Informal Private Providers Research Articles

Effectiveness of the health and wellness centers in improving identification and primary care of non-communicable diseases in Chhattisgarh State of India.

India launched a national initiative named Health and Wellness Centres (HWCs) in 2018 to provide population-based primary care including for the non-communicable diseases (NCDs) in rural areas. The current study assesses whether operationalization of HWCs improved the detection of NCDs and increased the share of public sector facilities in providing NCD services. Two rounds of household surveys were conducted in rural Chhattisgarh in 2019 and 2022. With a focus on NCDs, the household survey covered a representative sample of individuals above the age of 30 years - 2760 individuals in 2019 and 2638 in 2022. Multi-variate regression analysis was carried out to determine effects of HWCs on identification of NCDs and utilization of public sector services. The population covered by HWCs had 25% greater chance of being identified with NCDs as compared to the population without HWCs (AOR = 1.25, P = 0.03). The NCD patients living in areas covered by HWCs had 70% greater chance of utilizing the public healthcare facilities (AOR = 1.70, P = 0.01). In the population covered by HWCs, the share of the public sector in NCD care increased from 41.2% in 2019 to 62.1% in 2022, whereas the share of informal private providers dropped from 23.5% in 2019 to 8.4% in 2022. The HWCs showed effectiveness in increasing detection of NCDs at the population level and bringing a larger share of NCD patients to utilize public sector services. They can prove to be a crucial architectural correction for improving primary care service delivery for NCDs and other population health needs in India.

Cost of Care for Non-communicable Diseases: Which Types of Healthcare Providers are the Most Economical in India's Chhattisgarh State?

Non-communicable diseases (NCDs) affect a large number of people globally and their burden has been growing. Healthcare for NCDs often involves high out-of-pocket expenditure and rising costs of providing services. Financing and providing care for NCDs have become a major challenge for health systems. Despite the high burden of NCDs in India, there is little information available on the costs involved in NCD care. The study was aimed at finding out the average monthly cost of outpatient care per NCD patient. The average cost was defined as all resources spent directly by government and citizens to get a month of care for a NCD patient. The cost borne by the government on public facilities was taken into account and activity-based costing was used to apportion it to the function of providing outpatient NCD care. For robustness, time-driven activity-based costing and sensitivity analyses were also performed. The study was conducted in Chhattisgarh State and involved a household survey and a facility survey, conducted simultaneously at the end of 2022. The surveys had a sample representative of the state, covering 3500 individuals above age of 30 years and 108 health facilities. The average monthly cost per NCD patient was Indian Rupees (INR) 688 for public providers, INR 1389 for formal for-profit providers and INR 408 for informal private providers and they managed 53.5, 34.3 and 12.0% of NCD patients respectively. The disease profile of patients handled by different types of providers was similar. The average cost per patient was lowest for the primary care facilities in the public sector. The average direct cost of NCD care for government and citizens put together was substantially higher in case of formal for-profit providers compared with public facilities, even after taking into account the government subsidies to public sector. This has implications for allocative efficiency and the desired public-private provider mix in health systems.

Do private health providers help achieve Universal Health Coverage? A scoping review ofthe evidence from low-income countries.

Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.

Public sector engagement of private healthcare providers during the COVID-19 pandemic in Uttar Pradesh, India.

The COVID-19 pandemic has strained public health resources and overwhelmed health systems capacity of countries worldwide. In India, the private sector is a significant source of healthcare particularly in large states like Uttar Pradesh (UP). This study sought to examine: (i) the government's approach to engaging the private health sector in the COVID-19 response in UP; (ii) the effects of government's engagement on private providers' practices and (iii) the barriers and facilitators to effective private sector engagement during the period. While the literature acknowledges weaknesses in private sector engagement during emergencies, our study provides deep empirical insight into how this occurs, drawing on the UP experience. We reviewed 102 Government of UP (GOUP) policy documents and conducted 36 in-depth interviews with government officials, technical partners, and private providers at district- and state-levels. We developed timelines for policy change based on the policy review and analyzed interview transcripts thematically using a framework analysis. We found that GOUP's engagement of the private sector and private providers' experiences varied substantially. While the government rapidly engaged and mobilized private laboratories, and enlisted private hospitals to provide COVID-19 services, it undertook only limited engagement of solo private providers who largely acted as referral units for suspected cases and reported data to support contact tracing efforts. Informal private providers played no formal role in the COVID-19 response, but in one district supported community-level contact tracing. Allopathic, alternative medicine, and diagnostic private providers faced common barriers and facilitators affecting their engagement relating to provider fear, communication, testing capacity, case reporting, and regulations. The establishment of mixed diagnostic networks during COVID-19 demonstrates the potential for public-private collaboration, however, our study also reveals missed opportunities to engage smaller-scale private health providers and establish mechanisms to effectively communicate and mobilize them during the pandemic, and beyond.

