Private For-profit Facilities Research Articles

Private practitioners' practices for tuberculosis management in a city largely served by the private health sector in Uganda.

Globally, tuberculosis (TB) remains a significant cause of morbidity and mortality having caused 1.6 million deaths in 2021. Uganda is a high TB burden country with a large private sector that serves close to 60% of the urban population. However, private for-profit health facilities' involvement with the National TB and Leprosy Program (NTLP) activities remains poor. This study evaluated the practices of diagnosis and treatment of pulmonary tuberculosis (PTB) and associated factors among practitioners in private for-profit (PFP) healthcare facilities in Kampala, Uganda. We conducted a cross-sectional study among randomly selected private practitioners in Uganda's largest city, Kampala. A structured questionnaire was used for data collection. Descriptive statistics and generalized linear models with log Poisson link were used to analyze data. Practices were graded as standard or substandard. Of the 630 private practitioners studied, 46.2% (95% confidence interval (CI): 26.6 to 67.1) had overall standard practices. Being a laboratory technician (prevalence ratio (PR) = 2.7, p< 0.001) or doctor (PR = 1.2, p< 0.001), a bachelor's degree level of qualification (PR = 1.1, p = 0.021), quarterly supervision by the national TB program (PR = 1.3, p = 0.023), and acceptable knowledge of the practitioner about TB (PR = 1.8, p<0.001) were significantly associated with standard practices. The practices of TB management for practitioners from the PFP facilities in Kampala are suboptimal and this poses a challenge for the fight against TB given that these practitioners are a major source of primary health care in the city.

Utilization of Proximate Healthcare Facilities and Children’s Wait Times in Senegal: An IV-Tobit Analysis

Universal health coverage (UHC) defines individuals’ timely access to healthcare services without suffering any health-related financial constraints. The Senegalese government has shown commitments towards achievement of UHC as a way of improving access by the population to quality healthcare services. This is very pertinent for promoting some indicators of under-five health in Senegal. Therefore, this study analyzed the factors influencing sick children’s utilization of the nearest healthcare facilities and their wait times in Senegal. The data were from the Service Provision Assessment (SPA) survey, which was conducted in 2018. The instrumental Tobit regression model was used for data analysis. The results showed that 63.50% and 86.01% of the children utilized health posts and publicly owned facilities, respectively. Also, 98.46% of the children utilized urban facilities. The nearest facilities were utilized by 74.55%, and 78.19% spent less than an hour in the facilities. The likelihood of using the nearest healthcare facilities significantly reduced (p &lt; 0.05) with caregivers’ primary education, higher education, residence in some regions (Fatick, Kaokack, Saint Louis, Sediou, and Tambacounda), and use of private/NGO not-for-profit facilities, but increased with not having visited any other providers, residence in the Kaffrie region, vomiting symptoms, use of health centers, and use of health posts. Moreover, treatment wait times significantly increased (p &lt; 0.05) with the use of nearest facilities, residence in some regions (Diourbel, Kaokack, Matam and Saint Louis), use of private for-profit facilities, use of private not-for-profit facilities, and urban residence, but decreased with secondary education, use of health centers, use of health posts, vomiting symptoms, and showing other symptoms. It was concluded that reduction in wait times and utilization of the nearest healthcare facilities are fundamental to achieving UHC in Senegal. Therefore, more efforts should be integrated at promoting regional and sectoral equities through facilitated public and private healthcare investment.

Health Care Readiness in Management of Preeclampsia/Eclampsia in Ethiopia: Evidence from National Facility-Based Survey.

BackgroundEarly case detection, treatment, and timely referral for better services can significantly reduce the negative outcomes of preeclampsia and eclampsia. However, evidence on health facilities’ readiness to provide such services and the associated challenges is limited in Ethiopia. Therefore, this study aimed to assess the readiness of Ethiopian health care facilities to manage preeclampsia and eclampsia.MethodsThis study used the 2016 Ethiopia national emergency management of obstetrics and newborn care (EmONC) survey. This survey was a national cross-sectional census of health facilities that provided delivery services. Data on facility infrastructure, equipment and supplies were collected through a facility checklist, and interview health provider experiences. Cross tabulation, summarisation and chi square tests by facility type, location, and management authority were conducted.ResultsThere were 3804 health facilities included in the survey across all regions of Ethiopia. The majority of facilities (92%) were public/government managed with only 1% of available hospitals located in rural areas. Poor availability of dipsticks for proteinuria tests (55.3%), caesarean sections (7.9%), and ambulance services (18.4%) were reported across health facilities with high variations in terms of facility type, location, and type of managing authority. Diazepam was a widely available anticonvulsant compared with magnesium sulfate (MgSO4), with more available in private for-profit facilities compared with public facilities. Nearly one third of health care providers were not trained to administer MgSO4 intravenously. The result indicated that the chi-square test was statistically significant at P < 0.001.Conclusions and RecommendationsThere were notable gaps in readiness of facilities in detection and management of preeclampsia/eclampsia that increase maternal and perinatal mortality in Ethiopia. Therefore, availability of essential supplies, medications, and referrals are required. In addition, refresher training to healthcare providers on screening, diagnosis and management of preeclampsia/eclampsia and continuous supervision should be provided.

