Use of family planning and child health services in the private sector: an equity analysis of 12 DHS surveys

Mapping inequalities in health service coverage in Africa: a scoping review

OBJECTIVE

In this scoping review, we aim to consolidate the evidence on inequalities in service coverage in Africa using a comprehensive set of stratifiers. These stratifiers include place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status and social capital. Our approach provides a more holistic understanding of the different dimensions of inequality in the context of universal health coverage (UHC).

DESIGN

We conducted a scoping review following the Joanna Briggs Institute Manual for Evidence Synthesis.

DATA SOURCES

We searched MEDLINE, Embase, Web of Science, CINAHL, PyscINFO, Cochrane Library, Google Scholar and Global Index Medicus for articles published between 1 January 2005 and 29 August 2022 examining inequalities in utilisation of health services for reproductive, maternal, newborn and child health (RMNCH), infectious or non-communicable diseases in Africa.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included any empirical research that assessed inequalities in relation to services for RMNCH (eg, family planning), infectious diseases (eg, tuberculosis treatment) and non-communicable diseases (eg, cervical cancer screening) in Africa.

DATA EXTRACTION AND SYNTHESIS

The data abstraction process followed a stepwise approach. A pilot-tested form capturing study setting, inequality assessment and service coverage indicators was developed and finalised. Data were extracted by one reviewer and cross-checked by another, with discrepancies resolved through consensus meetings. If a consensus was not reached, senior reviewers made the final decision. We used a narrative approach to describe the study characteristics and mapped findings against PROGRESS-Plus stratifiers and health service indicators. Quantitative findings were categorised as 'proequity', 'antiequity' or 'equal' based on service utilisation across social groups.

RESULTS

We included 178 studies in our review, most studies published within the last 5 years (61.1%). Most studies assessed inequality using socioeconomic status (70.6%), followed by age (62.4%), education (60.7%) and place of residence (59.0%). Few studies focused on disability, social capital and ethnicity/race and intersectionality of stratifiers. Most studies were on RMNCH services (53.4%) and infectious disease services (43.3%). Few studies were qualitative or behavioural analyses. Results highlight significant inequalities across different equity stratifiers and services with inconsistent trends of inequalities over time after the implementation of strategies to increase demand of services and strengthen health systems.

CONCLUSION

There is a need to examine equity in service coverage for a variety of health conditions among various populations beyond the traditional classification of social groups. This also requires using diverse research methods identifying disparities in service use and various barriers to care. By addressing these knowledge gaps, future research and health system reforms can support countries in moving closer to achievement of UHC targets.

Uses of private health provider data for governance in low-income and middle-income countries: results from a scoping review

This work grew from an interest in understanding how private data are used for health system governance in low-income and middle-income countries (LMICs).

OBJECTIVE

We conducted a scoping review to understand how the public sector collects routine data from the private health sector and uses it for governance purposes. The private health sector was defined to include both formal and informal, for-profit or non-profit, actors delivering healthcare services.

FINDINGS

We identified 4014 individual English language studies published between 2010 and 2021. We reviewed titles and abstracts of all, with 50% reviewed by two authors to ensure a common application of inclusion criteria. 89 studies were selected for review in full; following this, 26 articles were included in the final selection as they directly report on the use of routine private sector data for governance in LMICs. Only English language studies were included, limiting the scope of possible conclusions.

RESULTS

Data were most commonly collected by the Ministry of Health or a subministerial office, with extraction from District Health Information System 2 specifically cited for three studies. 16 studies collected data on infrastructure and distribution, 15 on service delivery, 12 on health financing, 7 on pharmaceuticals and other consumables, 4 on health workforce, 4 on quality of care and 4 on epidemic surveillance.

CONCLUSION

The studies identified provide examples of the public sector's capacity to collect and use data routinely collected from the private sector to perform essential governance functions. The paucity of studies identified is an indication that more attention is needed to ensure that this key area of health system governance is undertaken and that lessons learnt are shared. This review provides insights to understanding private sector health data collection and use for governance in LMICs, and for guiding activities to assess and improve this according to country context and capacity.