Comparing the average cost of outpatient care of public and for-profit private providers in India

IntroductionUnderstanding the cost of care associated with different kinds of healthcare providers is necessary for informing the policy debates in mixed health-systems like India’s. Existing studies reporting Out of Pocket Expenditure (OOPE) per episode of outpatient care in public and private providers in India do not provide a fair comparison because they have not taken into account the government subsidies received by public facilities. Public and private health insurance in India do not cover outpatient care and for-profit providers have to meet all their costs out of the payments they take from patients.MethodsThe average direct cost per acute episode of outpatient care was compared for public providers, for-profit formal providers and informal private providers in Chhattisgarh state of India. For public facilities, government subsidies for various inputs were taken into account. Resources used were apportioned using Activity Based Costing. Land provided free to public facilities was counted at market prices. The study used two datasets: a) household survey on outpatient utilisation and OOPE b) facility survey of public providers to find the input costs borne by government per outpatient-episode.ResultsThe average cost per episode of outpatient care was Indian Rupees (INR) 400 for public providers, INR 586 for informal private providers and INR 2643 for formal for-profit providers and they managed 39.3, 37.9 and 22.9% of episodes respectively. The average cost for government and households put together was greater for using formal for-profit providers than the public providers. The disease profile of care handled by different types of providers was similar. Volume of patients and human-resources were key cost drivers in public facilities. Close to community providers involved less cost than others.Conclusions and recommendationsThe findings have implications for the desired mix of public and private providers in India’s health-system. Poor regulation of for-profit providers was an important structural cost driver. Purchasing outpatient care from private providers may not reduce average cost. Policies to strengthen public provisioning of curative primary care close to communities can help in reducing cost.

Socio-spatial and seasonal dynamics of small, private water service providers in Khulna district, Bangladesh

ABSTRACT Small water service providers operating in informal markets across the Global South address critical gaps in public investments in the rural water sector. This study analyses the growth and operations of private desalination plants and distributing vendors in Khulna, Bangladesh, within the broader landscape of uncoordinated investments by government, donors and households. Household water choices and payment behaviour vary spatially and seasonally, with observable wealth differences in self-supply investments in rainwater tanks and tubewells. Monitoring and regulating informal private providers can improve sectoral coordination, increase efficiency of service delivery and unlock commercial finances against the backdrop of declining aid-based financing.

Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study.

Objective:A qualitative study was conducted to gain insight into challenges reported by Butaleja households during a previous household survey. Specifically, this paper discusses heads of households’ and caregivers’ perceptions of challenges they face when seeking care for their very young children with fever presumed to be malaria.Methods:Eleven focus groups (FGs) were carried out with household members (five with heads of households and six with household caregivers) residing in five sub-counties located across the district. Purposive sampling was used to ensure the sample represented the religious diversity and geographical distance from the peri-urban center of the district. Each FG consisted of five to six participants. The FGs were conducted at a community centre by two pairs of researchers residing in the district and who were fluent in both English and the local dialect of Lunyole. The discussions were recorded, translated, and transcribed. Transcripts were reviewed and coded with the assistance of QDA Miner (version 4.0) qualitative data management software, and analyzed using thematic content analysis.Results:The FG discussions identified four major areas of challenges when managing acute febrile illness in their child under the age of five with presumed malaria (1) difficulties with getting to public health facilities due to long geographical distances and lack of affordable transportation; (2) poor service once at a public health facility, including denial of care, delay in treatment, and negative experiences with the staff; (3) difficulties with managing the child’s illness at home, including challenges with keeping home-stock medicines and administering medicines as prescribed; and (4) constrained to use private outlets despite their shortcomings.Conclusions:Future interventions may need to look beyond the public health system to improve case management of childhood malaria at the community level in rural districts such as Butaleja. Given the difficulties with accessing quality private health outlets, there is a need to partner with the private sector to explore feasible models of community-based health insurance programs and expand the role of informal private providers.