The price of quality care: cross-sectional associations between out-of-pocket payments and quality of care in six low-income countries.

To assess the relationship between out-of-pocket (OOP) payments and primary health care quality in six low-income countries: Afghanistan, the Democratic Republic of the Congo (DRC), Haiti, Nepal, Senegal and Tanzania. We examined the association between OOP payments and quality of care during antenatal care and sick child care visits using Service Provision Assessments data. We defined four process quality outcomes from observations of clinical care: visit duration, history-taking items asked, exam items performed, and counselling items delivered. The outcome is the total amount paid for services. We used multilevel models to test the relationship between OOP payments and each quality measure in public, private non-profit and private for-profit facilities controlling for patient, provider, and facility characteristics. Across the six countries, an average of 42% of the 29677 observed clients paid for their visit. In the adjusted models, OOP payments were positively associated with the visit duration during sick child visits, with history-taking and exam items during antenatal care visits, and with counselling in private for-profit facilities for both visit types. These associations were strong particularly in Afghanistan, the DRC and Haiti; for example, a high-quality antenatal care visit in the DRC would cost approximately USD 1.12 more than a visit with median quality. Provider effort was associated with higher OOP payments for sick child and antenatal care services in the six countries studied. While many families are already spending high amounts on care, they must often spend even more to receive higher quality care.

Monitoring caesarean births using the Robson ten group classification system: A cross-sectional survey of private for-profit facilities in urban Bangladesh.

BackgroundGlobally, Caesarean section (CS) rates are mounting and currently exceed the safe upper limit of 15%. Monitoring CS rates using clinical indications and obstetric sub-group analysis could confirm that women in need have been served. In Bangladesh, the reported CS rate was 31% in 2016, and almost twice that rate in urban settings. Delivering in the private healthcare sector was a strong determinant. This study uses Robson Ten Group Classification System (TGCS) to report CS rates in urban Bangladesh. The clinical causes and determining factors for CS births have also been examined.MethodsThis record linkage cross-sectional survey was undertaken in 34 urban for-profit private hospitals having CS facilities during the period June to August 2015. Data were supplied by inpatient case records and operation theatre registers. Descriptive analyses were performed to calculate the relative size of each group; the group-specific CS rate, and group contribution to total CS and overall CS rate. CS indications were grouped into eleven categories using ICD 10 codes. Binary logistic regression was performed to explore the determinants of CS.ResultsOut of 1307 births, delivery by CS occurred in 1077 (82%). Three obstetric groups contributed the most to overall CS rate: previous CS (24%), preterm (23%) and term elective groups (22%). The major clinical indications for CS were previous CS (35%), prolonged and obstructed labor (15%), fetal distress (11%) and amniotic fluid disorder (11%). Multiple gestation, non-cephalic presentation, previous bad obstetric history were positive predictors while oxytocin used for labour induction and increased parity were negative predictors of CS.ConclusionsAs the first ever study in urban private for-profit health facilities in Bangladesh, this study usefully identifies the burden of CS and where to intervene. Engagement of multiple stakeholders including the private sector is crucial in planning effective strategies for safe reduction of CS.

Technical quality of delivery care in private- and public-sector health facilities in Enugu and Lagos States, Nigeria.