Clinical surveillance systems obscure the true cholera infection burden in an endemic region

Our understanding of cholera transmission and burden largely relies on clinic-based surveillance, which can obscure trends, bias burden estimates and limit the impact of targeted cholera-prevention measures. Serological surveillance provides a complementary approach to monitoring infections, although the link between serologically derived infections and medically attended disease incidence-shaped by immunological, behavioral and clinical factors-remains poorly understood. We unravel this cascade in a cholera-endemic Bangladeshi community by integrating clinic-based surveillance, healthcare-seeking and longitudinal serological data through statistical modeling. Combining the serological trajectories with a reconstructed incidence timeline of symptomatic cholera, we estimated an annual Vibrio cholerae O1 infection incidence rate of 535 per 1,000 population (95% credible interval 514-556), with incidence increasing by age group. Clinic-based surveillance alone underestimated the number of infections and reported cases were not consistently correlated with infection timing. Of the infections, 4 in 3,280 resulted in symptoms, only 1 of which was reported through the surveillance system. These results impart insights into cholera transmission dynamics and burden in the epicenter of the seventh cholera pandemic, where >50% of our study population had an annual V. cholerae O1 infection, and emphasize the potential for a biased view of disease burden and infection risk when depending solely on clinical surveillance data.

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

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

Factors Associated With Initiating Breastfeeding and Continuing it for At Least 4 Months in Consuelo, a Rural Town in the Dominican Republic

Objective. We assessed the proportion of and factors associated with mothers initiating and continuing breastfeeding (BF) for ≥4 months in a rural town of the Dominican Republic. Methods. A survey was administered to 190 mothers of children cared for at a free clinic in Consuelo. Modified bivariate and multivariable Poisson regressions were utilized in data analysis. Results. BF was initiated in 89.5% of cases and continued ≥4 months in 81.7% of cases. Maternal education beyond secondary school [adjusted RR = 1.13, 95% CI: (1.04-1.24), 0.010], and visiting both public and private antenatal clinics [adjusted RR = 1.25; 95% CI: (1.10-1.37), 0.010] were associated with BF initiation. Public and private antenatal clinic attendance [adjusted RR = 1.01, 95% CI: (0.45-2.23), 0.020], Cesarean section [adjusted RR = 0.81, 95% CI: (0.68-0.98), 0.026], number of biological children [adjusted RR = 0.95, 95% CI: (0.90-1.00), 0.032] and maternal employment [adjusted RR = 0.89, 95% CI: (0.79-0.99), 0.048] were associated with BF continuation. Conclusions. These results provide valuable insights for targeting specific populations in future breastfeeding education interventions.

Male Involvement in Family Planning Decisions in Malawi and Tanzania: What Are the Determinants?

The participation of males in joint spousal decisions is urgently needed in achieving the fundamental indicators of reproductive health. The low involvement of males in family planning (FP) decision-making is a major determining factor in low FP usage in Malawi and Tanzania. Despite this, there are inconsistent findings regarding the extent of male involvement and the determinants that aid male participation in FP decisions in these two countries. The objective of this study was to assess the prevalence of male involvement in FP decisions and its associated determinants within the household context in Malawi and Tanzania. We used data from the 2015-2016 Malawi and Tanzania Demographic and Health Surveys (DHSs) to examine the prevalence and the determinants inhibiting male involvement in FP decisions. The total sample size of 7478 from Malawi and 3514 males from Tanzania aged 15-54 years was employed in the analysis by STATA version 17. Descriptive (graphs, tables and means), bi-variate (chi-square) and logistic regression analyses (unadjusted (U) and adjusted odds ratio (AOR)) were performed to identify the determinants associated with male involvement in FP decisions. The mean age of respondents in Malawi was 32 years (±8 SD) and in Tanzania, 36 years (±6 SD), with the prevalence of male involvement in FP decisions being 53.0% in Malawi and 26.6% in Tanzania. Being aged 35-44 years [AOR = 1.81; 95% CI: 1.59-2.05] and 45-54 years [AOR = 1.43; 95% CI: 1.22-1.67], educated (secondary/higher) [AOR = 1.62; 95% CI: 1.31-1.99], having access to media information [AOR = 1.35; 95% CI: 1.21-1.51] and having a female head of household [AOR = 1.79; 95% CI: 1.70-1.90] were determinant factors of male involvement in FP decisions in Malawi. Primary education [AOR = 1.94; 95% CI: 1.39-2.72], having a middle wealth index ranking [AOR = 1.46; 95% CI: 1.17-1.81], being married [AOR = 1.62; 95% CI: 1.38-1.90] and working [AOR = 2.86; 95% CI: 2.10-3.88] were higher predictors of male involvement in FP decisions in Tanzania. Increasing the role of males in FP decisions and involvement in FP utilization may improve uptake and continuity of FP usage. Therefore, the findings from this cross-sectional study will support redesigning the ineffective strategic FP programs that accommodate socio-demographic determinants that may increase the likelihood of male involvement in FP decisions, especially in the grassroots settings in Malawi and Tanzania.

