Vouchers as Demand Side Financing Instruments for Health Care: A Review of the Bangladesh Maternal Voucher Scheme

Schmidt JO, Ensor T, Hossain A, Khan S. Health Policy 96 (2010) 98–107

Schmidt et al. review a maternal voucher scheme in Bangladesh, finding that the program has significantly increased facility-based child delivery without incentivizing unnecessary surgical procedures but having a negligible effect on competition. The Bangladesh Ministry of Health implemented the Maternal Health Voucher Scheme in 2006 to combat high maternal and infant mortality, particularly among the poor; the program now covers 10.3 million people, or 7% of the country’s population. The program distributes vouchers to expectant mothers, which can be used in designated public or private sector facilities to cover three antenatal care visits, safe delivery in an institution or by a skilled birth attendant at home, one postnatal care visit, and a cash subsidy for transportation and nutritious food. The authors find the number of facility-based deliveries has increased significantly in intervention areas compared to non-intervention areas, with total facility deliveries increasing most significantly in areas without means testing for vouchers. Schmidt et al. did not find that the voucher program resulted in an increase in cesarean sections in the population, despite the significant financial incentive for providers to provide the procedure. Furthermore, the authors note that the scheme did not promote quality enhancing competition between service providers for vouchers. Schmidt et al. argue that set reimbursements for procedures were too low to attract significant private sector involvement and noted that the total number of providers was highly limited in some areas. The authors believe the voucher system shows promise as a demand side financing technique, but needs to streamline several management and administration issues to improve effectiveness.

Effect of Food Coupon Incentives on Timely Completion of DTP Immunization Series in Children from a Low-Income Area in Karachi, Pakistan

Chandir S, Khan S, Hussain H, et al., Vaccine 28 (2010) 3473–3478

Chandir et al. evaluate the effectiveness of incentive vouchers in increasing diptheria, tetanus, and pertussis (DTP) immunization coverage among infants in Karachi, Pakistan. The authors designed a case control study in which selected participants received a “food/medicine coupon” worth $2.00 for attending two subsequent DTP booster appointments during the next 18 weeks. Chandir et al. found that the intervention group had a “more than 2 times higher probability” of completing the DTP vaccine schedule compared to the control group. The authors argue that their study adds to growing evidence of the effectiveness of voucher incentives in increasing immunization coverage. Yet, they note a paucity of evidence on the sustainability of such programs, as well as on the differential effectiveness of voucher programs for higher socioeconomic groups.

Branding in Contraceptive Social Marketing: The Pakistani Experience

Samad N, Nwankwo S, and Gbadamosi A. Social Marketing Quarterly, 16: 2, 50 — 68 2010.

Samad et al. analyze three case studies of contraceptive social marketing programs in Pakistan to discuss issues surrounding branding in a “highly regulated market space.” Specifically, the authors discuss the development of the Sathi project to distribute affordable condoms to low income men; the Greenstar brand for family planning tools, including condoms, IUDs, and oral contraceptives; and the Key Social Marketing project for oral contraceptives. Samad et al. argue for the importance of branding in “facilitat[ing] the design and implementation of effective marketing campaigns.” Additionally, the authors argue that the case studies highlight the importance of brand ownership in providing implementing organizations “leverage and flexibility” in their program implementation. Samad et al. also note that competition between social marketed brands run counter to the goal of social marketing -- “increasing contraceptive usage, irrespective of brands.”

Improvements in Access To Malaria Treatment in Tanzania Following Community, Retail Sector and Health Facility Interventions - A User Perspective

Alba S, Dillip A, Hetzel M. Malaria Journal 2010, 9:163

Alba et al. evaluate two parallel programs, ACCESS and ADDO, in the Kilombero and Ulanga Districts in southeastern Tanzania, that aim to increase public understanding of malaria and improve access to malaria treatment by enhancing private sector delivery. The ACCESS program uses social marketing to improve public recognition of malaria symptoms and promote appropriate care seeking behaviors. It also provided training to health workers and clinical staff to improve the quality of malaria care. The ADDO (Accredited Drug Dispensing Outlet) program aimed to improve access and availability of antimalarials and improve quality of malaria care in private drug stores through “training, incentives, accreditation and regulation.” Alba et al. argue that together, the ACCESS and ADDO programs increased public knowledge of malaria symptoms and adult malaria treatment in health facilities and in the private retail sector, raised the quality of malaria treatment in the private sector, and overall, fostered the public’s timely access to malaria drug treatment. They authors argue however that the success of the ACCESS and ADDO programs was constrained by a government shift from promoting sulphadoxine- pyrimethamine antimalarial drugs as the first-line treatment for malaria to promoting artemether-lumefantrine (ALu) drugs, without efforts to bolster the ALu supply in correspondence. The authors also contend that the availability of anti-malarials (“i.e. the presence of a drug outlet in [a] patient’s village of residence”) was the primary determinant of timely and effective malaria treatment, rather than affordability. Alba et al. conclude that the two programs successfully provide an integrated approach to improve malaria treatment and should be expanded within the region.

Comparison of Medicine Price and Availability Between the Public and Private Sector in Brazil and 13 African Countries.

Pinto C, Miranda E, Emmerick I, et al., Rev Saude Publica. 2010 Jun 25. and Twagirumukiza M, Annemans L, Kips J, et al., Tropical Medicine and International Health, volume 15 no 3 pp 350–361 March 2010

In two separate studies, Pinto et al. and Twagirumukiza et al. compare medicine prices between the public and private sectors in Brazil and Africa, respectively. In 2004, the Brazilian Ministry of Health established the People’s Pharmacy Program (FPB), which subsidizes a formulary of 107 drugs to individuals who provide a co-payment. Members can purchase the subsidized medicines at either public or accredited private pharmacies. In a comparison of four common hypertension and diabetes drugs, Pinto et al. find that in the private sector, both independent and accredited private FPB pharmacies showed a higher rate of medicine availability. The authors additionally found that the price variability in both the public and private FPB pharmacies were less than in the unaccredited private sector. Overall prices in private FPB pharmacies were “over 90% cheaper than those in the [unaccredited, non-participating] private sector.” In contrast, in a study of 10 antihypertensive drug formularies in 13 African countries, Twagirumukiza et al. found prices in the private sector more than twice that of the same medicines within the public sector. They also found that medicine price variations were greater in the private sector due to a lack of regulation.

Educational Interventions to Improve Quality in Drug Shops in Sub-Saharan Africa

Wafula F and Goodman C. International Journal for Quality in Health Care, 2010; pp. 1–8. DOI: 10.1093/intqhc/mzq022

Wafula and Goodman survey educational interventions to improve specialized drug shop quality in Sub-Saharan Africa. In their evaluation of ten studies, the authors conclude that educational interventions successfully altered knowledge outcomes among participants, including appropriate prescribing, referral, and disease management practices. Interventions improved certain communication measures, including counseling and advising patients, but were less successful on improving patient history taking. Wafula and Goodman found that some interventions reduced “inappropriate dispensing of medicines” by “empower[ing] sellers to refuse client requests for drugs in certain instances.” The few studies that documented patient-based outcomes noted higher patient satisfaction, an improvement in patient compliance, and patient knowledge of risk factors. Interventions did not affect the amount of money spent of medicines. Wafula and Goodman also note the importance of profit motives of drug shops that can lead to product substitution, unnecessary treatment over referral of patients, and adoption of techniques that would reduce sales.

Integration of Malaria and HIV/AIDS Prevention Services Through the Private Sector in Uganda

Mbonye A, Hansen K, Wamono F, et al. International Health 2 (2010) 52–58

Mbonye et al. study the feasibility of programs for private midwives to provide HIV/AIDS prevention services alongside malaria prevention services to pregnant women in Uganda’s Wakono district. Within the study population, the authors found that 22% of pregnant women received antenatal care from private midwives, and 63.5% of pregnant women sought information on malaria prevention from midwives. However, less than ten percent of women sought HIV testing, family planning services, or ARV treatment from private midwives. Interviews noted that constraints to the integration of HIV/AIDS services into existing service lines by private midwives included: “inadequate skills, the high cost of drugs and supplies, and the lack of supervision from the district.” Informants also noted that integration of services could be fostered through: refresher courses on HIV and malaria; government subsidization of drugs, testing kits, and nets; government supervision; and community sentization to the importance of care through trained health workers. Mbonye et al. argue that integration of HIV/AIDS and malaria services can be expanded with increased of government support, including subsidized drugs and supplies.