Designing malaria surveillance strategies for mobile and migrant populations in Nepal: a mixed-methods study

BackgroundAs malaria cases have declined throughout Nepal, imported cases comprise an increasing share of the remaining malaria caseload, yet how to effectively target mobile and migrant populations (MMPs) at greatest risk is not well understood. This formative research aimed to confirm the link between imported and indigenous cases, characterize high-risk MMPs, and identify opportunities to adapt surveillance and intervention strategies to them.MethodsThe study used a mixed-methods approach in three districts in far and mid-western Nepal, including (i) a retrospective analysis of passive surveillance data, (ii) a quantitative health facility-based survey of imported cases and their MMP social contacts recruited by peer-referral, and (iii) focus group (FG) discussions and key informant interviews (KIIs) with a subset of survey participants. Retrospective case data were summarised and the association between monthly indigenous case counts and importation rates in the previous month was investigated using Bayesian spatio-temporal regression models. Quantitative data from structured interviews were summarised to develop profiles of imported cases and MMP contacts, including travel characteristics and malaria knowledge, attitudes and practice. Descriptive statistics of the size of cases’ MMP social networks are presented as a measure of potential programme reach. To explore opportunities and barriers for targeted malaria surveillance, data from FGs and KIIs were formally analysed using a thematic content analysis approach.ResultsMore than half (54.1%) of malaria cases between 2013 and 2016 were classified as imported and there was a positive association between monthly indigenous cases (incidence rate ratio (IRR) 1.02 95% CI 1.01–1.03) and the previous month’s case importation rate. High-risk MMPs were identified as predominantly adult male labourers, who travel to malaria endemic areas of India, often lack a basic understanding of malaria transmission and prevention, rarely use ITNs while travelling and tend not to seek treatment when ill or prefer informal private providers. Important obstacles were identified to accessing Nepali MMPs at border crossings and at workplaces within India. However, strong social connectivity during travel and while in India, as well as return to Nepal for large seasonal festivals, provide opportunities for peer-referral-based and venue-based surveillance and intervention approaches, respectively.ConclusionsPopulation mobility and imported malaria cases from India may help to drive local transmission in border areas of far and mid-western Nepal. Enhanced surveillance targeting high-risk MMP subgroups would improve early malaria diagnosis and treatment, as well as provide a platform for education and intervention campaigns. A combination of community-based approaches is likely necessary to achieve malaria elimination in Nepal.

From Rowdy Cartels to Organized Ones? The Transfer of Power in Urban Water Supply in Kenya

Due to the limited presence of formal water utilities in urban low-income areas in many developing countries, water supply is carried out by informal private providers. As part of efforts towards improving water services to low-income areas, the activities of these informal providers are currently being acknowledged through various formalization approaches. This article investigates one such formalization approach, which consists of partnerships between the utility and the informal providers. This is an approach which allows the utility to partially withdraw from service provisioning to the low-income areas. Based on empirical evidence from three such partnerships in low-income areas in three Kenyan cities, we show in this article that formalization redefines and strengthens the legal capacity of informal providers to gain control of service provision in these areas. This can bring benefits for the utility as well as for consumers. However, it also risks legitimizing and furthering the exploitation of consumers by informal providers.

Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems.

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Management of childhood diarrhea among private providers in Uttar Pradesh, India.

BackgroundIn Uttar Pradesh (UP), India, a new initiative to introduce zinc and reinvigorate ORS for diarrhea treatment in the public and private sectors was rolled out in selected districts. We conducted an external evaluation of the program that included assessing the knowledge and practices of private sector providers 6 months after the initial program rollout.MethodsWe conducted interviews and direct observations among a randomly selected group of formal and informal private sector providers in 12 districts of UP. We calculated summary statistics for reported provider characteristics, diarrhea treatment knowledge and preferred treatments, as well as the treatments advised during consultation with a child with diarrhea.ResultsWe interviewed 232 providers, of whom 67% reported receiving a diarrhea treatment training/drug detailing visit. In the interview, 14% of providers reported prescribing zinc to all children with diarrhea and 36% reported prescribing zinc to more than half of diarrhea cases. During direct observation, ORS and zinc were prescribed by 77.3% and 29.9% of providers, respectively. Treatments other than zinc and ORS were also commonly prescribed, including antibiotics (61.9%) and antidiarrheals (17.5%).ConclusionAdequate treatment of childhood diarrhea with zinc and ORS remains a challenge among private sector providers in rural UP, India. Additional training and knowledge transfer activities are needed to curb the overprescription of antibiotics and antidiarrheals and to increase the confidence of private providers in advising zinc and ORS. In addition, policymakers and program implementers must ensure collaborative efforts to target and meaningfully engage informal private providers who play a major role in childhood diarrhea treatment in hard–to–reach areas.

