Executive Summary

Most poor people in most poor countries get most of their healthcare from private rather than public sources. This paper reviews current evidence about the way in which the private sector delivers Sexual and Reproductive Health (SRH) and Maternal and Neonatal Health (MNH) services. The paper focuses on three particular issues – equity, quality and cost-effectiveness. The private sector covers all health providers who are not directly managed and paid by the state. It includes for-profit and not-for-profit providers in the formal sector (who are generally trained, and licensed to practice or sell medicines), as well as the mass of informal providers, and shop-keepers who sell medicines. The review draws mainly on evidence published in peer-reviewed journals, and grades the strength of the evidence using WHO’s scale of 1-5. ‘Grey’ literature is included where it meets a minimum standard. A range of sources were searched, and about 50 papers on SRH and 100 papers on MNH were included in the final review.

Although there is some published literature on private healthcare in developing countries, most of it is about market interventions in the way providers organise their work, the majority of them donor-funded. These have been divided into two categories – ‘service delivery’ such as training or franchising, and ‘financing’ such as vouchers.

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Equity
Very few of the studies reviewed here provide any evidence on the question of equity. The population, households or patients being studied are rarely differentiated by socio-economic status. On the other hand, many interventions were targeted at the poor, for example by being located in poor areas, or by access being restricted to those in receipt of some other benefit such as government-run schemes providing cash or subsidised food to the poor.

The strongest evidence for government and donor-funded interventions involving the private sector to improve access for the poor came from three types of intervention – social franchising for family planning; government-run Conditional Cash Transfers (CCTs) for antenatal care (ANC) and safe delivery by public, NGO and for-profit providers; and governments contracting private providers to provide obstetric care. CCTs in India and Mexico have increased utilisation of ANC and safe delivery services by the poor, because the subsidy is targeted at the poor. Contracting can be a successful supply-side intervention, for example in Cambodia with NGOs and in Gujarat, India with for-profit obstetricians, improving access for the poor while motivating the providers. There is also some evidence that social marketing is effective at widening access (though obviously it does not reach the very poor who cannot afford to pay for the product or service). Making a highly effective drug such as misoprostol, for the prevention and treatment of post-partum haemorrhage (PPH), available to informal private providers at village level and thus to the poorest women, has a strong equity effect.

Quality
There is strong evidence that quality of care (QOC) given by private providers can be improved by selected interventions. Training private providers in family planning (FP) and, as noted above, enabling them to dispense misoprostol; giving vouchers for SRH to marginalised groups such as sex-workers; and social marketing of clean delivery kits, all work well to improve quality. Conditional cash transfers also improve the quality of antenatal care, but their impact on family planning quality has not been assessed.

Training might be expected to improve QOC, as might franchising, but the evidence for both is mixed. Training community-based workers to administer injectable contraceptives has expanded both choice and quality almost everywhere, but training TBAs in safe delivery, and pharmacists and private providers in syndromic management of STIs, has had mixed results. Reimbursing private providers through CCT and voucher schemes improved the quality of ANC in Mexico and of SRH for marginalised groups in Nicaragua by compensating providers to provide adequate numbers of services and adequate nutritional supplements. Moreover, there is some moderate evidence that if contracting and vouchers are set up as competitive schemes, they push providers to do better by their clients in order to increase business for themselves.

Cost effectiveness
Of the three criteria, there is least evidence for cost-effectiveness. It is rare to find a prospectively designed study that has built cost-effectiveness in from the beginning. A few strong studies point to the cost-effectiveness of contraceptive social marketing globally; of SRH vouchers for high risk groups in Nicaragua; and of community-based administration of misoprostol for prevention of PPH in India.Sexual and Reproductive Health (SRH)
For SRH, the strongest evidence for market interventions showed that franchising can expand private sector access to family planning for the poor; social marketing of FP messages and products can improve access for everyone (though not necessarily the poor) and raise awareness and knowledge; that private sector community-based workers can be trained to administer injectable contraceptives with a high quality of care; that social marketing is as or more cost-effective than other channels for getting contraceptives to those who want them and for increasing demand, and for reaching adolescents; and that vouchers can improve QOC for marginalised populations, and is cost effective compared to having no voucher program to expand access to SRH.

