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Private Sector Healthcare

Private Sector Healthcare

Studying private healthcare provision – how it works, how to improve it and where fits in universal health care

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About

From corporate hospitals to itinerant drug vendors, private healthcare provision plays a growing role in global health.

Team

We draw on perspectives from health economics, political science, anthropology and public health.

Projects

We analyse all types of private healthcare providers and evaluate interventions to improve their performance.

About
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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. 

Team
Team Block
Team

Benjamin
Palafox

Research Fellow

Ellen
Nolte

Professor

Jessica
King

Research Fellow

Kara
Hanson

Professor

Manon
Haemmerli

Research Fellow

Marco
Liverani

Associate Professor

Meenakshi
Gautham

Assistant Professor

Mishal
Khan

Associate Professor

Sergio
TorresRueda

Research Fellow

Shunmay
Yeung

Professor

Sonia
Rego

Research Fellow

Timothy
Powell-Jackson

Associate Professor

Meherunissa
Hamid

Research Degree Student
Projects
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One Health Antibiotic Stewardship in Society II (OASIS-II). A multi-stakeholder approach towards operationalising antibiotic stewardship in India's pluralistic rural health system

In this study we propose to co-design, and pilot a multi-stakeholder antibiotic stewardship intervention to reduce and improve antibiotic use in the community setting in rural India. We will focus on informal providers for human and veterinary health, but also work with communities, formal doctors and vets and pharmaceutical industry stakeholders. The resulting intervention will be evaluated for its feasibility and acceptability, provider level outcomes, and for its effect on the stakeholders, individually and collectively.

People

Dates

2019 - 22

Antibiotic stewardship in agricultural communities in Africa and Asia: A unified One Health strategy to optimise antibiotic use in animals and humans 

We shall pool the knowledge and insights that have been generated in six projects previously funded by GCRF, to compare the situations, norms, experiences, and motivations that affect antibiotic use in humans and animals across a range of countries in Africa and Asia - to identify processes that can deter misuse of these valuable medicines and/or incentivize good practice. Our particular focus will be on antibiotics purchased from drug shops and informal providers in rural agricultural areas with limited access to healthcare. Our projects also look at the influence of interactions between private providers, government health workers and public officials, to gain a better understanding of how health systems in low-income countries can more effectively raise the quality of care available from private providers and improve treatment practices. We shall use this collective evidence to design an overarching intervention strategy, comprised of mutually-reinforcing components, aimed at combatting misuse of antibiotics purchased from drug shops and improving rural treatment services for humans and animals. This strategy will be tested in future studies.

People

Dates

2020 - 21

Smart regulation of antibiotic use in India: Understanding, innovating and improving compliance 

The containment of AMR is a multi-faceted task that needs a one-health approach as suggested in the World Health Organization's (WHO) 2015 Global Action Plan (GAP) on AMR. Countries including India have aligned their National Action Plans (NAPs) on AMR with this international guidance. One of the important links for various activities for AMR containment is the appropriate use of antibiotics to reduce selection pressure on microbes. According to the GAP, effective regulation will be a key tool for ensuring that national standards aimed at optimising the use of antimicrobial medicines in human and animal health are followed in practice. Fundamental questions  arise about whether a credible and enforceable AMR regulatory framework can be developed for India, and if so, how best to tackle this complex challenge. The core idea of this project is to apply the ideas and methods of 'smart regulation' to better understand the underlying problems and co-produce innovative regulations with regulators and regulatory subjects that will likely lead to mutually acceptable regulations and improved compliance.

People

  • Meenakshi Gautham (CO-I)

Dates

2018 - 21

Development of an intervention for improved management (by private and public frontline health workers) of self-reported abnormal vaginal discharge by women in rural north India 

Self-reported ‘abnormal vaginal discharge’ (AVD) is a common clinical symptom of sexually transmitted infections (chlamydia, gonorrhoea or trichomoniasis) or endogenous reproductive tract infections (bacterial vaginosis or candidiasis) and its clinical management is done through the syndromic management approach. This approach was advocated by WHO for low resource settings where laboratory diagnostics is unavailable. However, it is now accepted that AVD (or vaginal discharge syndrome) is neither sensitive nor specific for sexually transmitted infections (STIs), leading to considerable over treatment with antibiotics (up to 65% for gonorrhoea and chlamydia). While more cases of AVD may be attributed to RTIs (bacterial vaginosis and candidiasis) than to STIs, there may be other cultural and psychosocial factors leading to the complaint. In South Asia, a large body of literature suggests that self-reported AVD may be associated with mental health risk factors including stress, social conflict, marital discord, gender disadvantage and poverty. Studies in India and Pakistan have found a strong association between AVD and scores on mental health screening instruments, suggesting a link between AVD and common mental disorders (CMDs). This further confounds the management of AVD in S. Asia.