Private-sector providers are increasingly being recognized as important contributors to the delivery of healthcare. Countries with high disease burdens and limited public-sector resources are considering using the private sector to achieve universal health coverage. However, evidence for the technical quality of private-sector care is lacking. This study assesses the technical quality of maternal healthcare during delivery in public- and private-sector facilities in resource-limited settings, from a systems and programmatic perspective. A summary index (the skilled attendance index, SAI), was used. Two-staged cluster sampling with stratification was used to select representative samples of case records in public- and private-sector facilities in Enugu and Lagos States, Nigeria. Information to assess criteria was extracted, and the SAI calculated. Linear regression models examined the relationship between SAI and the private and public sectors, controlling for confounders. The median SAI was 54.8% in Enugu and 85.7% in Lagos. The private for-profit sector's SAI was lower than and the private not-for-profit sector's SAI was higher than the public sector in Enugu [coefficient = -3.6 (P = 0.018) and 12.6 (P < 0.001), respectively]. In Lagos, the private for-profit sector's SAI was higher and the private not-for-profit sector's SAI was lower than the public sector [3.71 (P = 0.005) and -3.92 (P < 0.001)]. Results indicate that the technical quality of private for-profit providers' care was poorer than public providers where the public provision of care was weak, while private for-profit facilities provided better technical quality care than public facilities where the public sector was strong and there was a relatively strong regulatory body. Our findings raise important considerations relating to the quality of maternity care, the public-private mix and needs for regulation in global efforts to achieve universal healthcare.

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

BackgroundThe World Health Organization guidelines have recommended that all cases of suspected malaria should receive a confirmatory test with microscopy or a malaria rapid diagnostic test (RDT), however evidence from sub-Saharan Africa (SSA) illustrates that only one-third of children under five with a recent fever received a test. The aim of this study was to evaluate availability, price and market share of microscopy and RDT from 2009/11 to 2014/15 in 8 SSA countries, to better understand barriers to improving access to malaria confirmatory testing in the public and private health sectors.ResultsRepeated national cross-sectional quantitative surveys were conducted among a sample of outlets stocking anti-malarial medicines and/or diagnostics. In total, 169,655 outlets were screened. Availability of malaria blood testing among all screened public health facilities increased significantly between the first survey wave in 2009/11 and the most recent in 2014/15 in Benin (36.2, 85.4%, p < 0.001), Kenya (53.8, 93.0%, p < 0.001), mainland Tanzania (46.9, 89.9%, p < 0.001), Nigeria (28.5, 86.2%, p < 0.001), Katanga, the Democratic Republic of the Congo (DRC) (76.0, 88.2%, p < 0.05), and Uganda (38.9, 95.6%, p < 0.001). These findings were attributed to an increase in availability of RDTs. Diagnostic availability remained high in Kinshasa (the DRC) (87.6, 97.6%) and Zambia (87.9, 91.6%). Testing availability in public health facilities significantly decreased in Madagascar (88.1, 73.1%, p < 0.01). In the most recent survey round, the majority of malaria testing was performed in the public sector in Zambia (90.9%), Benin (90.3%), Madagascar (84.5%), Katanga (74.3%), mainland Tanzania (73.5%), Uganda (71.8%), Nigeria (68.4%), Kenya (53.2%) and Kinshasa (51.9%). In the anti-malarial stocking private sector, significant increases in availability of diagnostic tests among private for-profit facilities were observed between the first and final survey rounds in Kinshasa (82.1, 94.0%, p < 0.05), Nigeria (37.0, 66.0%, p < 0.05), Kenya (52.8, 74.3%, p < 0.001), mainland Tanzania (66.8, 93.5%, p < 0.01), Uganda (47.1, 70.1%, p < 0.001), and Madagascar (14.5, 45.0%, p < 0.01). Blood testing availability remained low over time among anti-malarial stocking private health facilities in Benin (33.1, 20.7%), and high over time in Zambia (94.4, 87.5%), with evidence of falls in availability in Katanga (72.7, 55.6%, p < 0.05). Availability among anti-malarial stocking pharmacies and drug stores—which are the most common source of anti-malarial medicines—was rare in all settings, and highest in Uganda in 2015 (21.5%). Median private sector price of RDT for a child was equal to the price of pre-packaged quality-assured artemisinin-based combination therapy (QAACT) treatment for a two-year old child in some countries, and 1.5–2.5 times higher in others. Median private sector QAACT price for an adult varied from having parity with an RDT for an adult to being up to 2 times more expensive. The exception was in both Kinshasa and Katanga, where the median price of QAACT was less expensive than RDTs.ConclusionsSignificant strides have been made in the availability of testing, mainly through the widespread distribution of RDT, and especially in public health facilities. Significant barriers to universal coverage of diagnostic testing can be attributed to very low availability in the private sector, particularly among pharmacies and drug stores, which are responsible for most anti-malarial distribution. Where tests are available, price may serve as a barrier to uptake, particularly for young children. Several initiatives that have introduced RDT into the private sector can be modified and expanded as a means to close this gap in malaria testing availability and promote universal diagnosis.

