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Equity lessons from a large scale private-sector healthcare intervention in Ghana and Kenya: Results for a multi-year qualitative study.

ABSTRACT: Background: The poor fall sick more frequently than the wealthy, and are less likely to seek care when they do. Private provision in many Low- and Middle-Income Countries makes up half or more of all outpatient care, including among poor paitents. Understanding the preferences of poor patients which impel them to choose private providers, and how 3 rd party payment influences these preferences, is important for policy makers considering expansion of national health insurance financing to advance Universal Health Coverage. This paper reports on the results of a qualitative evaluation of the African Health Markets for Equity intiative (AHME), a multi-year initiative in Ghana and Kenya to increase options and improve quality for outpatient services, especially for the poor. Methods: Interviews with patients from private clinics were conducted annually between 2013 and 2018. Field staff recruited women for exit interviews as they were leaving these clinics. In the final round of data collection (2018), interviewers screened patients for wealth quintile and selected one third of the sample (approximately 10 patients per country) that fell into the two lowest wealth quintiles (Q1 and Q2). Transcripts were coded using Atlas.ti and coded for analysis using an inductive, thematic approach. Results: We found four primary drivers of patient preferences for private clinics: convenience; efficiency and predictability, perceived higher quality, and empowerment which was derived from greater choice in where to go. Conclusions: Our findings indicate that more options will lead to more opportunities for treatment, and decrease the percentage of those, mostly poor, who become ill and go without care of any kind. This should be considered as a priority by policy makers seeking to make the best use of existing national infrastructure and expertise to assure equal health for all. In this way, private providers offer an opportunity to advance national goals.

SUBMITTER: Montagu D

PROVIDER: S-EPMC7520554 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Equity lessons from a large scale private-sector healthcare intervention in Ghana and Kenya: Results for a multi-year qualitative study.

Montagu Dominic D Suchman Lauren L Seefeld Charlotte Avery CA

Gates open research 20200914

<b>Background:</b> The poor fall sick more frequently than the wealthy, and are less likely to seek care when they do. Private provision in many Low- and Middle-Income Countries makes up half or more of all outpatient care, including among poor paitents. Understanding the preferences of poor patients which impel them to choose private providers, and how 3 <sup>rd</sup> party payment influences these preferences, is important for policy makers considering expansion of national health insurance ...[more]

PMID: 33134857

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Project description:BackgroundIncorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers' perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa-the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.MethodsIn-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers' reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.ResultsMost providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers' participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.ConclusionsIn expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Project description:OBJECTIVES:This paper explores the underlying motivations and strategies of formal small and medium-sized formal private for-profit sector hospitals and clinics in urban Bangladesh and their implications for quality and access. METHODS:This exploratory qualitative study was conducted in Dhaka, Sylhet and Khulna City Corporations. Data collection methods included key informant interviews (20) with government and private sector leaders, in-depth interviews (30) with clinic owners, managers and providers and exit interviews (30) with healthcare clients. RESULTS:Profit generation is a driving force behind entry into the private healthcare business and the provision of services. However, non-financial motivations are also emphasised such as aspirations to serve the disadvantaged, personal ambition, desire for greater social status, obligations to continue family business and adverse family events.The discussion of private sector motivations and strategies is framed using the Business Policy Model. This model is comprised of three components: products and services, and efforts to make these attractive including patient-friendly discounts and service-packages, and building 'good' doctor-patient relationships; the market environment, cultivated using medical brokers and referral fees to bring in fresh clientele, and receipt of pharmaceutical incentives; and finally, organisational capabilities, in this case overcoming human resource shortages by relying on medical staff from the public sector, consultant specialists, on-call and less experienced doctors in training, unqualified nursing staff and referring complicated cases to public facilities. CONCLUSIONS:In the context of low public sector capacity and growing healthcare demands in urban Bangladesh, private for-profit engagement is critical to achieving universal health coverage (UHC). Given the informality of the sector, the nascent state of healthcare financing, and a weak regulatory framework, the process of engagement must be gradual. Further research is needed to explore how engagement in UHC can be enabled while maintaining profitability. Incentives that support private sector efforts to improve quality, affordability and accountability are a first step in building this relationship.

