From corporate hospitals to itinerant drug vendors, private healthcare provision plays a growing role in global health.
We draw on perspectives from health economics, political science, anthropology and public health.
We analyse all types of private healthcare providers and evaluate interventions to improve their performance.
The private sector is responsible for a large and growing share of treatment provision in many low and middle income countries, from international-standard corporate hospitals, to small-scale clinics, pharmacies, drug shops, and in some settings general retailers and itinerant drug vendors.
Our group aims to:
- understand the operation of private healthcare providers
- inform and evaluate interventions and policies to improve the functioning of the private sector
- consider the place of private provision in the evolution of the broader health system and universal health coverage (UHC)
- enhance methods for studying the private sector, and in particular for assessing their quality of care
The appropriate role of these private providers is much contested in global health: while some emphasise their high utilisation, breadth of service provision, and potential contribution to UHC, others are sceptical about the incentives of for-profit providers and the equity implications.
Professor; Dean, Faculty Of Public Health And Policy
- Combating drug resistance through better governance of informal antibiotic sellers in Cambodia
Informal health care providers in low and middle income countries (LMIC) commonly sell antibiotics for minor illnesses but their role is under-researched. This is the first project to investigate invisible medicine sellers in Cambodia, who provide health services without having a designated outlet for this purpose. We sought to better understand:
- the health system gaps
- they fill the features that allow them to become trusted health providers
- their knowledge of antibiotics
- policymakers' views on controlling inappropriate access to antibiotics
We conducted community focus group discussions in two peri-urban districts in Phnom Penh to identify all visible and invisible healthcare providers, and then interviewed all identified providers as well as policy actors at the community and national level.
Funded by Health Systems Research Initiative (MRC, ESRC, Wellcome Trust, DFID).
- University of Health Sciences, Cambodia
- Mishal Khan, Sonia Rego, Julia Spencer, Prescription only access to antibiotics could exacerbate health inequalities in LMICs, The BMJ Opinion, 2018
- Sovandhitha Suy et al, Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia, BMJ Global Health, 2019
- Mishal Khan et al, Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries?, BMC, 2020
- Addressing conflict of interest driving irrational prescribing of antibiotics in pluralistic health systems: an interventional study in Pakistan
Pakistan has no organised system of primary healthcare in urban areas, and over 80% of the urban population uses for-profit private doctors as the first point of healthcare seeking. The professionalism of private doctors in Pakistan – which includes their technical knowledge and ethical practice – therefore determines the quality of care received.
This three-year study:
- identifies strategies for large scale improvement in the quality of healthcare provided by private doctors in Pakistan, paying attention to addressing conflicts of interest owing to profit generation motives
- tests the effectiveness of an intervention developed through formative research to provide evidence for policy change
Funded by Health Systems Research Initiative (MRC, ESRC, Wellcome Trust, DFID).
Aga Khan University, Pakistan: Sadia Shakoor, Rumina Hasa, Wafa Aftab, Sameen Siddiqi, Rehana Siddiqui
- Mishal Khan et al, Is enhancing the professionalism of healthcare providers critical to tackling antimicrobial resistance in low- and middle-income countries? Human Resources for Health, Feb 2020
2020 – 23
- Systems for quality measurement in the private sector
We were commissioned by the Lancet Commission on High Quality Health Systems to develop a typology of mechanisms for quality measurement in the private health care sector, and to assess country experiences with these mechanisms.
- Addressing quality in the private healthcare sector: A randomised controlled trial of the SafeCare Quality Improvement Programme in Tanzania
SafeCare is a quality improvement model developed by the NGO PharmAccess, aimed at public and private health facilities in sub-Saharan Africa. We undertook a large-scale randomised controlled trial to evaluate the impact on quality of care of the roll out of SafeCare in private for-profit and faith-based facilities in Tanzania. Quality of care was measured using standardised patients and observations of infection prevention and control practices, with experiences and opinions about the intervention documented through in-depth interviews.
Please visit the SafeCare project page for more information.
- Matrika social franchising programme in Uttar Pradesh, India
We evaluated whether the Matrika social franchising model – a multifaceted intervention that established a network of private providers and strengthened the skills of both public and private sector clinicians – could improve the quality and coverage of health services along the continuum of care for maternal, newborn, and reproductive health.
The evaluation drew on quantitative and qualitative methods to show the impact of the Matrika project on the quality and coverage of health services along the continuum of care for reproductive, maternal and newborn health. We also aimed to understand the scale of the social franchise network, the extent to which various components of the programme were implemented and how impacts were achieved.