Socio-economic and education related inequities in use of modern contraceptive in seven sub-regions in Uganda

BACKGROUND

Advocacy for equity in health service utilization and access, including Family Planning (FP) continues to be a cornerstone in increasing universal health coverage. Inequities in Family planning are highlighted by the differences in reproductive health outcomes or in the distribution of resources among different population groups. In this study we examine inequities in use of modern contraceptives with respect to Socio-economic and Education dimensions in seven sub-regions in Uganda.

METHODS

The data were obtained from a baseline cross-sectional study in seven statistical regions where a program entitled "Reducing High Fertility Rates and Improving Sexual Reproductive Health Outcomes in Uganda, (RISE)" is implemented in Uganda. There was a total of 3,607 respondents, half of whom were women of reproductive age (15-49 years) and the other half men (18-54 years). Equity in family planning utilization was assessed by geography, wealth/economic and social-demographics. The use of modern family planning was measured as; using or not using modern FP. Concentration indices were used to measure the degree of Inequality in the use of modern contraceptives. Prevalence Ratios to compare use of modern FP were computed using modified Poisson regression run in STATA V15.

RESULTS

Three-quarters (75.6%) of the participants in rural areas were married compared to only 63% in the urban. Overall use of modern contraceptives was 34.2% [CI:30.9, 37.6], without significant variation by rural/urban settings. Women in the higher socio-economic status (SES) were more advantaged in use of modern contraceptives compared to lower SES women. The overall Erreygers Concentration Index, as a measure of inequity, was 0.172, p<0.001. Overall, inequity in use of modern contraceptives by education was highest in favor of women with higher education (ECI=0.146, p=0.0001), and the concentration of use of modern contraceptives in women with higher education was significant in the rural but not urban areas CONCLUSION: Inequities in the use of modern contraceptives still exist in favor of women with more education or higher socio-economic status, mainly in the rural settings. Focused programmatic interventions in rural settings should be delivered if universal Family Planning uptake is to be improved.

What are the sources of contraceptives for married and unmarried adolescents: Health services or friends? Analysis of 59 low- and middle-income countries

Background

Despite the efforts to promote universal coverage for family planning, inequalities are still high in several countries. Our aim was to identify which sources of contraceptives women mostly rely on in low- and middle-income countries (LMICs). We also explored the different sources according to age and marital status.

Methods

We used data from national health surveys carried out in 59 LMICs since 2010. Among all sexually active women at reproductive age, we explored inequalities in demand for family planning satisfied by modern methods (mDFPS) and in the source of modern contraceptives according to women's age, classified as: 15-19, 20-34, or 35-49 years of age. Among adolescents, mDFPS and source of method were explored by marital status, classified as married or in union and not married nor in a union.

Results

mDFPS was lower among adolescents than among adult women in 28 of the 59 countries. The lowest levels of mDFPS among adolescents were identified in Albania (6.1%) and Chad (8.2%). According to adolescents' marital status, the pattern of inequalities in mDFPS varied widely between regions, with married and unmarried adolescents showing similar levels of coverage in Latin America and the Caribbean, higher coverage among unmarried adolescents in Africa, and lower coverage among unmarried adolescents in Asia. Public and private health services were the main sources, with a lower share of the public sector among adolescents in almost all countries. The proportion of adolescents who obtained their contraceptives in the public sector was lower among unmarried girls than married ones in 31 of the 38 countries with data. Friends or relatives were a more significant source of contraceptives among unmarried compared to married adolescents in all regions.

Conclusions

Our findings indicate lower levels of mDFPS and lower use of the public sector by adolescents, especially unmarried girls. More attention is needed to provide high-quality and affordable family planning services for adolescents, especially for those who are not married.