Retail Sector Distribution Chains for Malaria Treatment in the Developing World: A Review of the Literature

Patouillard E, Hansen K, Goodman C. Malaria Journal 2010, 9:50

Patouillard et al. conduct a literature review of the role of local retailers in the distribution chain for malaria treatment throughout the developing world. The authors find that the distribution chain for retailers has a “pyramid shape” with “fewer suppliers at the top and more numerous suppliers at the bottom. The number of tiers within the supply chain ranged from zero (where “retailers obtained drugs directly from the factory gate) to four, with more levels present for “more remote locations and those with less qualified staff.” The authors found competition in the anti-malarial market, particularly on the top level. The authors found that anti-malarial drug mark-ups varied “ranging from 27% to 99% at primary level, 8% at intermediate and 2% to 67% at terminal level.” Patouillard et al. found higher mark-ups for the retail market, which varied based on the outlet type with levels “between 3% and 566% in pharmacies, 29% and 669% in drug shops and 100% and 233% in general shops.” The authors found little evidence for the reasons for differential pricing decisions and argue for additional research on the distribution chain for anti-malarial medication, especially for the new Affordable Medicine Facility for malaria which aims to increase coverage for ACTs by subsidizing at the top of the distribution chain.

Factors Influencing Implementation of the Ministry of Health-led Private Medicine Retailer Programmes on Malaria in Kenya

Rowa Y, Abuya T, Mutemi W, et al. BMC Public Health 2010, 10:93

Rowa et al. conduct a qualitative analysis of a Kenyan government-directed intervention to expand private medicine retailers’ appropriate treatment practices and public access to anti-malarial medication. The Kenyan Ministry of Health program trained private medical retailers to diagnose, prevent, treat, and refer malaria cases and disseminated information to the public about the role of private medicine retailers in the national malaria control strategy. Rowa et al. found major barriers to the program’s successful implementation, including limited government oversight, the “relative instability of outlets, medicines stocked and retail personnel,” substandard medicine quality, lack of consumer trust, and the “reluctance of [customers] to accept advice to buy different, more expensive, medicines.” Despite these challenges, Rowa et al. argue that the program is feasible because of retailers’ positive experiences, increased customer satisfaction, and strengthened business outcomes from “more rational purchasing of medicine stock and increased medicine sales.” The authors additionally report that access to in-need rural areas was proscribed by the limited buying power of rural residents and retailers, concluding that subsidies are integral to expanding anti-malarial access in more remote locations. Finally, the authors note that public information can strengthen training programs by engaging local communities and facilitating client-based performance monitoring.

Socioeconomic and Ethic Group Inequities in Antenatal Care Quality in the Public and Private Sector in Brazil.

Victora C, Matijasevich A, Silveria M, et al. Health Policy and Planning. 2010.; 1-9.

In an assessment of antenatal care quality in southern Brazil, Victora et al. found substantial socio-economic and racial inequities and a quality gap between public and private providers. More affluent individuals were more likely to start antenatal care earlier and white and mixed race individuals began care earlier than black women. For all socioeconomic quintiles, women who used private care experienced a higher number of antenatal procedures and were more likely to start care within the first trimester. Antenatal care quality was higher in the private sector across all socioeconomic quintiles.

The Impact of Social Franchising on the Use of Reproductive Health and Family Planning Services at Public Commune Health Stations in Vietnam

Ngo A., Alden D, Pham V, et al. BMC Health Services Research 2010, 10:45

Ngo et al. study government social franchises in Vietnam to determine whether franchising increases small public sector clinic patient volume and reproductive health and family planning service capacity and quality. Starting in 2007, the governments of Da Nang city and Khanh Hoa province, with the assistance of Marie Stopes International, recruited 36 small public clinics to incorporate into a social franchise network. Clinics underwent clinical and customer support training, branding, infrastructure improvements, and social marketing. Compared to other public clinics, after 12 months the franchised clinics displayed a 40% increase in total use, a 51% increase in reproductive health use, and a 45% increase in reproductive planning use. The authors note that higher client volumes “may have resulted from increased visit frequency by existing clients, not from new clients,” arguing that the franchise “may have motivated current users to more often keep follow-up appoints … and return to the (clinic) with questions and other matters related to the clinic’s RHFP services.” The franchising scheme may have decreased socioeconomic inequity as farmers were now more likely to visit the local CHS for RHFP services. Further expansions of the social franchise model are dependent on funding opportunities and a determination of the cost-effectiveness of the model.

Contracting for Health and Curative Care Use in Afghanistan between 2004 and 2005.

Arur A., Peters D., Hansen P., et al., Health Policy and Planning 2010; 25:135-144

Arur et al. evaluate contracting-out and contracting-in programs in Afghanistan and find that both interventions substantially increased service use as compared to non-contracted facilities. Following the ouster of the Taliban in 2002, a majority of health services in Afghanistan were provided by non-governmental organizations. To ensure health services in the country met a basic package of maternal and child health services, in 2003, the Afghan Ministry of Public Health decided to employ contracting with both international and Afghan NGOs. Different contracting-out approaches were employed which varied upon scale, performance-based payments, contract management, and monitoring. Arur et al. find that contracted-out facilities increased service use substantially over non-contracted facilities in terms of new outpatient visits (29.3%), female visits (41.0%), visits for the poorest quintile (67.9%), and under-5 visits (26.9%). Contracting-in facilities also increased service use over non-contracted facilities among outpatient visits (83.6%), female visits (101.5%), poorest quintile visits (112.3%), and under-5 visits (21.4%). The authors contend that the success of contracting within Afghanistan displays the viability of contracting in countries where the government has relative inexperience with the contracting mechanism.

Willingness to Pay for Community-Based Health Insurance in Nigeria: Do Economic Status and Place of Residence Matter?

Onwujekwe O., Okereke E, Onoka C. Health Policy and Planning 2010 25:155-161

In an examination of individual willingness to pay for community-based health insurance in southeastern Nigeria, Onwujekwe et al. find large variations depending on socioeconomic and geographic population differences. The authors find overall “less than 40% of the respondents were willing to pay for CBHI membership for themselves or other household members.” Willingness-to-pay displayed a positive relation with urban location, socioeconomic status, years of education, and male gender. Wealthier individuals and those in urban communities reported a higher amount they were willing to pay for monthly premiums. The authors contend that low demand for CBHI is caused by low promotion by the coordinating organization within the country. Also, the low amount of money respondents reported they were willing to pay suggests the need for external subsidies as to not exclude poor and rural groups.

Assessment of a National Voucher Scheme to Deliver Insecticide-Treated Mosquito Nets to Pregnant Women

Marchant T., Schellenberg D, Nathan R. et al. Canadian Medical Association Journal, 2010 182(2); 152-156

Marchant et al. analyze the effectiveness of a national voucher program in Tanzania to increase pregnant women’s use of insecticide-treated nets. The voucher program involved five steps: “attending an antenatal clinic, obtaining a voucher there, using the voucher to buy a mosquito net… treating the net with the insecticide, and, finally, using the net.” The authors found a greater than 90% completion rate for each of the first two steps but only 60-73% completion rates for each of the last three steps, resulting in a cumulative success rate of 30% for participants following all steps of the program. Women in the lowest socioeconomic quintile were about half as likely to complete all steps compared to women in the highest socio-economic quintile. Socioeconomic disparities were most notable in attending the antenatal clinic, using the insecticide on the net, and using the net. Marchant et al. argue that women of lower socioeconomic status must contend with barriers including “inadequate understanding of malaria, misconceptions about the efficacy of treated nets, and differences in number of nets owned relative to household size.” The authors suggest that providing nets previously treated with insecticide would increase the efficacy of the program from 30 to 52%.

Preference for Private Hospital-Based Maternity Services in Inner-City Lagos, Nigeria: An Observational Study

Olusanya B., Roberts A., Olufunlayo T. et al., Health Policy 2010.

Olusanya et al. conducted an observational study of pregnant mothers in Lagos, Nigeria to determine variables associated with preference for private sector facilities for child delivery. Within the study population, 50.3% of mothers delivered in private hospital whereas 49.7% delivered in public hospitals. The authors found that mothers who delivered at private hospital were more likely to belong to either middle or high social class, use herbal drugs during pregnancy, and identify as Islamic. Additionally, these women were less likely to require cesarean delivery or delivery before full term, but more likely to report undernourishment and a need for phototherapy or blood transfusion upon post-natal visits. The authors note that this “potential burden of adverse outcomes” following delivery may be attributed to a lack of private facilites that treat the conditions. Nonetheless, the authors acknowledge the integral role the private sector plays within the maternal health system and suggest an increased “regulatory/supervisory” framework to strengthen infant outcomes.

Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia

Ir, P., Horemans D, Souk N, et al. BMC Pregnancy and Childbirth 2010, 10:1

Ir et al. assess a government funded and NGO coordinated voucher program for expecting mothers in rural Cambodia that subsidizes access to skilled public sector birth attendants. In three rural target districts, local health volunteers and contracted NGO employees identify low-income pregnant women and provide them vouchers to receive cost-free antenatal, delivery, postnatal care by midwives and health professionals at government facilities, to reimburse transportation costs, and to cover health care referral costs in case of complications. The coordinating NGO reimburses public health centers per voucher collected and provides an advance for them to directly reimburse women’s transportation costs. The voucher program runs concurrently with a health equity fund that provides full or partial financial support to low-income women for health care user fees. Because of the program, the number of births in public health facilities in the area “increased sharply from 16.3% in 2006 to 24.9% in 2007 and 44.9% in 2008,” and “facility deliveries of voucher beneficiaries increased by 195.9% in two years, from 2.4% in 2007 to 7% in 2008.” While “voucher and [Health Equity Fund] beneficiaries accounted for 40.6% of the expected number of births among the poor” in 2008, 55.4% of individuals who received vouchers during the period did not use them, reporting health center distance, transportation problems, fear of uncompensated costs, and difficulty leaving the home and children unattended as the major reasons. The authors suggest allowing “qualified private providers” to participate in the voucher program to improve access.

Socioeconomic and Ethic Group Inequities in Antenatal Care Quality in the Public and Private Sector in Brazil.

Victora C, Matijasevich A, Silveria M, et al. Health Policy and Planning. 2010.; 1-9.

In an assessment of antenatal care quality in southern Brazil, Victora et al. found substantial socio-economic and racial inequities and a quality gap between public and private providers. More affluent individuals were more likely to start antenatal care earlier and white and mixed race individuals began care earlier than black women. For all socioeconomic quintiles, women who used private care experienced a higher number of antenatal procedures and were more likely to start care within the first trimester. Antenatal care quality was higher in the private sector across all socioeconomic quintiles.

Vouchers for Health A Demand Side Output Based Aid Approach to reproductive health services in Kenya

Janish C, Albrecht M, Wolfscheutz A. et al. Global Public Health 2010, 1-17

Janisch et al. analyze the initial stages of the joint Kenyan Government-KfW Voucher for Health Program in Kenya, which aims to improve maternal and sexual health by providing discount vouchers to increase women’s access to selected public and private sector health care providers. This voucher programs allows low-income individuals, identified with a poverty-grading tool, to purchase significantly subsidized vouchers for maternity, family planning, and gender violence medical services that they can reimburse at selected public and private health care providers that have been accredited and contracted by the voucher management agency. Contracted service providers are reimbursed a flat rate for voucher patients to encourage competition and increased care quality. During the first stage of the project, Janisch et al. report that over 45,000 maternity vouchers sold with a nearly 70% reimbursement rate, with sales more significant than initially expected and a 57% average increase in total assisted deliveries at contracted facilities. Family planning vouchers sold at a rate less than expected but use of family planning services in the target areas increased nearly 70% nonetheless, particularly long-term family planning strategies by low-income women. At this point, the authors are optimistic that the voucher program has increased access for low-income individuals within the target area and contracted providers report a “self-perceived increase in quality” and ability to upgrade infrastructure and staff because of increase income generation. Although a fuller analysis of program outcomes will come with the later stages of implementation, the authors believe the program offers many fundamental elements of a limited insurance system including “accreditation; quality assurance; reimbursement system; claim processing; costs and pricing; integrating private sector; client choice; provider competition; and access and equity.”

“This body does not want free medicines”: South African Consumer Perceptions of Drug Quality.

Patel A, Gauld R, Norris P. Health Policy and Planning 2010;25:61–69.

Patel et al. conducted a qualitative examination of consumer perceptions of drug quality in South Africa, finding numerous determinates of drug quality, including perceived effectiveness, prior knowledge, and cost. Consumers in the sample felt that the extent a medicine reduces or alleviates symptoms was the “main descriptor” of quality. Consumer perceptions of quality, however, were also significantly influenced by the site of care and the associated costs. Private sources were preferred, despite increased cost, due to the individualized care provided, consumer choice offered, quick turnaround, and increased trust in private providers. Additionally, consumers “displayed a general suspicion towards free and cheaper medicines supplied by the state,” lending support to the concept that consumers use price as a “proxy measure for quality.” The study documented increased consumer acceptance of generic medicines for chronic conditions and when the medical provider, rather than the dispenser, endorsed them. The authors argue that South Africa’s recent policies to encourage pharmacists to substitute generic medicines and for the government to distribute free medicines could be enhanced by educating consumers about the benefits and quality of generic medications.

Medicine Prices in Urban Mozambique: A Public Health and Economic Study of Pharmaceutical Markets and Price Determinants in Low-Income Setting

Russo G and McPake B. Health Policy and Planning 2010;25:70–84.

Russo and McPake surveyed public, private, and state-owned private pharmacies in and around Maputo, Mozambique to determine medicine availability, price, and affordability, discovering highly inflated prices for medicines in private pharmacies because of local mark-ups, inadequate government regulation, and concerns surrounding quality. Private sector pharmacies stocked more generics and originator brands than public sector pharmacies but less generic brands than state-owned private pharmacies. Medicine prices were between four and five times the international reference in private and private state-owned pharmacies and less than half the international reference price in public sector pharmacies. Private pharmacies displayed a wider price variation for branded drugs than generics. An analysis of affordability “suggests only a small fraction of the urban population would be able to purchase brand drugs in private pharmacies” and that long-term treatments for chronic conditions were less affordable than acute conditions. Russo and McPake found that medicine prices were largely determined by local retailer mark-ups rather than the procurement costs and noted that government price regulation of pharmaceuticals through laws prohibiting large drug profit margins and through recommended selling prices were ineffective because of lax enforcement. The authors conclude that the government could expand the availability and affordability of generic drugs in urban Mozambique by actively regulating generic drugs, requiring “compulsory disclosure of product information” to facilitate consumer choice, and “invest[ing] in publicity measures … to promote generics of established quality.”

Eradicating Diseases: The Effect of Conditional Cash Transfers on Vaccination Coverage in Rural Nicaragua

Barham T, Maluccio J. J Health Economics 2009; 28(3):611-21

Barham et al. assess the Red de Proteccion Social (RPS) plan in central Nicaragua to determine the program’s effectiveness in providing vaccination services to rural households. The RPS plan provides mothers bimonthly cash transfers, contingent on their attendance at medical appointments and health education workshops and their child’s rate of weight gain. Although vaccinations were not explicitly required, Barham et al. discover that the RPS program significantly increased the on-time vaccination rate for children by between 15 to 20 percent. The RPS plan additionally produced a marginally significant 15 percent increase in vaccination coverage of older children who had missed previous vaccinations. The authors additionally note that the RPS plan showed particular success with populations experiencing geographic and educational barriers, leading to an equalization of vaccination rates between underserved groups and the larger population. The authors conclude that the success of the RPS program “underscores the ability of conditional cash transfers to reach sub- populations for whom supply-side oriented strategies have been less successful.”

Contracting Private Sector Providers for Public Sector Health Services in Jalisco, Mexico: Perspectives of System Actors

Nigenda G., Gonzalex L., Human Resources for Health 2009; 7(79)

Nigenda et al. analyze the experience of Jalisco Ministry of Health’s in contracting private providers to extend medical coverage to traditionally low- access rural and semi-urban populations and increase the efficiency of service provision. Contracting in Jalisco was seen as an opportunity to expand access on a cheaper basis than hiring permanent personnel. The contracting payment scheme included a mix of 50% fixed salary and a variable 50% based on monthly productivity (number of consultations). The system employed a strict regulatory mechanism where each health unit (consisting of a doctor, nurse, and health technician) produces productivity reports that are monitored and occasionally audited by government offices. Interviews with program managers showed satisfaction with the expansion of health access because of the program, as well as with the productivity and efficiency of contracted parties. Contracted personnel were less satisfied with the program than managers because of unsatisfactory work conditions and the lack of job security. The authors conclude that the contracting mechanism allows the Ministry of Health to better determine the geographic location of services provided than they could through the use of salaried public workers. The program successfully linked productivity to salary payments to increase the number of services offered. The authors applaud the system’s adaptability in allowing contracted providers to negotiate for health and retirement benefits, which influenced worker satisfaction and was an important factor for the long-term sustainability of the program.