The study utilised a range of data collection tools, including:
- two rounds of a household survey of 3600 women
- two rounds of a survey of 450 health providers
- direct observations of 250 births in public and private sector maternity facilities
- in-depth interviews with key informants
- village-level ethnographic fieldwork
Funded by Merck for Mothers, this study was undertaken by the Maternal Healthcare Markets Evaluation Team (MET).
- Sambodhi Research and Communications
- Penn-Kekana L, Powell-Jackson T, Haemmerli M, Dutt V, Lange IL, Mahapatra A, Sharma G, Singh K, Singh S, Shukla V, Goodman C. Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India. Implement Sci. 2018 Sep 24;13(1):124. PubMed PMID: 30249294; PubMed Central PMCID:PMC6154932.
- Tougher S, Dutt V, Pereira S, Haldar K, Shukla V, Singh K, Kumar P, Goodman C,Powell-Jackson T. Effect of a multifaceted social franchising model on quality and coverage of maternal, newborn, and reproductive health-care services in Uttar Pradesh, India: a quasi-experimental study. Lancet Glob Health. 2018 Feb;6(2):e211-e221. Epub 2017 Dec 20. PubMed PMID: 29275135.
- Pereira SK, Kumar P, Dutt V, Haldar K, Penn-Kekana L, Santos A, Powell-Jackson T. Protocol for the evaluation of a social franchising model to improve maternal health in Uttar Pradesh, India. Implement Sci. 2015 May 26;10:77. PubMed PMID: 26008202; PubMed Central PMCID:PMC4448271.
- Protecting Indonesia from the Threat of Antibiotic Resistance (PINTAR)
Improving the dispensing of antibiotics by private drug sellers in Indonesia is the missing tactic in the fight against antimicrobial resistance (AMR). Despite the prominence of private drug sellers (PDS) in Indonesia’s health system, little is known about their practices or how to improve governance of this sector.
The goal of this mixed-methods study is to develop and test strategies to improve antibiotic dispensing by PDS in Indonesia. Specific aims are to:
- understand the economic and social factors that influence the antibiotic dispensing practices of PDS
- Determine the proportion of consumer visits to PDSs for common clinical conditions in which antibiotics are dispensed without a prescription;
- Design and evaluate the effect and cost-effectiveness of a multi-faceted intervention to reduce inappropriate dispensing of antibiotics without prescription by PDS;
- Design a strategy for intervention expansion and monitoring across Indonesia;
- Build capacity in health systems research and evidence-based strategies for improving PDS governance and public-private collaboration (see criteria 2 for details).
Find out more about the PINTAR study.
- Wiseman V, Lagarde M, Kovacs R, et al. Using unannounced standardised patients to obtain data on quality of care in low-income and middle-income countries: key challenges and opportunities. BMJ Global Health 2019;4:e001908. doi:10.1136/ bmjgh-2019-001908
- University of Gadjah Mada
- University of Sebelas Maret
- Kirby Institute, University of New South Wales
- George Institute for Global Health, University of New South Wales
- Indonesian Ministry of Health
- Australian National Prescribing Service
Probadari A, Wibawa T, Jan S, Kaldor J, Law M, Guy R, Batura N, Schierhout G, Parathon H, Heaney A
2019 – 22
- The rise of chain pharmacies in India and implications for public health
For her PhD, Rosalind Miller studied private retail pharmacies in India. In many communities in low- and middle-income countries (LMICs), pharmacies are widely utilised for obtaining medicines and seeking health advice, but their practice is often poor. Insufficient history taking, a lack of adherence to treatment guidelines, and inappropriate dispensing of medicines are commonplace. In recent years, pharmacy chains have been emerging in South America, Africa and Asia. Chains may have the potential to improve quality, but this has been little studied in LMICs. Miller used mixed methods, including a standardised patient survey and key informant interviews, to understand the effect of chain pharmacies in Bangalore, India on the quality of case management for two tracer conditions.
The management of childhood diarrhoea and suspected tuberculosis was similarly substandard in chains and independents for most areas of assessment. However, chains were found to sell significantly fewer harmful and prescription-only medicines for the diarrhoea patient. In-depth interviews explored a set of hypotheses regarding how being organised in a chain may affected key behaviours relating to quality failures. In practice, few differences were identified in:
- employment of qualified staff
- regulation of firms are regulated
- financial incentives faced by staff
Chains were found to exert strong influence over their staff but the potential to exploit this has not been realised.
