Summary of findings

The systematic review identified 52 studies on working with private for-profit providers in low- and middle-income countries. These interventions concerned training (26), social marketing (14), pre-packaging of drugs (2), provision of vouchers (4), contracting-out (3), franchising (6), regulation (2), and accreditation (1).
The quality of the evidence across all of the interventions reported below was low, and the review authors did not provide enough information to produce GRADE summary of findings tables.

1) Social marketing and pre-packaging

Social marketing is the application of the tools and concepts of commercial marketing to social and health problems, in order to increase population coverage of effective and affordable interventions. Social marketing interventions may include a combination of promotional activities, branding, labelling, pre-packaging and subsidy of public health products.

Fourteen social marketing studies were identified, with two of them also including pre-packaged treatments. Two of the studies provided data on the impact on equity.

• All studies showed significant increases in the utilization of programme commodities and services, though of differing magnitudes across interventions. For example, social marketing increased condom use among women in urban Cameroon from 58% to 76%.
• A project in Tanzania which distributed branded insecticide-treated mosquito nets and net treatment kits through retail outlets led to asignificant increase (of 51%) in household net ownership among the poorest income quartile in the social marketing area compared to 32% in the control area.

2) Provision of vouchers

A voucher is a form of demand-side subsidy that the recipient can use as part or full-payment for a product or service from identified providers. The distribution of vouchers can be targeted to improve access for an identified population group such as the poorest households or pregnant women. Vouchers can either be competitively redeemed, where they are exchangeable at a number of different providers, or non-competitive where they are assigned to one particular provider.

Three studies focused on vouchers alone and a fourth one also included social marketing.

• The studies showed significant increases in the utilization of services, and positive changes in the ratio of utilization in the lowest compared to the highest socioeconomic quintiles (i.e. the equity ratio). For example, vouchers for free insecticide-treated mosquito nets and net treatment (integrated into a mass measles vaccination campaign) increased the equity ratio for net coverage from 0.66 to 1.19 in urban Zambia.

3) Regulation

Regulatory interventions aim to set up and ensure adequate technical quality of the services provided. They take the form of rules, enforcement systems and sanction mechanisms, and can be applied at the levels of the healthcare provider, organisation or facility. At the provider level, regulation may include requirements for pre-service training, continuing education, licensing and certification of providers. At the organisational or facility level, regulation may aim to control the location of facilities, their registration and minimum complement of staff or facilities. Pharmaceutical market regulation aims to limit the availability of harmful drugs and unregistered products, minimize drug misuse, control the sale of specific drugs through prescriptions, and regulate drug manufacture and importation.

Two studies were identified; one on banning a drug and its combination products (Nepal) and the other assessing the effects of a regulatory intervention to improve the quality of private for-profit pharmacy services (Lao People’s Democratic Republic).

• Banning a drug and its combination products led to a drop in the proportion of retail out-lets stocking the drug from 96.5% at baseline to 0% after sixteen months.
• The second study compared districts with intensified regulation of private for-profit pharmacy services with control districts. Whilst it could not be established that the intervention had a greater effect than routine regulation, moderate but significant improvements in quality were observed in all districts, with mean availability of essential materials increasing by 34% and mean order(including the presence of advertisements, and whether drugs were stored in their original packaging away from sunlight) in the pharmacy increasing by 19%.
• Neither of the two studies provided information on thesocioeconomic statusof study populations and so impacts on equity could not be assessed.

4) Training

Training interventions can take various forms, including formal training sessions, vendor-to vendor education, distribution of guidelines and job-aids. Training is often integrated into other interventions, such as franchising, accreditation and social marketing.

Twenty six studies on training were identified, covering different types of private for-profit providers: doctors (4), midwives (2), pharmacy workers (8), drug retailers (6), and a mix of provider types (6). Training aimed to improve the quality of treatment for a range of different conditions, including childhood illness (7), sexually transmitted infections (5), reproductive health services (5) and malaria. Only one study provided data on socioeconomic status.

• The training of private for-profit practitioners led to improvements in treatment quality for a range of different conditions. For instance, an intervention in Ghana to improve the management of sexually transmitted infections inprivate for-profit pharmacies found that when offered treatment, 38% of simulated clients received appropriate medication at intervention pharmacies compared with 18% at control pharmacies.
• Training private for-profit practitioners on the management of childhood illness in Pakistan benefited a generally poor population.

5) Franchising

Franchising refers to a contractual arrangement between a health service provider and a franchise organisation, which aims to improve access to quality- and price-controlled services. Franchisees are trained in standardized practices for which prices are predefined, and benefit from advertising of the logo or franchise name. The franchisees are monitored by the franchise organisation, which in public health is generally a government or donor-sponsored non-governmental organisation which subsidises the network.

Six interventions were identified in Pakistan (2), Ethiopia (1), India (1), Nepal (1) and Madagascar (1). Franchised services included reproductive health and family planning, diagnosis and manament of sexually trandsmitted infections, and HIV counselling.

• Both the effectiveness of the interventions and their impact on poor and disadvantaged populations were mixed.
• Clients were significantly more satisfied with the quality and quantity of franchised private for-profit services in some countries and less satisfied in others.
• Franchising benefited relatively poor groups in Nepal, Ethiopia, and India. However, in urban Pakistan wealthier groups were more likely to use franchised services.

6) Contracting-out

Contracting-out is a purchasing mechanism used to acquire specified services of a defined quality at an agreed price from a specific private for-profit provider and for a specific period of time. Governments may purchase clinical or non-clinical services from private for-profit providers to complement public provision.

Three studies were identified: contracting-out of hospital services in South Africa (1), and primary healthcare services in South Africa (1) and Lesotho (1). The primary care studies provided data on the socioeconomic status of the study populations.

• Public hospitals had better structural quality of care but contracted hospitals had better quality of nursing care. No significant differences were found in mortality rates between contracted and public hospitals.
• The primary care study in South Africa showed that patients with hypertension were less likely to have their blood pressure recorded when they sought care at contracted practices than at public health facilities.However, the study in Lesotho found the quality of services of contracted providers to be similar to that of public providers.
• The contracted primary care services were used by very poor communities.

7) Accreditation

Accreditation refers to a strategy to improve and control the quality of services provided at organisational or facility level through oversight by an independent quality control evaluation body which may be the government or a non-governmental organisation. It may include training providers in standardised practices. While accreditation is similar to franchising, the nature of the relationship between the provider and the accreditor is often voluntary, compared with the contractual relationship between the franchisee and the franchise organization.

One accreditation study was identified which aimed to improve access to affordable and quality medicines and pharmaceutical services through the training and supervision of outlet dispensing staff; inspections of outlets; marketing; and public education.

• The proportion of unregistered drugs decreased by 92% in the intervention and 66% in the control areas.
• No information was provided on the socioeconomic status of the participants and so impacts on equity cannot be assessed.