The Experiences of Districts in Implementing a National Incentive Program to Promote Safe Delivery in Nepal

Powell-Jackson T., Morrison J., Tiwari S., et al. BMC Health Services Research 2009; 9(97)

In an assessment of Nepal’s Safe Delivery Incentives Programme (SDIP), Powell-Jackson et al. argue that disbursement, communication, and planning issues ultimately hindered its success in increasing coverage for skilled birth attendance. The SDIP program was designed to provide a monetary incentive to women, regardless of socioeconomic status, to give birth in a public health facility. The cash incentive was primarily intended to alleviate the monetary barrier of transportation to such facilities. The program also provided a cash incentive to health workers who attended a delivery, regardless of whether the delivery occurred in an official facility or at a home. Finally, money was provided to the 25 least developed health districts in Nepal to provide delivery free to charge. Through a series of interviews, Powell-Jackson et al. discover that uptake of the program hindered by significantly delayed monetary disbursement, variations in implementation due to unclear instructions, and the misuse of funds stemming from an inadequate monitoring system. The bureaucratic delay of disbursement hindered program start up as local health districts were unable to disburse full funds to women at the time of delivery to cover transportation costs and other debts incurred in travel to the clinic. Because rapid scale-up of the program began without piloting or detailed district planning, there was considerable variation in eligibility, disbursement, and program promotion between health districts. The authors argue that implementation problems weakened community trust in the public health system and promoted tension between staff and providers in local health facilities. In late 2007, the Nepalese Government attempted to remedy these issues by simplifying eligibility criteria, conducting national awareness campaigns, and streamlining the disbursement of funds. The authors conclude that new conditional cash transfer programs should “give due attention to the challenges to implementation” and use “careful planning and roll-out programs with closer engagement with district level actors.”

Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

Pariyo G., Ekirapa-Kiracho E., Okui O., et al. International Journal for Equity in Health 2009; doi:10.1186/1475-9276-8-39

An assessment of Uganda’s recent health sector reforms reveals mixed results in promoting access to care for the poor in both public and private sector. In the recent past, Uganda has abolished user-fees, provided subsidies for non-profit health facilities, and decentralized resource allocation and delivery to health districts in an attempt to increase access and quality in both the public and non-profit sectors. Pariyo et al. analyzed the Uganda National Household Survey to track changes in health system use between the 2002/03 and 2005/06 surveys, discovering that use of public and private not-for profit services increased among rural and poor populations but that private for-profit providers continued to provide the majority of health services. Surprisingly, the authors found that during the study period the odds of not seeking care also increased, reflecting the continued influence of financial and geographic barriers in health access. The authors conclude the private for-profit providers need to be encouraged to provide safe, effective, and affordable care through “better measurement of performance and accountability mechanisms, contracting, or engagement of consumer groups, provider associations and franchises.” The authors also argue that targeted subsidies or community-based health insurance schemes could be used to increase care for poor and rural populations.

The Effect of Community-Based Health Insurance on the Utilization of Modern Health Care Services: Evidence from Burkina Faso

Gnawali D., Pokhrel S., Sie A., et al. Health Policy 2009; 90:214-222

In a study of the effect of community-based health insurance (CBHI) in Burkina Faso, Gnawali et al. find increased use of health facilities amongst insured individuals, but uneven rates of enrollment and use of services based on socio-economic status. The cohort enrolled in the CBHI scheme increased care-seeking behavior by forty percent for outpatient visits, with no significant increase in inpatient care, which the authors believe suggests CBHI enrollment increased initial provider contact and likelihood of patient follow-through. The authors found that affluent individuals were far more likely to enroll and use services (with the richest quartile most likely to access services), whereas financial barriers generally prevented poorer individuals from enrolling. When the government subsized CBHI premiums, the lowest socioeconomic quartile had a ten-fold increase in enrollment. Gnawali et al. found that membership in a CBHI scheme correlated with a decrease in home treatment and treatment by traditional healers, suggesting these modes of care are more a product of financial limitation than personal choice.

The Effect of Community-Based Health Insurance on the Utilization of Modern Health Care Services: Evidence from Burkina Faso

Gnawali D., Pokhrel S., Sie A., et al. Health Policy 2009; 90:214-222

In a study of the effect of community-based health insurance (CBHI) in Burkina Faso, Gnawali et al. find increased use of health facilities amongst insured individuals, but uneven rates of enrollment and use of services based on socio-economic status. The cohort enrolled in the CBHI scheme increased care-seeking behavior by forty percent for outpatient visits, with no significant increase in inpatient care, which the authors believe suggests CBHI enrollment increased initial provider contact and likelihood of patient follow-through. The authors found that affluent individuals were far more likely to enroll and use services (with the richest quartile most likely to access services), whereas financial barriers generally prevented poorer individuals from enrolling. When the government subsized CBHI premiums, the lowest socioeconomic quartile had a ten-fold increase in enrollment. Gnawali et al. found that membership in a CBHI scheme correlated with a decrease in home treatment and treatment by traditional healers, suggesting these modes of care are more a product of financial limitation than personal choice.

Out-of-Pocket Costs for Facility-Based Maternity Care in Three African Countries

Perkins M., Brazier E., Themmen E., et al. Health Policy and Planning 2009; 24:289-300

Perkins et al. survey out-of-pocket costs for child delivery in Kenya, Burkina Faso, and Tanzania and discover that over a quarter of all institutional deliveries occur in private sector facilities. Across both public and private sectors, hospital-based delivery costs mothers nearly twice the amount as in lower level health centers and maternity facilities. In Tanzania and Kenya, mean out-of-pocket fees for a normal delivery at a private facility are higher than those at a public facility, whereas in Burkina Faso, mean fees are lower at private religious health centers because drugs and supplies are subsidized. In all countries, the majority of deliveries occur outside the formal health center, largely because of affordability issues; non-institutional deliveries cost between ten and twenty-five percent of the price of an institutional delivery. Perkins et al. reveal that regardless of official government positions for cost-sharing or free-of-charge services in these three countries, all individuals were required to pay out-of-pocket fees to use public facilities. The authors document no difference in costs between the poorest and wealthiest quintiles suggesting that “both user fee and nominally free services [appear] to be equally regressive, and that waiver or exemptions to support the very poor are absent or ineffective.”

Severe Road Traffic Injuries in Kenya, Quality of Care and Access

Macharia W., Njeru E., Muli-Musiime F., et al. African Health Sciences 2009; 9(2)

In an analysis of the road traffic injuries (RTIs) in Kenya, Macharia et al. find broad differences in access and quality of care between public and private facilities. The authors note that accidents primarily occur in commuter mini-buses (70%), that the rate of seatbelt usage is less than two percent, and non-health professionals deliver the overwhelming majority of post-accident transportation (92.5%). The primary site of care for RTIs was public health facilities (72.3%) followed by private faith-based hospitals (15.6%) and ordinary private hospitals (12.2%). The authors attribute public hospital dominance to private hospital demands for monetary deposits prior to providing treatment. Macharia et al. note lower wait times in private hospitals compared to public and religious hospitals, and higher patient-rated quality of care in both religious and private hospitals. Public hospital personnel also report a low preparedness to handle trauma emergencies, with low levels of necessary supplies. Complete recovery of RTI victims to full physical health was low in all sites of care, with the rate of permanent disability estimated at 72.4% in public hospitals and 86.7% in private hospitals.

Public and Private Sector Treatment of Malaria in Lao PDR.

Nonaka D., Vongseththa K., Kobayashi J., et al. Acta Tropica 2009; doi:10.1016/j.actatropica.2009.08.013

In a study of care-seeking behavior, Nonaka et al. find the formal and informal private sector crucial in the continuum of care for malaria treatment in Lao PDR. The authors’ analysis reveals that more than a third of first-line malaria treatment occurs in the private sector, primarily in private pharmacies and with traditional healers. The researchers additionally find that more than half of individuals initially receiving treatment in the public sector migrate to the private sector for secondary sources of care. More than a third of individuals who begin treatment in the private sector stay exclusively within the sector. Nonaka et al. also find concordance between care-seeking behavior in Lao PDR and Africa as shown in previous studies, particularly that a large majority of patients (86.1%) who began treatment with traditional healers switch to a public care provider. The authors argue that the demonstrated care-seeking patterns necessitate collaboration between the public and private sector for malaria treatment to strengthen follow-up and referral systems for acute issues, as well as for the expansion of artemisinin combination therapy treatment in the region.

