency in the health system. Ten years after its legalization, the private sector has widely expanded its activities and become an important provider of health services for the Vietnamese people. However, little is known about its contribution to the overall objectives of the health system in Vietnam. This paper assesses the role of the private health care provider by examining utilization patterns and financial burden for households of private, as compared with public, services. We found that the private sector provided 60% of all outpatient contacts in Vietnam. There was no difference by education, sex or place of residence in the use of private ambulatory health care. Although there was evidence suggesting that rich people use private care more than the poor, this finding was not consistent across all income groups. The private sector served young children in particular. Also, people in households with several sick members at the same time relied more on private than public care, while those with severe illnesses tended to use less private care than public. The financial burden for households from private health care services was roughly a half of that imposed by the public providers. Expenditure on drugs accounted for a substantial percentage of household expenditure in general and health care expenditure in particular. These findings call for a prompt recognition of the private sector as a key player in Vietnam's health system. Health system policies should mobilize positive private sector contributions to health system goals where possible and reduce the negative effects of private provision development.     

Comparative quality of private and public health services in rural Vietnam

BACKGROUND: Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared. METHODS: A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes. RESULTS: There were 11.5 private providers per 10,000 population, compared with 6.7 public providers per 10,000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups. CONCLUSIONS: Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.     

Administrative and management issues in public-private collaboration

With the growing emphasis on developing public/private-sector collaborations for the provision of behavioral healthcare services to Medicaid recipients, one of the key issues will be clarifying the distinction between provider networks and systems of care. The latter provide a comprehensive spectrum of vertically and horizontally integrated services to targeted populations. Public/private collaborations will also require new and modified outcomes measurement systems and quality management programs, building on what already exists in each sector.     

Health care in China: the role of non-government providers

While China's health services are primarily financed by out-of-pocket spending (private financing), health care providers, especially the hospital industry, are still dominated by state ownership and government control (public provision). Even though the private sector plays an increasing role in the ambulatory sector, private services are not included in the social insurance benefit package, and thus, it primarily serves self-paying patients. The ambiguity of the government policy toward private provision stems from concerns that an increasing private sector would drive up costs and its services may be of questionable quality. This paper tries to gather evidence on the relative performance of private and public sector in China. Neither literature review nor our primary data analysis provides any support for the notion that the private sector charges a higher price and they serve primarily the better-off people. Quite on the contrary, available data seem to suggest that not only the private sector tends to serve disproportionately the low-middle income groups (this may well be due to its relative lower direct and indirect costs), consumer satisfaction also seems to be higher with regards to certain dimensions of the private than public sector.     

Market reforms and public incentives: finding a balance in the Republic of Macedonia

The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians-over 40% of all physicians-will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies.     

Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India

The private medical sector is an important and rapidly growing source of health care in India. Private medical providers (PMP) are a diverse group, known to be poorly regulated by government policies and variable in the quality of services provided. Studies of their practices have documented inappropriate prescribing as well as violation of ethical guidelines on patient care. However, despite the critique that inequitable services characterise the private medical sector, PMPs remain important and preferred providers of primary care. This paper argues that their greater involvement in the public health framework is imperative to addressing the goal of health equity. Through a review of two research studies conducted in Pune, India, to examine the role of PMPs in tuberculosis (TB) and HIV/AIDS care, the themes of equity and access arising in private sector delivery of care for TB and HIV/AIDS are explored and the future policy directions for involving PMPs in public health programmes are highlighted. The paper concludes that public-private partnerships can enhance continuity of care for patients with TB and HIV/AIDS and argues that interventions to involve PMPs must be supported by appropriate research, along with political commitment and leadership from both public and private sectors.     

Private health care provision in developing countries: a preliminary analysis of levels and composition

While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes.     

Quality of care assessment of public and private outpatient clinics in Metro Cebu,the Philippines

Despite large investments in primary health care in developing countries, evaluation of the quality of services has been neglected. Managers need information on service quality to identify specific ways to improve health-care delivery, and to determine how health programs can achieve their desired effects. We tested several quality-assessment methods in 48 public and private outpatient clinics in Metro Cebu, The Philippines. Structured observations of immunization sessions and clinic logistics highlighted functional problems at particular clinics that contributed to shortages of vaccines, sterilized needles and oral rehydration salts (ORS). Quality assessment of medical records for the treatment of diarrhea revealed a wide variation in the recorded quality of services. Clinical case histories were presented to public and private providers, who advised different approaches for case management, highlighting areas where improvement is needed. For example, public providers were more likely to use ORS to treat dehydration; private providers were more likely to enquire about symptoms of dysentery. Private providers were more likely to treat a mild respiratory infection with antibiotics, but few providers were likely to prescribe antibiotics for a child with signs suggestive of severe pneumonia. Advice to mothers was insufficient in most areas. These quality-assessment methods can be used by managers to develop training curricula and solve problems in the delivery of primary health-care services.     