Rosalind is now undertaking an ESRC-funded post-doctoral fellowship which seeks to address shortcomings in pharmacy practice in LMICs. She is working with the International Federation of Pharmacists (FIP) to survey national pharmacy associations to learn more about what guidelines, specifically written for pharmacies, are currently in existence. The ultimate aim of this project is to work towards the creation of a set of global level, pharmacy-specific guidelines for the management of key conditions.
- Miller, R; (2018) The rise of chain pharmacies in India: implications for public health. PhD (research paper style) thesis, London School of Hygiene & Tropical Medicine.
- Miller, Rosalind; Hutchinson, Eleanor; Goodman, Catherine; (2018) 'A smile is most important.' Why chains are not currently the answer to quality concerns in the Indian retail pharmacy sector. Social science & medicine, 212. pp. 9-16. ISSN 0277-9536
- Miller, Rosalind; Goodman, Catherine; (2017) Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India. BMJ global health, 2 (3). e000457-. ISSN 2059-7908
- Miller, Rosalind; Goodman, Catherine; (2016) Performance of retail pharmacies in low- and middle-income Asian settings: a systematic review. Health policy and planning, 31 (7). pp. 940-953. ISSN 0268-1080
- Evaluation of the Affordable Medicines Facility–Malaria (AMFm)
Use of the most effective treatments for malaria remains inadequate, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility-malaria (AMFm), to increase access to and use of quality-assured artemisinin-based combination therapies (QAACTs). A key innovation was the subsidy of QAACTs for distribution through private providers such as pharmacies, drug shops and clinics. Other components of the intervention were manufacturer price negotiations, and supporting interventions such as communications campaigns. AMFm was implemented in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania mainland, Uganda and Zanzibar.
The Independent Evaluation of AMFm assessed the impact on availability, price, market share and use of QAACTs, using a before and after study design, with nationally representative outlet surveys at baseline (2009/10) and follow-up (2011). Data from routine records and key informant interviews on implementation process and context were analysed to support causal inference. In all pilots except Niger and Madagascar, there were large increases in QAACT availability and market share, driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs were seen in the private for-profit sector in six pilots.
The results were used to inform decisions by national governments, the Global Fund and partners on future rollout of antimalarial subsidy programmes.
Funded by The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.
Tougher, S.; ACTwatch Group; Ye, Y.; Amuasi, J.H.; Kourgueni, I.A.; Thomson, R.; Goodman, C.; Mann, A.G.; Ren, R.; Willey, B.A.; Adegoke, C.A.; Amin, A.; Ansong, D.; Bruxvoort, K.; Diallo, D.A.; Diap, G.; Festo, C.; Johanes, B.; Juma, E.; Kalolella, A.; Malam, O.; Mberu, B.; Ndiaye, S.; Nguah, S.B.; Seydou, M.; Taylor, M.; Rueda, S.T.; Wamukoya, M.; Arnold, F.; Hanson, K.; Effect of the Affordable Medicines Facility-malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data. Lancet (2012) 380(9857):1916-26
AMFm Independent Evaluation Team: Hanson, K; Goodman, C; Tougher, S; Mann, A; Willey, B; Arnold, F; Ye, Y; Ren, R; Yoder, S. Independent Evaluation of Phase 1 of the Affordable Medicines Facility - malaria (AMFm), Multi-Country Independent Evaluation Final Report ICF International and London School of Hygiene and Tropical Medicine (Calverton, Maryland and London) 2012