Maternal healthcare financing: Gujarat’s Chiranjeevi Scheme and its beneficiaries

Bhat, R, Mavalankar D, Singh P, et al. Journal of Health, Population, and Nutrition 2009; 27(2):249-258

In an assessment of a maternal health voucher program in Gujarat, India, Bhat et al. find the program appropriately targets the poor and results in significant savings for the indigent. The Chiranjeevi scheme provides vouchers to expectant below-poverty line mothers to reimburse them for the out-of-pocket costs associated with delivery, ante-natal care, transportation, and accompaniment at a private provider. The assessment found that mothers enrolled in the scheme paid less than one-fifth as much as mothers not enrolled in the scheme, had a marked increase in ante-natal services, and were significantly more likely to birth in an institution. Assessment of the program also confirmed appropriate targeting of the poor. Deficits of the program included a low rate of post-natal care, and a failure to make delivery cost-free for mothers. Bhat et al. note that purchasing maternal health care packages in bulk from private obstetricians allowed for a significant economy of scale compared to market rates.

A comparison of the quality of family planning services provided in the public and private sector in Kenya.

Agha S, Do M. International Journal for Quality in Health Care 2009; 21(2):87-96

Agha and Do’s comparison of the quality of Kenyan family planning services in the private and public sectors reveals that private facilities maintain better infrastructure and service availability. Private providers were open for more days per week, more likely to have a have a trained provider present, in closer proximity to patients than public providers, and had shorter wait times. However, public facilities were noted to have better management, in particular stronger formal systems to review medical issues, stock organization and security, operating protocol, and record keeping. The authors noted that private facilities maintained higher provider motivation because of increased incentives and an appropriate workload. The authors also find no significant quality differences between public and private facilities in technical performance or interpersonal processes, but clients reported more than twice the level of satisfaction with their experience in the private sector over the public sector. Controlling for structural and process differences, the odds of a clients being satisfied at a private facility is three times higher than a public facility, suggesting client satisfaction may be affected by pre-service perceptions of higher quality in the private sector. The authors note further comparisons in quality of care between the formal and informal private sector are needed.

Public-private partnerships and public hospital performance in Sao Paulo, Brazil

La Forgia G, Harding A. Health Affairs 2009; 28(4):1114-1126

La Forgia and Harding assess the performance of public hospitals run by non-governmental organizations in Sao Paulo, Brazil. The PPP for hospital operation by contracted NGOs was based on rigid performance specifications to address governance and accountability issues in public hospitals. The contract allowed the operating agency increased managerial autonomy and altered the government’s role to monitoring the performance of contract specifications in volume, quality, and reporting. In a comparison between PPP hospitals and neighboring public hospitals, the PPP hospitals noted increased efficiency with fewer providers and no significant difference in quality. La Forgia and Harding contend that the PPP model created an “enabling incentive and accountability environment for human-resource and managerial practices that improved performance.” Integral to this process was the increased autonomy in recruiting, selecting, and dismissing personnel.

Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross-sectional household surveys

Hanson K, Marchant T, Nathan R, et al. British Medical Journal 2009; 399:b2434

In an evaluation of a national voucher scheme in Tanzania, Hanson et al. find vouchers to be a feasible mechanism for scaling-up access to bed-nets, although equity questions remain. The Tanzanian voucher program provides a set-value voucher to pregnant women that compensates for two-thirds of the cost of a bed-net. Vouchers are provided to expectant mothers during an antenatal visit, and free bed-net retreatment is provided during a postnatal measles vaccination appointment. In their assessment of the program, the authors note that the nearly three million bed-net vouchers were distributed within three years, and the vouchers contributed to a significant increase in bed-net coverage in Tanzania. The authors also report that the distribution of nets during this time period was marked by socioeconomic inequity. Poorer individuals had lower levels of access because they: did not undergo antenatal care where vouchers were distributed, could not afford to pay for the unsubsidized portion of the net, and were not in proximity to shops where vouchers could be redeemed. Hanson et al. suggest remedying these issues would further increase the efficiency of vouchers as a distribution mechanism for bed-nets.

Women’s Use of Private and Government Health Facilities for Childbirth in Nairobi’s Informal Settlements

Bazant E, Koenig M, Fotso JC, Mills S. Studies in Family Planning 2009; 40(1):39-50.

In an analysis of delivery location for slum-dwelling pregnant women in Nairobi, Kenya, Bazant et al. find mothers give birth in private facilities at almost twice the rate of public facilities. Of women surveyed, 42% gave birth in private clinics, and 3% in private mission hospitals, whereas 20% birthed in government hospitals, and 1% at government health centers. Over a third of those surveyed gave birth at home without assistance of a train professional. Distance to the site of care proved an important determinant to location of care; 72% of women who attended private clinics had an estimated travel time of less than 30 minutes, whereas the majority of women attending government hospitals traveled more than an hour to reach the facilities. Assistance during delivery was more likely to be provided by a nurse or midwife in the private sector, whereas doctors delivered a higher percentage of children in the public sector (55.3%) as compared to the private sector (47.5%). The median cost for uncomplicated deliveries at government hospitals was over 60% higher than the median cost for an uncomplicated delivery in the private sector. Predictors of birth in a private facility included: lower maternal and partner education, larger household size, a lack of prior complicated pregnancy, and private use of pre-natal care during pregnancy. Bazant et al conclude that given the “heavy reliance of women on private facilities for childbirth” public-private partnerships are needed for increased support and oversight. The authors additionally suggest social franchising “may enable the leveraging of human resources and standardization of maternal health-care provision.”

Dropout analysis of community-based health insurance membership at Nouna, Burka Faso

Dong H, De Alegri M, Gnawali D, et al. Health Policy 2009; doi:10.1016/j.healthpol.2009.03.013

Dong et al. analyze enrolment and dropout rates of individuals in a rural community-based health insurance (CBHI) scheme to identify the factors and motivations of individuals who do not re-enroll in the program. The CHBI in Nouna, Burkina Faso had a low overall enrolment rate (5.3% - 6.3% of the eligible population between 2004 and 2006), and a substantial dropout rate (45.7% in 2006). Households that dropped out of the CHBI were characterized as having: lower educational attainment, larger family sizes, rural location, and non-Muslim religious affiliation. The most significant factors that determined dropout rate included: inability to pay, perception of poor medical quality, and less health seeking or illness episodes in the recent past. More surprisingly, distance to the contracted health facility and high household expenditure were associated with dropping out of the scheme. Dong et al. stress that retaining enrollment is crucial for a CHBI to maintain viability, and further note that the presence of adverse selection in Nouma, wherein which only sick people re-enroll in the scheme thus lessening the risk pool, may affect the program’s long-term sustainability.

The Population-level Impacts of a National health Insurance Program and Franchise Midwife Clinics on Achievement of Prenatal and Delivery Care Standards in the Philippines

Kozhimannil K, Valera M, Adams A, et al. Health Policy 2009, doi:10.1016/j.healthpol.2009.02.009

Kozhimannil et al. conduct a population-level comparative analysis of a national health insurance program, PhilHealth, and a social franchise, Well Family Midwife Clinics, in the Philippines to determine whether the program affected prenatal care visits and institutional deliveries in pregnant women. Although both programs were associated with a statistically significant increase in prenatal care, only PhilHealth, the national insurance scheme, was associated with meeting the targeted standard of four pre-natal visits for expecting mothers. The authors determine that neither intervention significantly affected the probability of giving birth in an institutional setting. Kozhimannil et al. additionally find the national health insurance scheme more effectively reached more vulnerable poor and rural demographics than Well Family. The authors note the variable effectiveness between the programs may be due to Well Family’s smaller scale not being able reach enough individuals to have a “detectable change in the achievement of care standards on a population level.” Kozhimannil et al. also suggest that neither program was effective in increasing institutional deliveries because of a failure to change the calcified cultural tradition of home birth, or provide transportation for expecting mothers.