Determinants of care-seeking behaviour for fever, acute respiratory infection and diarrhoea among children under five in Nigeria

Background

Despite available, inexpensive and effective treatments, malaria, diarrhoea, and pneumonia still contribute the majority of the global burden of childhood morbidity and mortality. Nigeria has the highest absolute numbers of child deaths worldwide. Appropriate care-seeking is important for prompt diagnosis, appropriate and timely treatment, and prevention of complications. The objective of this cross-sectional study was to examine the prevalence of and factors associated with appropriate care-seeking for childhood illnesses.

Methods

We used the most recent Nigeria Demographic and Health Survey (2018) to assess the prevalence of appropriate care-seeking among mothers of children under five with symptoms of common childhood illnesses. For diarrhoea, we defined appropriate care-seeking as seeking care from a formal health provider. For fever and acute respiratory infection (ARI), appropriate care-seeking was defined as seeking care from a formal provider the day of or after symptom onset. Multivariate logistic regression was carried out to assess factors associated with optimal care-seeking for each illness.

Results

At least 25% of parents did not seek any care for children with fever or ARI; this figure was over one third for diarrhoea. Only 15% and 13% of caregivers showed appropriate care-seeking for their children with fever and ARI respectively, and 27% of mothers sought care from a formal provider for diarrhoea. Predictors of appropriate care-seeking varied according to childhood illness. Previous facility delivery was the only risk factor associated with increased odds of appropriate care-seeking for all three illnesses; other risk factors varied between illnesses.

Conclusion

Overall, care-seeking for childhood illnesses was suboptimal among caregivers in Nigeria. Interventions to increase caregivers’ awareness of the importance of appropriate care-seeking are needed alongside quality of care interventions that reinforce people’s trust in formal health facilities, to improve timely care-seeking and ultimately reduce the high burden of child deaths in Nigeria.

Identifying inequity in family planning: The Track20 equity tool

Background: With increases in contraceptive use in most countries in the world, within country inequities persist.  Equity in family planning does not mean an equal level of contraceptive use among all groups; differences in use of contraception could reflect variation in cultural beliefs and values and therefore not inequity.  Methods: Focusing on demand satisfied for modern methods and five dimensions (age, education, geography, parity, and wealth), we map inequities within 15 sub-Saharan African countries and across time.  We create a “Concentration of Inequity” to highlight the intersectionality of inequities in family planning and allows for more data informed programming.  Results: Inequities exist in all countries included in this analysis, though the range varies substantially. Over 85% of the countries included in this analysis had at least 1 subgroup in the population with demand satisfied 30% or more below the national level of demand satisfied. To help visualize inequities and stimulate discussion, we create an online tool to display multiple aspects of inequity.   Conclusions: Using demand satisfied with modern methods to measure inequity for family planning allows us to focus attention on women with desire to delay or limit childbearing.  Studying the intersections of demographic factors is fundamental for a deeper understanding of family planning equity.

Radio Communications on Family Planning: Case of West Africa

Sub-Saharan Africa will accommodate more population this century by having a multitude of births across the continent. Family planning methods provide women with techniques to manage their health and wellbeing. This study investigated how radio communications in family planning changed the perception of Ghanaian, Liberian, and Senegalese mothers toward having fewer children. Univariate and multivariate linear regression results after coarsened exact matching (CEM) with selected covariates for 15- to 49-year-old mothers from demographic and health survey (DHS) data implied the effectiveness of radio communications. This effort supports the need for further research on tailored communication methods for West African mothers over time.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats.

Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups.

Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats.

Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Evaluation of progress toward universal health coverage in Myanmar: A national and subnational analysis

BACKGROUND

Universal health coverage (UHC) encompasses 2 main components: access to essential healthcare services and protection from financial hardship when using healthcare. This study examines Myanmar's efforts to achieve UHC on a national and subnational level. It is a primer of studying the concept of UHC on a subnational level, and it also establishes a baseline for assessing future progress toward reaching UHC in Myanmar.

METHODS AND FINDINGS

The study uses the Demographic and Health Survey (2015) and the Myanmar Living Conditions Survey (MLCS; 2017) and adapts a previously developed UHC index to provide insights into the main barriers preventing the country's progress toward UHC. We find a negative correlation between the UHC index and the state/region poverty levels. The equity of access analysis reveals significant pro-rich inequity in access to all essential healthcare services. Socioeconomic status and limited availability of healthcare infrastructure are the main driving forces behind the unequal access to interventions that are crucial to achieving UHC by 2030. Finally, financial risk protection analysis shows that the poor are less likely to use healthcare services, and, once they do, they are at a greater risk of suffering financial catastrophe. Limitations of this study revolve around its correlational, rather than causal, nature.