Ye, Y. ; Arnold, F. ; Noor, A. ; Wamukoya, M. ; Amuasi, J. ; Blay, S. ; Mberu, B. ; Ren, R. ; Kyobutungi, C. ; Wekesah, F. ; Gatakaa, H. ; Toda, M. ; Njogu, J. ; Evance, I. ; O'Connell, K. ; Shewchuk, T. ; Thougher, S. ; Mann, A. ; Willey, B. ; Goodman, C. ; Hanson, K. ; The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention? Malar J (2015) 14(1):398
Thomson, R. ; Festo, C. ; Johanes, B. ; Kalolella, A. ; Bruxvoort, K. ; Nchimbi, H. ; Tougher, S. ; Cairns, M. ; Taylor, M. ; Kleinschmidt, I. ; Ye, Y. ; Mann, A. ; Ren, R. ; Willey, B. ; Arnold, F. ; Hanson, K. ; Kachur, S.P. ; Goodman, C. ; Has Tanzania Embraced the Green Leaf? Results from Outlet and Household Surveys before and after Implementation of the Affordable Medicines Facility -Malaria. PLoS One (2014) 9(5):e95607; Open Access
Tougher, S. ; Mann, A.G. ; ACTwatch Group, (inc. Palafox, B.;) Ye, Y. ; Kourgueni, I.A. ; Thomson, R. ; Amuasi, J.H. ; Ren, R. ; Willey, B.A. ; Ansong, D. ; Bruxvoort, K. ; Diap, G. ; Festo, C. ; Johanes, B. ; Kalolella, A. ; Mallam, O. ; Mberu, B. ; Ndiaye, S. ; Nguah, S.B. ; Seydou, M. ; Taylor, M. ; Wamukoya, M. ; Arnold, F. ; Hanson, K. ; Goodman, C. ; Improving access to malaria medicine through private-sector subsidies in seven african countries. Health Aff (Millwood) (2014) 33(9):1576-85
Willey, B.A. ; Tougher, S. ; Ye, Y. ; The ACTwatchGroup, (inc. Palafox, B.;) Mann, A.G. ; Thomson, R. ; Kourgueni, I.A. ; Amuasi, J.H. ; Ren, R. ; Wamukoya, M. ; Rueda, S.T. ; Taylor, M. ; Seydou, M. ; Nguah, S.B. ; Ndiaye, S. ; Mberu, B. ; Malam, O. ; Kalolella, A. ; Juma, E. ; Johanes, B. ; Festo, C. ; Diap, G. ; Diallo, D. ; Bruxvoort, K. ; Ansong, D. ; Amin, A. ; Adegoke, C.A. ; Hanson, K. ; Arnold, F. ; Goodman, C. ; Communicating the AMFm message: exploring the effect of communication and training interventions on private for-profit provider awareness and knowledge related to a multi-country anti-malarial subsidy intervention. Malar J (2014) 13(1):46
- Kara Hanson
- Catherine Goodman
- Sarah Tougher
- Barbara Willey
- Benjamin Palafox
- Sergio TorresRueda
- Andrea Mann
ICF International: Yazoume Ye, Ruilin Ren, Fred Arnold, Abdinasir Amin
The ACTwatch Group, Population Services International
Ifakara Health Institute, Tanzania: Charles Festo, Boniface Johanes, Admirabilis Kalolella, Mark Taylor
Centre de Recherche pour le Développement Humain, Senegal: Salif Ndiaye
Centre International d'Études et de Recherches sur les Populations Africaines, Niger: Idrissa A Kourgueni
Drugs for Neglected Diseases initiative: Graciela Diap
Komfo Anokye Teaching Hospital, Ghana: Daniel Ansong, Samuel B Nguah, John H Amuasi
African Population and Health Research Center, Kenya: Blessing Mberu, Marilyn Wamukoya
Kenya Medical Research Institute, Kenya: Elizabeth Juma
Phar-Mark Consultants, Nigeria: Catherine A Adegoke
Institut National de la Statistique, Niger: Idrissa A Kourgueni, Oumarou Malam, Moctar Seydou
ACTwatch was a multi-country programme that gathered and synthesised data on markets for malaria diagnostics and antimalarial medicines in the private and public health sectors in Africa and Southeast Asia. The objective was to provide policymakers with evidence on trends in availability, price, use and distribution chain for antimalarial drugs and diagnostics, using standardized, representative survey methodologies. The project was led by PSI; LSHTM provided technical support, and led a component on the supply chain for antimalarials and diagnostics.
Funded by Bill & Melinda Gates Foundation.