An Experiment with Community Health Funds in Afghanistan

Rao K, Waters H, Steinhardt L, et al. Health Policy and Planning 2009, 1-11, doi:10.1093/heapol/czp018

Rao et al. assess the performance of the Community Health Fund (CHF), a community-based health insurance (CBHI) scheme piloted in post-conflict Afghanistan between 2005 and 2006. The authors report that enrollment within the program was modest at 6% of the eligible cachement households. Rao et al. primarily attribute the low enrollment to the premium price, which fell within the range of expected yearly healthcare expenditures and thus offered little substantial financial incentive to enrollment. Additionally, the low enrollment may be because of a lack of “active and continuous” community engagement resulting in low program awareness, as well as perceptions of poor quality of service at CHF sites. During the pilot, the program recovered 12% of its operating costs, surpassing recovery rates of similar CBHI schemes in Rwanda and Tanzania. Additionally, CHF members were documented to have increase healthcare utilization once enrolling in the program, raising the possibility of moral hazard if the program is expanded. The authors conclude that the pilot demonstrates CBHI schemes are a viable method to rebuild health systems in post-conflict states, yet need to be paired with other financing sources.

The Quality of Private Pharmacy Service in Low and Middle-income Countries: A Systematic Review

Smith F. Pharm World Sci, published online 03 Apr, 2009. DOI 10.1007/s11096-009-9294-z

In a meta-analysis of 30 studies on pharmacy quality in low and middle-income countries, Smith finds widespread concern over the quality of professional practice of pharmacists, yet notes the potential for pharmacies to contribute to successful primary health care. Smith finds that researchers consider pharmacies crucial to healthcare provision in the developing world, as they are a primary source of consultation and treatment. However, studies show local pharmacies fail to appropriately question clients, commonly misdiagnose ailments, and do not adhere well to guidelines or established protocols of medicine sale and advice provision. Smith additionally notes that numerous studies did not differentiate between licensed pharmacies and community shops, and that when researchers did differentiate between the two, no discernable variability in quality was reported.

Universal Precautions and Surgery in Sierra Leone: The Unprotected Workforce

Kingman T, Kamara T, Daoh K, et al. (2009) World Journal of Surgery, published online

In a comparative survey of government and private hospitals in Sierra Leone, Kingman et al. note mission and private hospitals maintain a much higher level of HIV protective supplies as compared to their government counterparts. Government hospitals were found to have low levels of sterile gloves (20%), eye protections (20%), sterilizers (50%), and sharps containers (50%), all of which were present at the private hospitals. The authors argue that low levels of universal precautions may be attributed to a lack of knowledge and scarce resources. Kingman et al. note that these findings spurred an international NGO to develop a program to locally procure supplies to protect the surgical workforce.

Developing and Launching the Government Social Franchise Model of Reproductive Health Care Service Delivery in Vietnam

Ngo, A, Alden, D., Hang, N. and Dinh, N. (2009) Social Marketing Quarterly,15:1,71 — 89

Ngo et al. analyze the development of a government-run social franchise of rural reproductive health clinics in Vietnam. In the 1990s in Vietnam user fees were imposed in government health centers and private practices were legalized. Following this, the public perceived commune health stations as providing lower quality care, having worse outcomes, and providing less availability of essential supplies than their private counterparts. With the technical assistance of Marie Stopes International, the two provincial government health departments in central Vietnam developed a fractional social franchise for reproductive health and family planning services for community health stations. A preliminary evaluation of the program revealed increased quality and client satisfaction, a willingness of clients to pay for additional services, and a shift from private clinics to the government franchise for RH and FP services.

Concentration and Drug Prices in the Retail Market for Malaria Treatment in Rural Tanzania

Goodman C, Kachur S, Abdulla S, et al. Health Economics (2009)

Goodman et al. analyze the retail market for anti-malarial drugs in rural Tanzania to explore the relationship between drug prices and competition. The market for malaria medicines appears to be competitive due to the large number of drug providers, the tradable nature of the product, the lack of a prescription requirement, and the high rate of store turnover. However, the analysis reveals that the anti-malarial drug market is highly concentrated and geographically segmented, leading to a lack of competition and to high drug prices. Because of the difficulty of attaining new stock, Goodman et al. surmise that drug outlets often choose high prices over high volume; this may also contribute to the current market condition. The authors also note the possibility of collusion between retailers leading to price fixing. The analysis also confirms previous studies that indicate that geography, poor consumer and provider information, and lack of affordability limit drug access. Goodman et al. suggest several measures to increase competition and reduce prices, including: expanding the number of drug shops, stocking general stores with anti-malarial medicines, enforcing price regulation, or distributing medicines with recommended retail prices. The authors conclude that without policies to reduce the concentration and market power of individual shops, new, heavily subsidized ACTs may not reach poor populations.

Is Community-based Health Insurance an Equitable Strategy for Paying for Health Care? Experiences from Southeast Nigeria

Onwujekwe, O. Onoka, C, Uzochukwu, B. Health Policy (2009)

Onwujeke et al. examine differences in enrollment and utilization in two community-based insurance (CBHI) schemes in Nigeria. The authors find that enrollment was associated with enrollee perception of financial risk protection and quality treatment, and the primary reasons for non-enrollment were inability to pay premiums, concurrent enrollment in a government scheme, and distance from an enrolled facility. The authors argue that although overall enrollment in both programs was low, enrollment was equitable among different socioeconomic groups. This was due to the flexible payment schemes, which allowed the premium to be paid in installments. The authors note that differential enrollment in the two programs can be attributed to: insufficient community involvement, a lack of trust in the programs, and the voluntary nature of the enrollment. The authors argue that both CBHI schemes are not sustainable because of small risk pools and dependency on subsidies, and they recommend the creation of exemptions for in-need groups.

Study of Artemisinin Combination Therapy Reveals Effectiveness Well Beyond 2-Year Shelf Life

In a recent study published in the Malaria Journal, Bate et al. report on a multi-pronged investigation into the chemical and physical effectiveness of artemisinin combo-therapy (ACT) in uncontrolled conditions in tropical Africa. The researchers found that 94% of the drug samples collected from private pharmacies in seven tropical African countries maintained their chemical effectiveness between eight and 65 months after the expiration date. The authors argue for additional testing of the chemical effectiveness of ACT, and a re-evaluation of the recommended shelf life by drug regulatory authorities.

Equity in Community Health Insurance Schemes: Evidence and Lessons from Armenia

Polonsky J, et al. Health Policy and Planning, 2009:1-8

Polonsky et al. examine whether community health insurance (CHI) schemes equitably provide care in rural Armenia. The CHI schemes, established by Oxfam and coordinated by local NGOs, attempt to address rural Armenian equity and access problems caused by large out-of-pocket costs and informal payments for the state-funded health system. From a survey of villages with and without CHI schemes, the authors conclude that healthcare utilization is higher in villages with CHI plans, particularly among the poorest quintile, women, and the elderly. Additionally, in villages with an established CHI scheme, both members participating in the scheme and non-members had higher rates of utilization compared to non-CHI villages, possibly related to improvement in the quality of care. Yet Polonsky et al note that the overall participation rate in CHI schemes was low, possibly due to issues of affordability, dissatisfaction with the package of care offered, and free-riding of non-members to emergency services. The authors conclude the increased equity present in rural Armenia can be attributed to a “sustained and significant external subsidy,” close supervision by funders and implementing NGOs, local ownership, and premium exemptions for the poorest residents.

The Effect of Removing Direct Payment for Health Care Utilization and Health Outcomes on Ghanaian Children: A Randomized Control Trial

Ansah E, Narh-Bana S, Asiamah S, et al. PLoS Med 6(1):e10000007

A newly published study in PLoS reports on a randomized control trial of free health care in rural Ghana to determine the degree to which out-of-pocket payments, rather than quality of service, cultural factors, availability of services, or distance to services, affect health-seeking behavior and associated health outcomes. In the trial, 1227 Ghanaian youth were provided free access to primary and secondary care and free drugs while the control group received no financial assistance. The intervention group demonstrated a marked decrease in the use of informal health care, such as traditional healers or home remedies, compared to the control group. Free health care further had a “modest but significant” impact on health care use - children were taken to primary health care facilities more frequently in the intervention group (2.8 episodes per person year) than in the control group (2.5 episodes per person year). The researchers found no significant difference between the groups in number of episodes of fever, deaths, or prevalence of anemia or malaria. These results, showing a lack of effect between free healthcare and health outcomes, call into question the idea that fees provide a significant barrier to health access, suggesting a greater role for other factors such as distance to health care facility and lack of knowledge about when to use health care services in producing outcomes.

Social Mobilization and Social Marketing to Promote NaFeEDTA-fortified Soya Sauce in an Iron-Deficient Population Through a Public Private Partnership

Wang B, Zhan S, Sun J, Lee L. Public Health and Nutrition, 2008 Dec 23:1-9.