People

  • Meenakshi Gautham (PI)
  • Abhijit Nadkarni (CO-PI)
  • Suzanna Francis (CO-I)
  • Heiner Grosskurth (CO-I)
  • Victoria Simms (CO-I)

Dates

2021 - 22

Concentration and fragmentation: analysing the implications of the structure of Georgia’s private healthcare market for quality and accessibility

Foundation Award – Health Systems Research Initiative, 2020-2021

The private sector is increasingly recognized as playing an important role in health systems in low- and middle-income countries (LMIC), yet policymakers struggle to identify the role of the private sector in relation to their Universal Health Coverage objectives. Policies for engaging with private healthcare providers should be based on a good understanding of how healthcare markets operate. Healthcare markets can range from highly fragmented (a large number of small firms), through to highly concentrated (one or a few large firms). While the risks of excess concentration have long been recognised, evidence is emerging from a number of LMICs about the potential risks to patients of excess fragmentation. The overall aim of this study is to elaborate this conceptual framing of risks of harm from concentration and fragmentation of healthcare markets and develop a set of tools for undertaking healthcare market analysis. The goal is to inform policy options for shaping healthcare markets in the context of UHC. We are undertaking this research in Georgia, a lower-middle income former soviet country which has undergone extensive privatisation in the healthcare sector. This project will set the foundation for evaluating future policy changes in Georgia and extending the analytic approach to other settings in future.

People

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).

People

Aga Khan University, Pakistan: Sadia Shakoor, Rumina Hasa, Wafa Aftab, Sameen Siddiqi, Rehana Siddiqui

Publications

Dates

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.

People

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 lower-level public and private health facilities in sub-Saharan Africa. The private sector is a major and growing source of care, but there are concerns about quality and safety, and these are insufficiently addressed by government regulation or international hospital accreditation standards. SafeCare was designed to address this gap, offering realistic setting-appropriate standards and stepwise certification, as well as access to credit for implementing improvements.

We undertook a large-scale randomised controlled trial to evaluate the impact on quality of care of the roll out of SafeCare to private for-profit and faith-based facilities in Tanzania. The trial assessed the effects on the quality of care received by patients through comparison of 237 intervention and control facilities after 1.5–2 years of implementation. To do this, we:

  • measured clinical quality through standardised patient surveys
  • observed infection prevention and control (IPC) behaviours
  • conducted in-depth interviews with facility in-charges and implementing staff to assess the perceived benefits and costs of participating, and the factors affecting quality improvement and business performance.
  • interviewed national level key informants to explore how the SafeCare model had shaped the market for healthcare and the policy environment

The results are expected to make an important contribution to the evidence base on improving private sector care, and to the literature on measuring process quality of patient care. 

Publications

Other outputs 

People

Ifakara Health Institute: Christina Makungu, Abdallah Mkopi

PharmAccess Foundation: Nicole Spieker, Peter Risha

Dates

Until end of June 2020

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.

Publications

Partners

  • 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
  • UCL
  • Indonesian Ministry of Health
  • Australian National Prescribing Service

People

Probadari A, Wibawa T, Jan S, Kaldor J, Law M, Guy R, Batura N, Schierhout G, Parathon H, Heaney A

Dates

2019 – 22

Completed Projects

Social, behavioural and economic drivers of inappropriate antibiotic use by informal private healthcare providers in rural India. One Health Antibiotic Stewardship in Society II (OASIS-I). (2016-2018)

A major driver for the overuse of antibiotics in humans is antibiotic over-prescribing and dispensing by health care providers. This is a big challenge in low and middle income countries where health systems are weak, regulatory frameworks for health workers and the pharmaceutical industry either do not exist or are weakly enforced, and the majority of poor and rural populations rely on informally trained and unlicensed providers who use antibiotics excessively and inappropriately in their treatments. These informal providers ( IPs) may constitute from 50% to 96% of all providers in LMICs, including in India, but there is very little in-depth knowledge of the factors that influence their inappropriate antibiotic use and what interventions can feasibly and effectively arrest this inappropriate use. Evidence from the formal sector suggests that antibiotic use is influenced by socio-cultural, behavioural and economic factors. However the precise nature of these factors and how they interact has not been explored in the case of IPs. We conducted this study with the goal of understanding the social, economic and behavioural drivers of antibiotic  use by IPs in rural West Bengal. We surveyed 300 IPs in districts South24Parganas and Birbhum, collected data on antibiotic stocks in clinics and interviewed 30 IPs in-depth to understand the patterns and drivers of antibiotic use. Other stakeholders including formal doctors, health and regulatory department officials, pharmaceutical representatives, and wholesale drug sellers were interviewed in-depth, and eight focus group discussions were conducted with community members. We found  that informalities of antibiotic practices cut across multiple actors in that setting: communities, informal as well as formal providers, pharmaceutical supply chain actors and regulatory authorities. These were driven by a variety of mutual dependencies between the different actors.         

People

Publications

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

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.

Chains were found to exert strong influence over their staff but the potential to exploit this has not been realised.

Papers

People

Outputs

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).

Partners

People

Publications 

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).

Partners

  • University of Health Sciences, Cambodia

Publications

Papers

Outputs

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.

Publications

People

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

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.

Publications

People

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).

Publications

Outputs

People

Strathmore University: Francis Wafula (co-PI), Gilbert Kokwaro, Eric Tama, Irene Khayoni, Timothy Chege, Dosila Ogira

World Bank Group: Njeri Mwaura

Dates

Completed February 2020