Maternal and Neonatal Health (MNH)
The strongest evidence in support of market interventions in MNH is that conditional cash transfers provide better access to ANC for the poor, and better QOC; and that social marketing can expand access to iron and folic acid supplements for pregnant women. To improve safe delivery, conditional cash transfers and contracting give the poor better access and can improve quality of care, while social marketing of clean delivery kits can improve QOC. In postpar tum care the administration by community-based private providers of misoprostol to prevent and treat PPH gives better access for all, better quality of care, and is cost-effective compared to home births attended by a TBA whose only recourse for PPH was to arrange referral.

Other Issues
The literature on six other issues is also reviewed: regulation; dual practice; accreditation; fragile states; crowding-out and crowding-in; and gender. (This literature is generally descriptive so we have not rated the strength of the evidence). There is little in the public health literature about government regulation of the private health sector in developing countries. What has been examined (and not very critically) mostly concerns private pharmacies and does not specifically address SRH/MNH issues. Yet regulation (or lack thereof) is especially important for the poor as they not only waste money on providers or products that do not work and which keep them sick, but they are further impoverished by fees and charges.

Dual practice, by which salaried public sector providers operate private practices at the same time, raises particular issues with respect to the poor, as such providers usually provide better quality care with shorter waiting times at their private clinics. The literature suggests that there are no easy solutions to abuse of dual practice, though one point of consensus is that context-specific reasons for dual practice must be understood before designing any regulatory or other response. Few experts advocate an ‘all or nothing’ approach. There is little discussion in the literature on accreditation for SRH and MNH. It used to be that only governments could regulate, and only professional associations could accredit, but nowadays these functions are being taken over by private entities. For example, franchising is a way of combining non-state regulation and accreditation by an agency other than a professional association. Franchising, insurance, voucher and contracting schemes can deny participation to non-performing or non-compliant providers, though not all do so.

There are many examples of SRH and MNH services being delivered in fragile states, mostly by NGOs. But there is little in the literature evaluating these interventions. Weak government and the absence of bureaucratic impediments in fragile states means there are opportunities for innovation and for scaling-up faster than would be possible in a more peaceful situation, but the results are often difficult for government to oversee and regulate, and the short-term gains may be at the expense of longer-term strengthening of the overall health system. We did not find a single study provid ing adequate evidence about the impact on the whole market of introducing subsidised products and services. The main concern is that new entrants to the commercial sector will be discouraged (crowding out), but where the financing mechanism is set up to encourage competition among providers, there is a potential for spill-over improvements in quality of care throughout some or all of the market.

As for gender, the great majority of the evidence for MNH focuses on women, which seems appropriate and obvious except in the case of communications campaigns targeted at male involvement. The SRH literature should, but does not always, have something to say about gender, often because the study design does not account for or is not aimed at finding sex differentials in outcomes. Men often self-treat STIs with inappropriate medicines bought without a prescription from shops, but there is little evidence about this.

Options for Private Sector Engagement

There is a broad range of options for working with the for-profit formal sector (doctors, nurses, etc.) in SRH/MNH, from training to contracting to voucher schemes. Options for engaging the informal sector (TBAs, drug sellers, traditional healers etc) are more limited, but include provision of subsidised products through social marketing, and training and ongoing supervision through social franchising/accreditation. But their status as unlicensed providers does make it difficult for governments to engage the informal sector. Working with the not-for-profit sector (NGOs, faith-based organizations, etc.) requires government or donor funding to this sector for franchising, social marketing, voucher management, and contracted service delivery. There are options for engagement at all levels but these vary greatly by context and scope.