Project description:Clinical trials conducted in Africa often require substantial investments to support trial centres and public health facilities. Trial resources could potentially generate benefits for routine health service delivery but may have unintended consequences. Strengthening ethical practice requires understanding the potential effects of trial inputs on the perceptions and practices of routine health care providers. This study explores the influence of malaria vaccine trials on health service delivery in Ghana, Kenya and Burkina Faso.We conducted: audits of trial inputs in 10 trial facilities and among 144 health workers; individual interviews with frontline providers (n=99) and health managers (n=14); and group discussions with fieldworkers (n=9 discussions). Descriptive summaries were generated from audit data. Qualitative data were analysed using a framework approach.Facilities involved in trials benefited from infrastructure and equipment upgrades, support with essential drugs, access to trial vehicles, and placement of additional qualified trial staff. Qualified trial staff in facilities were often seen as role models by their colleagues; assisting with supportive supervision and reducing facility workload. Some facility staff in place before the trial also received formal training and salary top-ups from the trials. However, differential access to support caused dissatisfaction, and some interviewees expressed concerns about what would happen at the end of the trial once financial and supervisory support was removed.Clinical trials function as short-term complex health service delivery interventions in the facilities in which they are based. They have the potential to both benefit facilities, staff and communities through providing the supportive environment required for improvements in routine care, but they can also generate dissatisfaction, relationship challenges and demoralisation among staff. Minimising trial related harm and maximising benefits requires careful planning and engagement of key actors at the outset of trials, throughout the trial and on its' completion.

Project description:BACKGROUND:A key component of universal health coverage is the ability to access quality healthcare without financial hardship. Poorer individuals are less likely to receive care than wealthier individuals, leading to important differences in health outcomes, and a needed focus on equity. To improve access to healthcare while minimizing financial hardships or inequitable service delivery we need to understand where individuals of different wealth seek care. To ensure progress toward SDG 3, we need to specifically understand where individuals seek reproductive, maternal, and child health services. METHODS:We analyzed Demographic and Health Survey data from Bangladesh, Cambodia, DRC, Dominican Republic, Ghana, Haiti, Kenya, Liberia, Mali, Nigeria, Senegal and Zambia. We conducted weighted descriptive analyses on current users of modern FP and the youngest household child under age 5 to understand and compare country-specific care seeking patterns in use of public or private facilities based on urban/rural residence and wealth quintile. RESULTS:Modern contraceptive prevalence rate ranged from 8.1% to 52.6% across countries, generally rising with increasing wealth within countries. For relatively wealthy women in all countries except Ghana, Liberia, Mali, Senegal and Zambia, the private sector was the dominant source. Source of FP and type of method sought across facilities types differed widely across countries. Across all countries women were more likely to use the public sector for permanent and long-acting reversible contraceptive methods. Wealthier women demonstrated greater use of the private sector for FP services than poorer women. Overall prevalence rates for diarrhea and fever/ARI were similar, and generally not associated with wealth. The majority of sick children in Haiti did not seek treatment for either diarrhea or fever/ARI, while over 40% of children with cough or fever did not seek treatment in DRC, Haiti, Mali, and Senegal. Of all children who sought care for diarrhea, more than half visited the public sector and just over 30% visited the private sector; differences are more pronounced in the lower wealth quintiles. CONCLUSIONS:Use of the private sector varies widely by reason for visit, country and wealth status. Given these differences, country-specific examination of the role of the private sector furthers our understanding of its utility in expanding access to services across wealth quintiles and providing equitable care.

Project description:OBJECTIVES:The subcutaneous depot medroxyprogesterone acetate (DMPA-SC) injectable contraceptive was introduced in South West Nigeria in 2015 through private sector channels. The introduction included community-based distribution and was supported by a social marketing approach. From program monitoring and evaluation, aimed at understanding performance, market reach and other process measures, we identify lessons learned to inform future scale-up efforts. METHODS:We synthesized the findings from a core set of key performance indicators collected through different methods: (1) implementer performance indicators, (2) phone survey of DMPA-SC users (n=541) with a follow-up after 3 months (n=342) and (3) in-depth interviews with 57 providers and 42 users of DMPA-SC. RESULTS:Distribution of DMPA-SC to private providers was concentrated in states with large urban populations. A shift toward focusing on high-volume family planning facilities coincided with a rapid increase in distribution in late 2016. Users reached in the phone survey were generally older and married with children; few were under age 25. Users and providers reported favorable opinions of DMPA-SC. Many users reported choosing DMPA-SC due to recommendations from providers and friends, and the hope of experiencing reduced side effects compared to other methods. While users reported positive experiences interacting with community-based distributors, the delivery model encountered a number of challenges - high turnover, low motivation, lack of an appropriate compensation package and logistical costs - and was ultimately disbanded. CONCLUSIONS:In the DMPA-SC introductory program in Nigeria, distribution was amplified when focused on high-volume contraceptive providers. Although community-based distribution can be one effective service delivery model for reaching underserved populations, more consideration for balancing cost recovery and public health goals through private sector approaches are needed in the context of South West Nigeria. Additional communications and outreach efforts are needed to reach younger, unmarried users with contraceptive services.

Dataset Information

Equity lessons from a large scale private-sector healthcare intervention in Ghana and Kenya: Results for a multi-year qualitative study.

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Equity lessons from a large scale private-sector healthcare intervention in Ghana and Kenya: Results for a multi-year qualitative study.

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