Decline In Public Substance Use Disorder Treatment Centers Most Serious In Counties With High Shares Of Black Residents.

Previous research has associated declines in health care resources such as hospitals and trauma centers with communities' racial composition. However, little is known about changes in the substance use disorder treatment infrastructure in recent years and the implications for black communities. We used data for the period 2002-10 from the National Survey of Substance Abuse Treatment Services to describe changes in the supply of public and private outpatient facilities for substance use disorder treatment, and to determine whether these trends had implications for the geographical availability of these facilities in counties with high percentages of black residents. During the study period the number of publicly owned facilities declined 17.2percent, whereas the number of private for-profit facilities grew 19.1percent. At baseline, counties with very high percentages of black residents (that is, more than one standard deviation above the mean) were more likely than counties with less than the mean percentage of black residents to be served by public facilities and were thus disproportionately affected by the overall decline in public facilities. Future research should examine the effect of expanding eligibility for Medicaid on the supply of substance use disorder treatment facilities across diverse communities.

Obstetricians' Opinions of the Optimal Caesarean Rate: A Global Survey.

BackgroundThe debate surrounding the optimal caesarean rate has been ongoing for several decades, with the WHO recommending an “acceptable” rate of 5–15% since 1997, despite a weak evidence base. Global expert opinion from obstetric care providers on the optimal caesarean rate has not been documented. The objective of this study was to examine providers’ opinions of the optimal caesarean rate worldwide, among all deliveries and within specific sub-groups of deliveries.MethodsA global online survey of medical doctors who had performed at least one caesarean in the last five years was conducted between August 2013 and January 2014. Respondents were asked to report their opinion of the optimal caesarean rate—defined as the caesarean rate that would minimise poor maternal and perinatal outcomes—at the population level and within specific sub-groups of deliveries (including women with demographic and clinical risk factors for caesareans). Median reported optimal rates and corresponding inter-quartile ranges (IQRs) were calculated for the sample, and stratified according to national caesarean rate, institutional caesarean rate, facility level, and respondent characteristics.ResultsResponses were collected from 1,057 medical doctors from 96 countries. The median reported optimal caesarean rate was 20% (IQR: 15–30%) for all deliveries. Providers in private for-profit facilities and in facilities with high institutional rates reported optimal rates of 30% or above, while those in Europe, in public facilities and in facilities with low institutional rates reported rates of 15% or less. Reported optimal rates were lowest among low-risk deliveries and highest for Absolute Maternal Indications (AMIs), with wide IQRs observed for most categories other than AMIs.ConclusionsThree-quarters of respondents reported an optimal caesarean rate above the WHO 15% upper threshold. There was substantial variation in responses, highlighting a lack of consensus around which women are in need of a caesarean among obstetric care providers worldwide.

Met and unmet needs for surgery in Sierra Leone: A comprehensive, retrospective, countrywide survey from all health care facilities performing operations in 2012

Understanding a country's baseline operative actors and capacity is critical to improving the quality of services and outcomes. The aim of this study was to describe all operative providers and national operative production, to evaluate district and nationwide population rates for operations, and to estimate unmet operative need in Sierra Leone. A nationwide, exhaustive, retrospective, facility-based study of operative actors and surgical procedures was performed in Sierra Leone. Between January and May 2013, 4 teams of 12 medical students collected data on the characteristics of the institutions and of the operations performed in 2012. Data were retrieved from the log books of operations, anesthesia, and delivery. A total of 24,152 operative procedures were identified, equal to a national rate of 400 operative procedures per 100,000 inhabitants (district range 32-909/100,000, interquartile range 95-502/100,000). Hernia repair was the most common operative procedure at 86.1 per 100,000 inhabitants (22.4% of the total national volume) followed by cesarean delivery at 80.6 per 100,000 (21.0% of the total). Private, nonprofit facilities performed 54.0% of the operations, compared with 39.6% by governmental and 6.4% by private for-profit facilities. More than 90% of the estimated operative need in Sierra Leone was unmet in 2012. The unmet operative need in Sierra Leone is very high. The 30-fold difference in operative output between districts also is very high. As the main training institution, operative services within the governmental sector need to be strengthened. An understanding of the existing operative platform is a good start for expanding operative services.

Does ownership matter? An overview of systematic reviews of the performance of private for-profit, private not-for-profit and public healthcare providers.