Microfinance investments in quality at private clinics in Uganda: a case-control study

Background  

Small private-sector health care providers can play an important role in meeting the developing country health care needs, but a lack of credit can prove major constraint to small-provider expansion. This study examines the potential of small, microfinance loans to strengthen the private health sector and improve access to quality preventive and curative health services in Uganda.     

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

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.     

The public and private sectors in health: economic issues

Major changes in the public/private mix of health services are occurring in many countries. These changes may be analysed by examining the financing and provision of services and subsidization of the purchase of the factors of production. The public sector and not-for-profit and for-profit elements of the private sector must be viewed as separate entities in such analyses due to their differing objectives, motives and form of operation. The issues to be dealt with by countries in finding the public/private mix which is appropriate for their health system and achieves their objectives include efficiency, quality, regulation, equity and consumer choice and satisfaction. The recommendations for action for countries include: promoting collaboration between private and public sectors; testing different public/private mix models; identifying appropriate expansion paths for private sector services; improving information for policy and planning decisions; enhancing management capacity; and, reviewing programme and project support. International agencies also have a role in this process by supporting countries through the provision of technical assistance, financial aid, promoting policy reviews, and facilitating the sharing of information and experiences among countries concerning these public/private mix issues.     

A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.     

Third sector primary care for vulnerable populations.

This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based M?ori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.     

Vouchers for primary healthcare services in an ageing world? The perspectives of elderly voucher recipients in Hong Kong

Considering the ageing population in economically advanced regions across the world, measures are necessary to enhance the health of the older population as well as contain public healthcare spending. Hong Kong implements the Elderly Health Care Voucher Scheme (EHCVS), providing older people aged 65 or above an annual subsidy of visiting private healthcare service providers for chronic disease prevention and management. The services also aim at reallocating demand from the public to private sector as well as improve quality of services. This qualitative study explored the experiences of EHCVS recipients (n = 55, aged 61–94) with eight focus group interviews in Hong Kong in the year 2016. Convenience sampling was used. Research questions were: (1) Why do older people choose not to use EHCVS for preventive as well as disease management services among older people in Hong Kong? (2) What are the barriers to reallocating demand from the public to private sector? (3) In what ways did EHCVS improve the quality of primary care services for older people? Using a deductive and inductive approach, eight qualitative themes were identified. Findings suggested that the non‐targeted services and inadequate knowledge on EHCVS deterred older people from using the vouchers for disease management and prevention. The relatively expensive private services, lack of trust in the private sector, low public clinic fees and good services quality of the public sector, together with inadequate private practitioners in the healthcare market were barriers that hinder demand reallocation. Nevertheless, the quality of primary care services had been improved after the implementation of EHCVS with shortened wait times and opportunities to discuss health‐related issues with private practitioners. Findings were discussed with practice, policy and research implications.     

Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

Provider Perceptions of Reproductive Health Service Quality in Jordanian Public Community Health Centers

Enhancing the quality of reproductive health care delivery in developing countries is a key prerequisite to increased utilization and sustainability of these services in the target population. Our objective was to assess the perception of quality of reproductive health (RH) care services provided by Jordanian Ministry of Health community-based centers from the perspective of service providers in these settings. A purposeful nationwide sample of 50 primary health care providers took part in five focus group discussions with the purpose of exploring their perceptions of the quality of care provided by their centers and perceived barriers to the provision of quality RH care. Health care providers felt that the quality of RH care provided by their centers was suboptimal. Focus group participants reported numerous barriers to the provision of high quality-care in the clinical setting. These included issues related to patient overload, patient and physician characteristics, as well as problems inherent to supervisory and administrative functions. Exploring and aligning goals and expectations of RH care providers and administrators may result in improvements in the quality of RH care service delivery and morale in public health settings in Jordan, which is a requirement for public sector reform.