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Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review  [PDF]
Sanjay Basu ,Jason Andrews,Sandeep Kishore,Rajesh Panjabi,David Stuckler
PLOS Medicine , 2012, DOI: 10.1371/journal.pmed.1001244
Abstract: Introduction Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries. Methods and Findings Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers. When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care. “Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff. Conclusions Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients. Please see later in the article for the Editors' Summary
Promoting safe motherhood through the private sector in low- and middle-income countries
Brugha,Ruairí; Pritze-Aliassime,Susanne;
Bulletin of the World Health Organization , 2003, DOI: 10.1590/S0042-96862003000800012
Abstract: the formal private sector could play a significant role in determining whether success or failure is achieved in working towards goals for safe motherhood in many low- and middle-income settings. established private providers, especially nurses/midwives, have the potential to contribute to safe motherhood practices if they are involved in the care continuum. however, they have largely been overlooked by policy-makers in low-income settings. the private sector (mainly doctors) contributes to overprovision and high caesarean section rates in settings where it provides care to wealthier segments of the population; such care is often funded through third-party payment schemes. in poorer settings, especially rural areas, private nurses/midwives and the women who choose to use them are likely to experience similar constraints to those encountered in the public sector - for example, poor or unaffordable access to higher level facilities for the management of obstetrical emergencies. policy-makers at the country-level need to map the health system and understand the nature and distribution of the private sector, and what influences it. this potential resource could then be mobilized to work towards the achievement of safe motherhood goals.
Promoting safe motherhood through the private sector in low- and middle-income countries  [cached]
Brugha Ruairí,Pritze-Aliassime Susanne
Bulletin of the World Health Organization , 2003,
Abstract: The formal private sector could play a significant role in determining whether success or failure is achieved in working towards goals for safe motherhood in many low- and middle-income settings. Established private providers, especially nurses/midwives, have the potential to contribute to safe motherhood practices if they are involved in the care continuum. However, they have largely been overlooked by policy-makers in low-income settings. The private sector (mainly doctors) contributes to overprovision and high Caesarean section rates in settings where it provides care to wealthier segments of the population; such care is often funded through third-party payment schemes. In poorer settings, especially rural areas, private nurses/midwives and the women who choose to use them are likely to experience similar constraints to those encountered in the public sector - for example, poor or unaffordable access to higher level facilities for the management of obstetrical emergencies. Policy-makers at the country-level need to map the health system and understand the nature and distribution of the private sector, and what influences it. This potential resource could then be mobilized to work towards the achievement of safe motherhood goals.
Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies  [PDF]
Sima Berendes,Peter Heywood,Sandy Oliver,Paul Garner
PLOS Medicine , 2011, DOI: 10.1371/journal.pmed.1000433
Abstract: Background In developing countries, the private sector provides a substantial proportion of primary health care to low income groups for communicable and non-communicable diseases. These providers are therefore central to improving health outcomes. We need to know how their services compare to those of the public sector to inform policy options. Methods and Findings We summarised reliable research comparing the quality of formal private versus public ambulatory health care in low and middle income countries. We selected studies against inclusion criteria following a comprehensive search, yielding 80 studies. We compared quality under standard categories, converted values to a linear 100% scale, calculated differences between providers within studies, and summarised median values of the differences across studies. As the results for for-profit and not-for-profit providers were similar, we combined them. Overall, median values indicated that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence, and practice. Overall, the private sector performed better in relation to drug supply, responsiveness, and effort. No difference between provider groups was detected for patient satisfaction or competence. Synthesis of qualitative components indicates the private sector is more client centred. Conclusions Although data are limited, quality in both provider groups seems poor, with the private sector performing better in drug availability and aspects of delivery of care, including responsiveness and effort, and possibly being more client orientated. Strategies seeking to influence quality in both groups are needed to improve care delivery and outcomes for the poor, including managing the increasing burden of non-communicable diseases. Please see later in the article for the Editors' Summary
What can be done about the private health sector in low-income countries?
Mills,Anne; Brugha,Ruairi; Hanson,Kara; McPake,Barbara;
Bulletin of the World Health Organization , 2002, DOI: 10.1590/S0042-96862002000400012
Abstract: a very large private health sector exists in low-income countries. it consists of a great variety of providers and is used by a wide cross-section of the population. there are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. this is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. how can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. there is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.
What can be done about the private health sector in low-income countries?  [cached]
Mills Anne,Brugha Ruairi,Hanson Kara,McPake Barbara
Bulletin of the World Health Organization , 2002,
Abstract: A very large private health sector exists in low-income countries. It consists of a great variety of providers and is used by a wide cross-section of the population. There are substantial concerns about the quality of care given, especially at the more informal end of the range of providers. This is particularly true for diseases of public health importance such as tuberculosis, malaria, and sexually transmitted infections. How can the activities of the private sector in these countries be influenced so that they help to meet national health objectives? Although the evidence base is not good, there is a fair amount of information on the types of intervention that are most successful in directly influencing the behaviour of providers and on what might be the necessary conditions for success. There is much less evidence, however, of effective approaches to interventions on the demand side and policies that involve strengthening the purchasing and regulatory roles of governments.