- ACTwatch Group; Hanson, K. ; Goodman, C. ; Testing times: trends in availability, price, and market share of malaria diagnostics in the public and private healthcare sector across eight sub-Saharan African countries from 2009 to 2015. Malar J (2017) 16(1):205;
ACTwatch Group; Newton, P.N. ; Hanson, K. ; Goodman, C. ; Do anti-malarials in Africa meet quality standards? The market penetration of non quality-assured artemisinin combination therapy in eight African countries. Malar J (2017) 16(1):204;
ACTwatch Group; Tougher, S. ; Hanson, K. ; Goodman, C. ; What happened to anti-malarial markets after the Affordable Medicines Facility-malaria pilot? Trends in ACT availability, price and market share from five African countries under continuation of the private sector co-payment mechanism. Malar J (2017) 16(1):173;
Palafox B, Goodman C, Hanson K. Malaria, medicines and miles: A novel approach to measuring access to treatment from a household perspective. SSM - Population Health 7:100376 06 Mar 2019
Palafox, B.; Patouillard, E.; Tougher, S.; Goodman, C.; Hanson, K.; Kleinschmidt, I.; Torres Rueda, S.; Kiefer, S.; O'Connell, K.; Zinsou, C.; Phok, S.; Akulayi, L.; Arogundade, E.; Buyungo, P.; Mpasela, F.; Poyer, S.; Chavasse, D.; Prices and mark-ups on antimalarials: evidence from nationally representative studies in six malaria-endemic countries. Health Policy Plan (2016) 31(2):148-60;
Patouillard, E. ; Hanson, K. ; Kleinschmidt, I. ; Palafox, B. ; Tougher, S. ; Pok, S. ; O'Connell, K. ; Goodman, C. ; Determinants of price setting decisions on anti-malarial drugs at retail shops in Cambodia. Malar J (2015) 14(1):224;
Poyer, S. ; Shewchuk, T. ; Tougher, S. ; Ye, Y. ; ACTwatch Group, . ; Mann, A.G. ; Willey, B.A. ; Thomson, R. ; Amuasi, J.H. ; Ren, R. ; Wamukoya, M. ; Taylor, M. ; Nguah, S.B. ; Mberu, B. ; Kalolella, A. ; Juma, E. ; Festo, C. ; Johanes, B. ; Diap, G. ; Bruxvoort, K. ; Ansong, D. ; Hanson, K. ; Arnold, F. ; Goodman, C.; Availability and price of malaria rapid diagnostic tests in the public and private health sectors in 2011: results from 10 nationally representative cross-sectional retail surveys Tropical Medicine & International Health (2015) 20(6):744-56;
Palafox, B. ; Patouillard, E. ; Tougher, S. ; Goodman, C. ; Hanson, K. ; Kleinschmidt, I. ; Rueda, S.T. ; Kiefer, S. ; O'Connell, K.A. ; Zinsou, C. ; Phok, S. ; Akulayi, L. ; Arogundade, E. ; Buyungo, P. ; Mpasela, F. ; Chavasse, D. ; Understanding private sector antimalarial distribution chains: a cross-sectional mixed methods study in six malaria-endemic countries. PLoS One (2014) 9(4):e93763;
O'Connell, K.A. ; Poyer, S. ; Solomon, T. ; Munroe, E. ; Patouillard, E. ; Njogu, J. ; Evance, I. ; Hanson, K. ; Shewchuk, T. ; Goodman, C. ; Methods for implementing a medicine outlet survey: lessons from the anti-malarial market. Malar J (2013) 12:52;
Patouillard, E. ; Kleinschmidt, I. ; Hanson, K. ; Pok, S. ; Palafox, B. ; Tougher, S. ; O Connell, K. ; Goodman, C. ; Comparative analysis of two methods for measuring sales volumes during malaria medicine outlet surveys. Malar J (2013) 12(1):311;
The ACTwatch Group, Population Services International
- KePSIE-Qual – Understanding the impact of innovations in the regulation of Kenya’s health facilities
There has been little evaluation of strategies to strengthen regulation in low and middle-income countries (LMIC), a notable exception being the Kenya Patient Safety Impact Evaluation (KePSIE), a collaboration between the Kenyan Ministry of Health and the World Bank. This randomised controlled trial assessed the impact of a set of innovative regulatory interventions in public and private facilities:
- a Joint Health Inspection Checklist
- increased inspection frequency
- risk-based timing of inspections
- display of regulatory results outside facilities
To understand the effectiveness of the intervention and why aspects did (or did not) work, we conducted a companion study of the perceptions and experience of all stakeholders involved, though a mix of document review and in-depth interviews. We also assessed the incremental costs of the JHIC interventions compared to those of the current regulatory system.
The study demonstrated that objectivity and transparency are central for regulatory legitimacy, and an inspection culture supportive to facility staff is important. The system must be designed to avoid both opportunities for corruption and logistical challenges. The display of scorecards had little impact on patients but did raise reputational concerns for staff. A reformed inspection system can support compliance with licensing, but requires licensing procedures that are themselves efficient.
Finally, inspection is necessary but not sufficient to improve patient safety – this also requires financial and technical support for some facilities, strong focus on continuous process improvement and an emphasis on behaviour change.
Funded by Health Systems Research Initiative (MRC, ESRC, Wellcome Trust, DFID).
- Catherine Goodman (co-PI)
Strathmore University: Francis Wafula (co-PI), Gilbert Kokwaro, Eric Tama, Irene Khayoni, Timothy Chege, Dosila Ogira
World Bank Group: Njeri Mwaura
Completed February 2020