Cost-effectiveness analysis of malaria rapid diagnostic test incentive schemes for informal private healthcare providers in Myanmar.

BackgroundThe emergence of artemisinin-resistant Plasmodium falciparum parasites in Southeast Asia threatens global malaria control efforts. One strategy to counter this problem is a subsidy of malaria rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT) within the informal private sector, where the majority of malaria care in Myanmar is provided. A study in Myanmar evaluated the effectiveness of financial incentives vs information, education and counselling (IEC) in driving the proper use of subsidized malaria RDTs among informal private providers. This cost-effectiveness analysis compares intervention options.MethodsA decision tree was constructed in a spreadsheet to estimate the incremental cost-effectiveness ratios (ICERs) among four strategies: no intervention, simple subsidy, subsidy with financial incentives, and subsidy with IEC. Model inputs included programmatic costs (in dollars), malaria epidemiology and observed study outcomes. Data sources included expenditure records, study data and scientific literature. Model outcomes included the proportion of properly and improperly treated individuals with and without P. falciparum malaria, and associated disability-adjusted life years (DALYs). Results are reported as ICERs in US dollars per DALY averted. One-way sensitivity analysis assessed how outcomes depend on uncertainty in inputs.ResultsICERs from the least to most expensive intervention are: $1,169/DALY averted for simple subsidy vs no intervention, $185/DALY averted for subsidy with financial incentives vs simple subsidy, and $200/DALY averted for a subsidy with IEC vs subsidy with financial incentives. Due to decreasing ICERs, each strategy was also compared to no intervention. The subsidy with IEC was the most favourable, costing $639/DALY averted compared with no intervention. One-way sensitivity analysis shows that ICERs are most affected by programme costs, RDT uptake, treatment-seeking behaviour, and the prevalence and virulence of non-malarial fevers. In conclusion, private provider subsidies with IEC or a combination of IEC and financial incentives may be a good investment for malaria control.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0569-7) contains supplementary material, which is available to authorized users.

Can interventions improve health services from informal private providers in low and middle-income countries? A comprehensive review of the literature

BACKGROUND There is a growing interest in the role of private health providers in low- and middle-income countries (LMICs). Informal private providers (IPPs) provide a significant portion of health care in many LMICs, but they have not received training in allopathic medicine. Interventions have been developed to take advantage of their potential to expand access to essential health services, although their success is not well measured. This paper addresses this information gap through a review of interventions designed to improve the quality, coverage, or costs of health services provided by IPPs in LMICs. METHODS A search for published literature in the last 15 years for any intervention dealing with IPPs in a LMIC, where at least one outcome was measured, was conducted through electronic databases PubMed and Global Health, as well as Google for grey literature from the Internet. RESULTS A total of 1272 articles were retrieved, of which 70 separate studies met inclusion criteria. The majority (70%) of outcomes measured proximate indicators such as provider knowledge (61% were positive) and behaviour (56% positive). Training IPPs was the most common intervention tested (77% of studies), but the more effective strategies did not involve training alone. Interventions that changed the institutional relationships and contributed to changing the incentives and accountability environment were most successful, and often required combinations of interventions. CONCLUSION Although there are documented interventions among IPPs, there are few good quality studies. Strategies that change the market conditions for IPPs-by changing incentives and accountability-appear more likely to succeed than those that depend on building individual capacities of IPPs. Understanding the effectiveness of these and other strategies will also require more rigorous research designs that assess contextual factors and document outcomes over longer periods.

Government engagement with non‐state providers of water and sanitation services

AbstractIncreasingly, governments in developing countries recognise that the public sector alone cannot provide adequate water and sanitation services to all. Non‐state providers (NSPs) including both formal and informal private providers, as well as civil society institutions, also have important roles to play. There are clear challenges for governments intending to work with NSPs, not least of which is the institutional compatibility between bureaucratic agencies and informal water and sanitation NSPs. However, positive examples of government agencies working effectively with NSPs are emerging in many countries. Government engagement with water and sanitation NSPs can be split into five main types: recognition, dialogue, facilitation/collaboration, contracting and regulation. In many situations, a lack of formal recognition of water or sanitation NSPs is an impediment to more productive forms of engagement. There are a number of potential intervention options within each of the five types of engagement that government agencies should carefully consider when supporting the development of NSP water and sanitation services. Copyright © 2006 John Wiley & Sons, Ltd.