Wang et al. report on a pilot public-private partnership between the Chinese government and Zhenji soy sauce production company to shape the attitudes of adult women about iron deficiency and anemia and promote the sale of iron-fortified soy sauce. Researchers employed social marketing and social promotion tactics in China’s Hebei province to inform the population about iron deficiency. Additionally the researchers and the Chinese government coordinated with a major soya sauce producer to create and market an iron fortified soy sauce to the target population. After the campaign, adult women showed increased awareness of the symptoms and health effects of iron deficiency and bought more fortified soy sauce. The intervention resulted in increased blood iron levels and lower levels of anemia in the population.

Effects of Mutual Health Organizations on Use of Priority Health-Care Services in Urban and Rural Mali: A Case Control Study

Franco L, Diop F, Burgert C, Kelley A, Makinen M, Simpara C. Bulletin of the World Health Organization, 2008 Nov 86(11): 830-8381

Franco et al. report on a case-control study examining whether enrollment in a mutual health organization (MHO) in Mali changes families’ use of “curative, maternal and child health interventions,” or provides financial protection for enrollees. Results: MHO members in Mali were significantly more likely to seek treatment for fever and diarrhea in a modern facility, and more likely to make at least four prenatal visits during pregnancy. The study found a smaller difference in MHO enrollment based on income than previous studies. The authors also demonstrate that MHO enrollment lowers household health expenditures.

Barriers of Mistrust: Public and Private Health Sectors’ Perceptions of Each Other in Madhya Pradesh, India

De Costa A, Johansson E, Diwan V. Qualitative Health Research, 18(6) 756-766.

De Costa et al interview key policy stakeholders in the Madhya Pradesh, India, to unpack causes of inadequate coordination between public and private health services. According to their analysis, a “mutual lack of confidence” undermined collaboration between the public and private groups. Public sector stakeholders perceived the private sector as being motivated solely by economic interests, “poorly responsive to partnership initiatives, and focused on self-interest,” while the private sector stakeholders viewed the public sector as “non-supportive, corrupt, and making unrealistic partnership demands.” The authors argue that an important factor contributing to mistrust derives from higher private sector salaries. They suggest, modestly, that collaboration between the public and private sectors could be assisted by altering the predominantly out-of-pocket payment system for health that predominates in India.

Poverty and Access to Health Care in Developing Countries

Peters D, Garg A, Bloom G, et al. Annals of the New York Academy of Sciences. 2008; 1136:161-171

Peters et al examine the relationship between poverty and health care in the developing world and formulate a theoretical framework for access to care. They argue that access to health services is defined by geographic availability (the distance or travel time to a service delivery point), availability (including hours of operation, appropriate service providers, and materials), financial accessibility (the relationship between the price of services and the willingness of users to pay for services), and acceptability (responsiveness of health service provider to social and cultural expectations of individual users). The authors use the framework to examine barriers to access, advocating for its usefulness in planning and implementing policies to foster equity.

NGO Facilitation of a Government Community-Based Maternal and Neonatal Health Programme in Rural India: Improvements in Equity

Baqui A, Rosecrans A, Williams E, Agrawal P, et. al. Health Policy and Planning 2008 23: 234 – 43.

Baqui et al use a quasi-experimental design with one intervention and one control district to evaluate the neonatal component of a governmental program for integrated nutrition and health in Uttar Pradesh India after a private NGO, CARE-India, was engaged to aid in planning, training, and logistic support of government provided infrastructure, health workers, and supplies. The district with government services supported by the NGO showed improvements in coverage and equity for all health measures. Improvements were attributed to NGO-provided additional training, planning, supervision and monitoring of community health workers. Despite the relative gains. overall equity, use of facilities, and quality remained low. The authors recommend ongoing collaborations between government and NGOs to increase utilization and decrease barriers to equity.

Strengthening Health Systems in Poor Countries: A Code of Conduct for Nongovernmental Organizations

Pfeiffer J, Johnson W, Fort M, Shakow A, Hagopian A, Gloyd S, Gimbel-Sherr K. American Journal of Public Health, 2008. 98(12): 2134 – 38

Pfeiffer et al. argue that inordinate distribution of international aid through NGOs, rather than local ministries of health, can undermine public systems of care by fragmenting services, promoting a brain drain from the public sector, fostering unsustainable and limited health projects, and increasing administrative burden of local health officials. The authors believe that a code of conduct for NGOs could “help strengthen health systems by promoting a more constructive role for NGOs” with the public sector in aid delivery. The code of conduct would restrain NGOs from hiring from the public health system and require them to pay salaries commensurate with the public sector, support the development of local health professionals, plan services with local ministries of health and adhere to ministerial norms in terms of administration and personnel.

Medicine Prices, Availability, and Affordability in 36 Developing and Middle-Income Countries: A Secondary Analysis

Cameron A, Ewen M, Ross-Degnan D, Ball D, Laing R. The Lancet. Published online December 1, 2008. DOI: 10.1016/S0140-6736(08)61345-8

In a recent study, WHO and Health Action International researchers report that common essential prescription drugs remain unavailable and unaffordable to the majority of people in thirty-six middle and low-income countries but that availability was consistently higher in the private sector than public sector.  The authors ascribe this to “inadequate funding, lack of incentives for maintaining stocks, inefficient distribution systems, or leakage of medicines for private resale” in the public sector as well as the common public sector practice of marking up drug prices to cross-subsidize other components of the health system.  Cameron et al also contend that generics were more available than costlier originator brands in the private sector in survey countries. The authors believe that drug availability could be increased by “improving procurement efficiency” through national pooled purchasing, procuring drugs by generic name, and making medicines available in the private sector at subsidized prices.  The authors also contend that affordability could be increased by regulating mark-ups, increasing the use of generic medicines through “ensuring the quality of generic products, encouraging price competition,” and increasing the confidence of health professionals in the quality of generic medicines.

Pragmatism about the Private Sector: A debate in PLoS

Hanson K, Gilson L, Goodman C, Mills A, Smith R, Feachem R, Sekhri-Feachem N, Koehlmoos TP, Kinlaw H. PLoS 2008. Blog review by April Harding, Center for Global Development.

Discussions of the private health sector in developing countries have long been dominated by dogmatism on both sides. For public-sector-purists, the existence and rapid growth of the private sector in the 80s and 90s was a symptom of what was wrong with developing country health systems, and good policies were those that would strengthen the public sector in such a way as to lead to the fading away of the private sector. For the private-sector-believers, the growing private sector revealed the unfixable problems of the public sector, and made it clear that to achieve sectoral goals you’d have to engage the private sector. The public-sector-purists thought the private-sector believers were anti-poor, since they believed only the public sector could look after their interests. The believers though the purists were in denial about the fixable-ness (and pro-poorness) of the public sector. For years, this, rather sterile, debate raged - with relatively little benefit. In the past 2 years, this debate has moved on. Both the purists and the believers have shifted to the middle, with growing consensus on the need to work with the private sector (broadly defined), if not where this ranks in the long list of health policy priorities for developing countries.

Contracting for Health Services: Effects of Utilization and Quality on the Costs of the Basic Package of Health Services in Afghanistan

Ameli O, Newbrander W. Bulletin of the World Health Organization 2008: 86

Following the fall of the Taliban in 2001, the Afghanistan Ministry of Public Health developed a basic set of health services to prioritize the most-pressing public health problems. Supporting this, the US Agency for International Development took responsibility for funding services in several provinces, contracting with national and international nongovernmental organizations to provide primary health access. On reviewing the contracting experience, Ameli et al. found that the majority of program expenses were from fixed costs not related to the security situation or remoteness of covered regions. The authors recommend that standardizing fixed cost elements would reduce the contracting organization’s management and monitoring needs. A secondary finding was that the use of female health workers alongside other health personnel increased both patient satisfaction and utilization of health services.

An additional commentary by B Loevinsohn about the contracting experience in Afghanistan.

Medicines Coverage and Community-Based Health Insurance in Low-Income Countries.

Vialle-Valentin C, Ross-Degnan D, Ntaganira J, Wagner A. Health Research and Policy Systems 2008, 6:11

Among the highlighted community-based health insurance (CHI) plans are two in Rwanda (Gibumbi and CUSP), where the government is supporting CHI as part of a move towards universal health insurance. The authors note the success of the Gibumbi plan in increasing access and use of medicine among the poor. This is the result of Gibumbi’s ‘family enrollment’ policy and cross-subsidy program to allow free enrollment of the poor, viable in part because out-patient drug coverage is restricted within the plan. The competing CUSP plan does not include subsidized members and uses a fixed co-payment with no drug restrictions. The poor are less represented among CUSP members than among Gibumbi, though benefits to members are higher.