IntroductionOwnership of healthcare providers has been considered as one factor that might influence their health and healthcare related performance. The aim of this article was to provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers -namely public, private non-for-profit (PNFP) and private for-profit (PFP)- based on the findings of systematic reviews (SR).Methods and FindingsAn overview of systematic reviews was performed. Different databases were searched in order to select SRs according to an explicit comprehensive criterion. Included SRs were assessed to determine their methodological quality. Of the 5918 references reviewed, fifteen SR were included, but six of them were rated as having major limitations, so they weren't incorporated in the analyses. According to the nine analyzed SR, ownership does seem to have an effect on health and healthcare related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of mortality of patients and payments to facilities have been found, both being higher in PFP facilities. In terms of quality and economic indicators such as efficiency, there are no concluding results. When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found.ConclusionPFP providers seem to have worst results than their PNFP counterparts, but there are still important evidence gaps in the literature that needs to be covered, including the comparison between public and both PFP and PNFP providers. More research is needed in low and middle income countries to understand the impact on and development of healthcare delivery systems.

Comparative performance of public and private sector delivery of BCG vaccination: Evidence from Sub-Saharan Africa

BackgroundThe private sector is an important source of health care in the developing world. However, there is limited evidence on how private providers compare to public providers, particularly for preventive services such as immunizations. We used data from Sub-Saharan Africa (SSA) to assess public–private differences in Bacillus Calmette–Guérin (BCG) vaccine delivery. Methods and findingsWe used demographic and health surveys from 102,629 children aged 0–59 months from 29 countries across SSA to measure differences in BCG status for children born at private versus public health facilities (BCG is recommended at birth). We used a probit model to estimate public–private differences in BCG delivery, while controlling for key confounders. Next, we estimated how differences in BCG status evolved over time for children born at private versus public facilities. Finally, we estimated heterogeneity in public–private differences based on wealth and rural–urban residency. We found that children born at a private facility were 7.1 percentage points less likely to receive BCG vaccine in the same month as birth than children born at a public facility (95% CI 6.3–8.0; p<0.001). Most of this difference was driven by for-profit private providers (as opposed to NGOs) where the BCG provision rate was 10.0 percentage points less than public providers (95% CI 9.0–11.2; p<0.001) compared to only 2.4 percentage points for NGOs (95% CI 1.0–3. 8; p<0.01). Moreover, children born at private for-profit facilities remained less likely to be vaccinated up to 59 months after birth. Finally, public–private differences were more pronounced for poorer children and children in rural areas. ConclusionsThe for-profit private sector performed substantially worse than the public sector in providing BCG vaccine to newborns, resulting in a longer duration of vulnerability to tuberculosis. This disparity was greater for poorer children and children in rural areas.

Private and public health care in rural areas of Uganda

BackgroundIn many low and middle income countries, the private sector is increasingly becoming an important source of health care, filling gaps where no or little public health care is available. However, knowledge on the private sector providers is limited The objective of this study was to determine the type and number of different types of health care providers, and the quality, cost and utilization of care delivered by those providers in rural Uganda.MethodsThe study was carried out in three rural districts. Methods included (1) mapping of health care providers; (2) a household survey to determine morbidity and health care utilization; (3) a health facility survey to assess quality of care; (4) focus group discussions to get qualitative information on providers and provider choice; and (5) key informant interviews to further explore service characteristics.Results95.7% of all 445 facilities surveyed were private while 4.3% were public. Traditional practitioners and general merchandise shops that sold medicines comprised 77.1% of all providers. They had limited infrastructure and skills but were often located in the villages and therefore easily accessible. Among the formal providers there were 4 times as many private for profit providers than public, 76 versus 18. However, most of the private units were one-person drug shops.In the household survey, 2580 persons were interviewed. 1097 (42%) had experienced illness during the preceding month. Care was sought in 54.1% of the cases. 35.6% were given self-treatment and in 10.3% no action was taken. Of the episodes for which people sought care at a health care facility, 37.0% visited a public health care provider, 39.7% a for profit provider, 11.8% a private not for profit provider, and 10.6% a traditional practitioner. Private for profit facilities were the most popular for ambulatory health care, while public facilities were preferred for more serious conditions and for hospitalization. Traditional practitioners were many but saw relatively few patients. They were mostly used for social problems and limited medical specific conditions.ConclusionsPrivate providers play a major role in health care delivery in rural Uganda; reaching a wide client base. Traditional practitioners are many but have as much a social as a medical function in the community. The significance of the private health care sector points to the need to establish a policy that addresses quality and affordability issues and creates a strong regulatory environment for private practice in sub-Saharan Africa.