Political economy of tobacco control in low-income and middle-income countries: lessons from Thailand and Zimbabwe
,;
Bulletin of the World Health Organization , 2000, DOI: 10.1590/S0042-96862000000700009
Abstract: crucial to the success of the proposed framework convention on tobacco control will be an understanding of the political and economic context for tobacco control policies, particularly in low-income and middle-income countries. policy studies in thailand and zimbabwe employed the analytical perspective of political economy and a research strategy that used political mapping, a technique for characterizing and evaluating the political environment surrounding a policy issue, and stakeholder analysis, which seeks to identify key actors and to determine their capacity to shape policy outcomes. these policy studies clearly revealed how tobacco control in low-income and middle-income countries is also being shaped by developments in the global and regional political economy. hence efforts to strengthen national control policies need to be set within the context of globalization and the international context. besides the transnational tobacco companies, international tobacco groups and foreign governments, international agencies and nongovernmental organizations are also playing influential roles. it cannot be assumed, therefore, that the tobacco control strategies being implemented in industrialized countries will be just as effective and appropriate when implemented in developing countries. there is an urgent need to expand the number of such tobacco policy studies, particularly in low-income and middle-income countries. comprehensive guidelines for tobacco policy analysis and research are required to support this process, as is a broader international strategy to coordinate further tobacco policy research studies at country, regional and global levels.
The role and uptake of private health insurance in different health care systems: are there lessons for developing countries?
Odeyemi IA, Nixon J
ClinicoEconomics and Outcomes Research , 2013, DOI: http://dx.doi.org/10.2147/CEOR.S40386
Abstract: ole and uptake of private health insurance in different health care systems: are there lessons for developing countries? Review (376) Total Article Views Authors: Odeyemi IA, Nixon J Published Date March 2013 Volume 2013:5 Pages 109 - 118 DOI: http://dx.doi.org/10.2147/CEOR.S40386 Received: 15 November 2012 Accepted: 05 December 2012 Published: 05 March 2013 Isaac AO Odeyemi,1 John Nixon2 1Senior Director and Head of Health Economics and Outcomes Research, Astellas Pharma UK Ltd, Chertsey, UK; 2Teaching Associate in Health Economics, Department of Economics and Related Studies, University of York, York, UK Background: Social and national health insurance schemes are being introduced in many developing countries in moving towards universal health care. However, gaps in coverage are common and can only be met by out-of-pocket payments, general taxation, or private health insurance (PHI). This study provides an overview of PHI in different health care systems and discusses factors that affect its uptake and equity. Methods: A representative sample of countries was identified (United States, United Kingdom, The Netherlands, France, Australia, and Latvia) that illustrates the principal forms and roles of PHI. Literature describing each country's health care system was used to summarize how PHI is utilized and the factors that affect its uptake and equity. Results: In the United States, PHI is a primary source of funding in conjunction with tax-based programs to support vulnerable groups; in the UK and Latvia, PHI is used in a supplementary role to universal tax-based systems; in France and Latvia, complementary PHI is utilized to cover gaps in public funding; in The Netherlands, PHI is supplementary to statutory private and social health insurance; in Australia, the government incentivizes the uptake of complementary PHI through tax rebates and penalties. The uptake of PHI is influenced by age, income, education, health care system typology, and the incentives or disincentives applied by governments. The effect on equity can either be positive or negative depending on the type of PHI adopted and its role within the wider health care system. Conclusion: PHI has many manifestations depending on the type of health care system used and its role within that system. This study has illustrated its common applications and the factors that affect its uptake and equity in different health care systems. The results are anticipated to be helpful in informing how developing countries may utilize PHI to meet the aim of achieving universal health care.
Translating evidence into policy in low-income countries: lessons from co-trimoxazole preventive therapy
Hutchinson,Eleanor; Droti,Benson; Gibb,Diana; Chishinga,Nathaniel; Hoskins,Susan; Phiri,Sam; Parkhurst,Justin;
Bulletin of the World Health Organization , 2011, DOI: 10.1590/S0042-96862011000400015
Abstract: in the april 2010 issue of this journal, date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. this short paper discusses the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. doing so will help them to understand and address the concerns raised by date et al. and other experts. mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.
The Market Dynamics of Generic Medicines in the Private Sector of 19 Low and Middle Income Countries between 2001 and 2011: A Descriptive Time Series Analysis  [PDF]
Warren A. Kaplan, Veronika J. Wirtz, Peter Stephens
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0074399
Abstract: This observational study investigates the private sector, retail pharmaceutical market of 19 low and middle income countries (LMICs) in Latin America, Asia and the Middle East/South Africa analyzing the relationships between volume market share of generic and originator medicines over a time series from 2001 to 2011. Over 5000 individual pharmaceutical substances were divided into generic (unbranded generic, branded generic medicines) and originator categories for each country, including the United States as a comparator. In 9 selected LMICs, the market share of those originator substances with the largest decrease over time was compared to the market share of their counterpart generic versions. Generic medicines (branded generic plus unbranded generic) represent between 70 and 80% of market share in the private sector of these LMICs which exceeds that of most European countries. Branded generic medicine market share is higher than that of unbranded generics in all three regions and this is in contrast to the U.S. Although switching from an originator to its generic counterpart can save money, this narrative in reality is complex at the level of individual medicines. In some countries, the market behavior of some originator medicines that showed the most temporal decrease, showed switching to their generic counterpart. In other countries such as in the Middle East/South Africa and Asia, the loss of these originators was not accompanied by any change at all in market share of the equivalent generic version. For those countries with a significant increase in generic medicines market share and/or with evidence of comprehensive “switching” to generic versions, notably in Latin America, it would be worthwhile to establish cause-effect relationships between pharmaceutical policies and uptake of generic medicines. The absence of change in the generic medicines market share in other countries suggests that, at a minimum, generic medicines have not been strongly promoted.
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