The review also examines the emerging national CHI project in Lao PDR, noting challenges with the program’s voluntary membership and it’s difficulty reaching the poorest populations. CHI plans need to improve revenue collection and strategic purchasing, specifically in negotiating supplier payments and designing incentives for recommended medicines. There are few tools to assist CHI managers in designing and managing benefit packages adapted to low-income environments and a little support for managers to analyze dispensing data in order to improve use of medicines.

The Effectiveness of Contracting-out Primary Health Care Services in Developing Countries: A Review of the Evidence.

Liu X, Hotchkiss DR, Bose S. Health Policy and Planning 2008; 23:1–13

Contracting between governments and non-governmental primary health providers has grown in recent years due to a surge in international health initiatives, frustration over the efficacy and quality of public services, shortages of personnel, and public preference for private care. However, there is a dearth of evidence on whether government contracting out of primary health care services improves the effectiveness and performance of health programs and systems. Reviewing thirteen contracting case studies, the authors see mixed overall performance.

The authors argue that contracting improves access to health services and equity if “services that most benefit the poor are targeted” but does not necessarily improve equity more than public providers, has mixed results in boosting efficiency, and has unclear results in increasing quality. The authors note that variations in contracting success depend heavily on the specific context of implementation and on the specific design features of intervention. In addition, the authors note that there is “relatively little understanding… of how contracting-out primary health care services influences the broader health system” and that further research is greatly needed.

Women's Social Position and Health-Seeking Behaviors: Is the Health Care System Accessible and Responsive in Pakistan?

Shaikh B, Haran D, Hatcher J - Health Care for Women International 29:8 (2008) 945 — 959

This survey of women’s health-seeking behaviors in rural northern Pakistan highlights the success of the private non-profit Aga Khan Health Services (AKHSP) in promoting access to services by facilitating culturally appropriate treatment. Survey participants noted the presence of female staff, positive staff attitudes, and high quality services and medicines at AKHSP. Surveyed women visited AKHSP more frequently than other health services despite increased costs and inconvenient access, stating that the presence of female staff was their main reason for visiting AKHSP over government-run services. To increase women’s use of health services, Shaikh et al recommend social marketing with community health workers and mass-level health education campaigns to inform and empower women, as well as increased communication and coordination between the private and public health services.

Choice of healthcare provider following reform in Vietnam

T Nguyen, C Lofgren, L Lindholm, T Nguyen, C Kim - BMC Health Services Research 8: 162 (2008)

Nguyen et al argue that changes in Vietnam’s health care system have paralleled the country’s transition to a market economy: since 1989, the Vietnamese government has transformed the country’s health system by introducing user fees and health insurance and by deregulating pharmaceuticals. These changes aimed to increase quality but have also led to increased out-of-pocket costs leaving many individuals unable to afford care. Nguyen et al surveyed households in rural Northern Vietnam to determine factors influencing health care provider choice.

Rural Vietnamese households overwhelmingly used private providers (60%), followed by self-treatment (23%), then public providers (10%). People with higher education levels and larger families were more likely to seek routine treatment from private providers, while the poorest were more likely to use self-treatment for routine conditions. All rural individuals tended to use public health systems for the most costly treatments. Nguyen et al argue that recent changes in the Vietnamese health care system have given more affluent individuals increased access to private health care, while the increased availability of medicines has led poorer individuals to self-treat rather than pay low quality public providers. The authors bring new information to this issue, highlighting that private providers are often considered better and cheaper than the nominally free government services.

Social Franchising to Improve Quality and Access in Private Health Care in Developing Countries

D Bishai, N Shah, D Walker, W Brieger, D Peters – Harvard Health Policy Review, 2008

An economic overview of the fundamentals of public-private healthcare system interests, and presentation of a case study of a social franchise in Pakistan to demonstrate the success of healthcare franchising in increasing quality and access to care.

Bishai et. al. use the case study of the Green Star private social healthcare franchise in Pakistan to reveal that healthcare franchises can be used as an effective mechanism to increase quality of care, access to care among poor clients, and efficiency of services. The paper identifies social franchises, like Green Star, can increase quality of care and access to services to the whole population in parallel to government and non-governmental health systems. The authors additionally provide an “economic model of public private interests in healthcare” centered around the concepts of “quality of service provision and access to care by disenfranchised groups” – concepts that cannot be ensured by complete free market mechanisms. The paper as well notes predictions regarding alternative business models of health care provisions, including vouchers, contract systems, and incentive payment systems.

Public Purchasers Contracting External Primary Care Providers in Central America for Better Responsiveness, Efficiency of Health Care, and Public Governance: Issues and Challenges

J Macq, P Martiny, L Villalobos, A Solis, J Miranda, H Mendez, C Collins – Health Policy 87 (2008) 377 – 388

A comparative case study of four Central American countries’ experience with limited contracting between public purchasing agencies and external health care providers using an analytical framework based on equity and efficiency.

Contracting between non-governmental primary care providers and a public purchasing agencies has occurred recently in several Latin America countries as a way to increase efficiency, quality, sustainability and accessibility. Macq et. al. identify that the performance of contracted parties are influenced by three factors: 1) “core descriptive elements of the contractual relation” (including the selection process, definition of benefits packages, management of resources, and quality management), 2) external factors (such as health related technical issues, as well as economic, political, social, and financial beliefs of the contracting agency), and 3) the relationship between the contracting agency and key stakeholders in the larger health system. Upon review of the contracting experiences, the authors conclude that the complexity of contracting requires making clear technical and value-based choices during the nascent stages and adopting flexible behaviors to cope with unexpected planning development and to manage contracting external providers.

Speciality Care Systems: A Pioneering Vision For Global Health

A Bhandari, S Dratler, K Raube, R.D. Thulasiraj – Health Affairs 27, no. 4 (2008): 964 – 976

An overview of successful core elements of private specialty care system models using the case study of Aravind Eye Care System in India.

Bhandari et. al, consider the specialty care model of medical service, one that focuses on a particular medical condition or disease area, has potential for “greater patient volume, better outcomes, improved quality of care, and lower costs” over traditional models when implemented successfully. The authors note that thriving specialty care businesses include: 1) a standardized and continuously improving management system with local ownership, 2) development of a specialized workforce, 3) access to low-cost technology, and 4) high patient volume. The authors consider Aravind Eye Care System an exemplar of these criteria. It employs a “serial production” model for medical operations to maximize efficiency and quality, and uses a semi-autonomous systems management agency to “improve the planning, efficiency, and effectiveness of all eye hospitals in India.” Aravind creates its specialized workforce though technical and value-based training programs of paramedical and medical staff. The program also focuses on technological development by building and operating a manufacturing plant for specialty lenses that has increased financial autonomy and reduced overall costs. Aravind in addition builds patient volume though a hub-and-spoke model which uses aggressive community outreach screening and then sending evaluated patient to its centralized surgery centers. The authors note that generalisability of this model is limited by the availability of a specialized workforce, density of the population, patient cultural norms, and the availability of low-cost technology.

Impact of Mutual Health Organizations: Evidence from West Africa

S Chankova, S Sulzbach, F Diop – Health Policy and Planning 23 (2008): 264 – 276

An analysis of Mutual Health Organizations’ effects on decreasing out-of-pocket health expenditures and increasing health care access in three West African Countries.

Mutual Health Organizations (MHOs) are health insurance providing voluntary membership organizations that are typically designed, owned, and managed by the communities they serve. MHOs have spread in the developing world in recent years. They are believed to increase use of health services and decrease out-of-pocket payments for users. Chankova et. al., surveying MHOs in Ghana, Mali, and Senegal, have found that MHO enrollment is highest in households that are headed by women and older individuals, more educated, and more affluent. Chankova et al. further note that in Ghana and Mali enrollments in MHOs have increased patient access to modern health care providers and patient hospitalization levels while significantly decreasing hospitalization-related expenditures. Enrollments have had an inconclusive effect on out-of-pocket health care due to their high cost sharing rates. To improve enrollment and social inclusion, the authors suggest that MHO managers should market to individuals with low educational levels, collect premiums on a monthly rather than yearly basis, alter service packages to increase outpatient care coverage and lower co-payments, and target populations close to health care facilities.