August, 2008 - SUPPORT Summary of a systematic review | print this article |
Concern regarding the technical failures of care provided by the private for-profit sector (i.e. private commercial providers) has led to the development of interventions aimed at addressing these limitations. The interventions implemented within the private for-profit sector and reviewed by the paper include social marketing, the use of vouchers, the pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out.
Social marketing is the application of the tools and concepts of commercial marketing to social and health problems. A voucher is a form of demand-side subsidy that the recipient can use as payment for a product or service from identified providers. Pre-packaging involves packaging drugs in pre-defined doses adequate for the targeted population and treatment length. A franchise is a contractual arrangement between a health service provider and a franchise organisation. Accreditation is a strategy to improve and control service quality at organisational or facility level through oversight by an independent quality control evaluation body. Training interventions can include formal training sessions, vendor-to-vendor education and the distribution of guidelines. Regulatory interventions aim to set up and ensure adequate technical quality of the services provided through binding regulations. Contracting-out is a purchasing mechanism used to acquire specified services of a defined quality at an agreed price from a specific private provider and for a specific period of time.
Growing concern regarding the technical failures of care provided by the private for-profit sector has led to the development of interventions aimed at addressing these limitations, which simultaneously take advantage of the potential for involving the private for-profit sector to achieve public health goals.
This summary of a systematic review published in 2007 by Patouillard et al., focuses on the effects of private for-profit sector interventions on expanding access to quality health services for poor and disadvantaged populations. The authors used two approaches to determine whether an intervention reached the poor. First, interventions were deemed to have reached the poor if they benefited generally poor areas based on the study site information provided in the original papers. Secondly, interventions were deemed to have reached the poor if the socioeconomic distribution of benefits favoured the most disadvantaged groups within a given population.
|Review Objectives: To assess the effects of interventions working with the private for-profit sector to improve the utilization and quality of health services for the poor.|
|/||What the review authors searched for||What the review authors found|
|Interventions||Studies of changes over time (pre-post), or comparing an intervention area with a control area (controlled), or comparing changes over time in an intervention area with changes over time in a control area (pre-post with control), with or without randomisation
52 studies were identified which had employed either a pre-post, controlled or pre-post with control design, with or without randomization.
|Participants||Only general information on target population was provided, such as country or town of residence or income level
|Settings||All studies conducted in low- and middle-income countries|
Utilization and quality of care for the poor.
Only five studies provided data on the distribution of benefits across socioeconomic groups
|Date of most recent search: November 2007|
|Limitations: This was an exhaustive review of English and French literature, but there were few evaluations of impact that allow robust conclusions to be drawn; especially as many of the interventions were not set up as research projects.|
Patouillard E, Goodman CA, Hanson KG, Mills AJ. Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature. Int J Equity Health 2007;6:17. See link
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.
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.
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.
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).
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.
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.
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.
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.
|MONITORING & EVALUATION|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see: http://supportsummaries.org/support-summaries/how-support-summaries-are-prepared/
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This summary was prepared by
Charles Shey Wiysonge, South African Cochrane Centre, Medical Research Council, Cape Town, South Africa
Conflict of interest
None declared. For details, see: Conflicts of Interest
This summary has been peer reviewed by: Edith Patouillard UK; Hugh Waters, USA; Jolene Skordis, UK; Ruairi Brugha, Ireland; Tracey Perez Koehlmoos, Bangladesh; Blanca Peñaloza, Chile; Simon Lewin, UK
This summary should be cited as
Wiysonge CS. Can working with private for-profit providers improve utilization and quality of health services for the poor? A SUPPORT Summary of a systematic review. August 2008.