CONCLUSIONS

We suggest a 2-pronged approach to help Myanmar achieve UHC: Government and state authorities should reduce the financial burden of seeking healthcare, and, coupled with this, significant investment in and expansion of health infrastructure and the health workforce should be made, particularly in the poorer and more remote states.

Methodological considerations for linking household and healthcare provider data for estimating effective coverage: a systematic review

OBJECTIVE

To assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit.

DESIGN

Systematic review of available literature.

DATA SOURCES

Medline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021.

ELIGIBILITY CRITERIA

Publications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates.

RESULTS

Of 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking).

CONCLUSIONS

Linking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.

Analysis of Non-Marital Fertility in Nigeria and Implications for Intervention and Future Research

Fertility and marriage are inextricably linked in sub-Saharan Africa, but recent changes, such as the rise in non-marital fertility, signals a weakening link, and the second demographic transition offers some explanations. Non-marital fertility comes with disadvantages, but it has not been adequately studied in Nigeria. Hence, this study examined the levels, patterns, and correlates of non-marital fertility, and offers implications for interventions and future research. Using data from the Nigeria Demographic and Survey 2008–2018, with a pooled weighted sample size of 11,925 unmarried women, percentage distribution was employed and a two-part model for count data was fitted, with the result showing that the level of non-marital fertility is 29%, and it is common among younger, rural dwelling, and uneducated unmarried women. The correlates of non-marital fertility include age, region of residence, level of education, religion, household wealth index, relationship status, ethnicity, work status, and age at sexual debut. Interventions to arrest rise of non-martial fertility due to its obvious disadvantages, should strengthen sexual and reproductive health programs for unmarried rural-dwelling young women, and revitalize welfare efforts for children born outside wedlock, for poor women, while future research should explore an in-depth understanding of non-marital births.

Recognizing and mediating bureaucratic barriers: increasing access to care through small private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers, making affordability a challenge. Expanding purchasing arrangements in many countries has helped integrate private providers into government-supported payment schemes and reduced financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in government-supported financing arrangements. The difficulties of this process can be exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion, effectively re-interpreting or re-making policy in practice. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and SHI officials. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a regulatory environment where regulations are weak and impermanent, officials created an accreditation process that was inconsistent and opaque: applying rules unevenly, requesting bribes, and minimizing communication with providers. The support provided by the implementing organizations clarified rules, reduced the power of local bureaucrats to apply regulations at their own discretion, gave providers greater confidence in the system, and helped to standardize the accreditation process. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses, reduce barriers to effective care expansion caused by street-level bureaucrats, and facilitate the adoption of systems which reduce rent-seeking practices that might otherwise delay or derail initiatives to reach universal health coverage.

Women Deprivation Index and Family Planning Utilisation in Urban Geography of West African Countries

Inequalities in health care utilisation and outcomes vary significantly across geographies. Though available evidence suggests disparity in contraceptive uptake in favour of urban compared with rural geographies, there are unassessed nuances among women in urban communities. This study examines some of these disparities within the context of socioeconomic deprivations and family planning utilisation among urban women in West Africa. A secondary analysis of the most recent Demographic and Health Survey dataset of five selected West African countries was conducted, using pooled data of 21,641 women aged 15-49 years. Associations between family planning utilisation and women's deprivation status were investigated using a binary logistic regression model. The findings show that more than one-quarter of the women were severely deprived across the countries except Senegal (17.4%), and the severely deprived consistently have relatively low contraceptive prevalence rates (CPR) (16.0-24.3%) compared with women with no/low deprivation across the countries except Senegal (39.8%). The results for long-acting reversible contraceptives (LARC) were not consistent across the five countries: whereas, LARC utilisation was lower among severely deprived women in Nigeria (9.1%), Guinea (9.6%), and Mali (19.3%), utilisation was similar across the deprivation groups in Benin and Senegal. In the multivariable analyses, the log-odds of modern contraceptive utilisation decreases by 0.27 among the moderately deprived (ß = -0.27, SE = 0.05, p < 0.01) and by 0.75 among the severely deprived women (ß = -0.75, SE = 0.05, p < 0.01) compared with those with no/low deprivation, with variations across the countries. Similarly, the log-odds of LARC utilisation decreases by 0.44-0.72 among the severely deprived women compared with those with no/low deprivation across the countries except Senegal. This study concluded that family planning intervention programmes and policies need to underscore the deprivation context of urban geographies, particularly among women living in informal settlements.

Standard Survey Data: Insights Into Private Sector Utilization

Universal Health Coverage in Low- and Middle-Income Countries is increasingly expanding through incorporation of private clinics, pharmacies, and hospitals into an overall health system funded in whole or part through government-managed health insurance. This underscores the importance of policies on health provision which apply across the whole delivery system regardless of ownership status. To advance understanding of private-sector policies, and to facilitate sharing of lessons across countries with similar public-private distributions, we have analyzed data on the source of inpatient and outpatient care from 65 countries. While past studies have conducted similar analysis, ours advances the field in two ways. First, we limit our analysis to data sets from 2010 through 2019, making our study more up-to-date than past studies, while changing health seeking patterns for maternal health since 2010 means that our data set is more representative of overall inpatient care. Second, while past multi-country analysis of public-private ownership have been based on the Demographic Health Surveys, we have added to this data from the Multiple Indicator Cluster Surveys, significantly increasing the countries in our analysis. We have aggregated our analysis by WHO's regions. Outside of the EURO region, where the private sector delivers just 4% of all healthcare services, the private sector remains significant, and in many countries represents more than half of all care. The private sector provides nearly 40% of all healthcare in PAHO, AFRO, and WPRO regions, 57% in SEARO, and 62% in EMRO. While specific countries with two recent surveys show variation in the scale of both inpatient and outpatient private provision, we did not find regional or global trends toward or away from private care within LMICs. Private inpatient care is most important for the wealthy in many countries; public vs. private care varies less, by wealth, for outpatient services.

Primary healthcare and child and maternal health in the Middle East and North Africa (MENA): A retrospective analysis of 29 national survey data from 13 countries

The objective of this paper is three-fold: (i) to analyse the coverage and equity of access to selected maternal and child healthcare interventions, particularly those delivered in Primary Healthcare (PHC) setting; (ii) to analyse the main drivers of inequitable access to selected interventions; and (iii) to synthesise and compare the results across the Middle East and North Africa (MENA) region as well as over time. We analysed data for five key maternal and child healthcare interventions from 29 national surveys (DHS and MICS) covering 13 MENA countries and spanning a period of almost 20 years (2000–2018). We calculated coverage indicators, concentration indices (CI) and decomposition of CIs according to standard definitions. We synthetized the results by country groups based on their human development index (HDI). Over time and among countries that started from a lower base, there has been an improvement in coverage and equity of selected interventions (four ante-natal care visits and skilled birth assistance). When considering the place of skilled delivery, there is a clear rich-poor divide, with women from richer wealth quintiles gravitating toward private healthcare facilities and those from poorer wealth quintiles toward public ones. While most of the care-seeking for common child illnesses occurs in PHC facilities, a fraction (20–30 percent) of care-seeking takes place in secondary healthcare facilities. PHC has played a role in improving coverage and equity of access in key maternal and child health interventions in the wider MENA region. Better integration of care, strengthening and improving the PHC network could increase the use of cost-effective interventions, which are key to improving maternal and child health.

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Over time, there has been an increase in the coverage of selected interventions delivered in PHC setting coupled with an increase in equity of access.

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Except in the low HDI countries, there is clear split indicating pro-rich inequity in delivery at private secondary healthcare facilities and pro-poor inequity in delivery at public ones.

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A fraction of care (about 20–30 percent) for common childhood illnesses takes place in secondary healthcare facilities.

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Richer households are more likely to seek care for the common child illnesses in private healthcare facilities (primary and secondary) while poorer ones are more likely to go in public healthcare facilities.

'They say we are money minded' exploring experiences of formal private for-profit health providers towards contribution to pro-poor access in post conflict Northern Uganda

Background: The perception within literature and populace is that the private for-profit sector is for the rich only, and this characteristic results in behaviours that hinder advancement of Universal health coverage (UHC) goals. The context of Northern Uganda presents an opportunity for understanding how the private sector continues to thrive in settings with high poverty levels and history of conflict.Objective: The study aimed at understanding access mechanisms employed by the formal private for-profit providers (FPFPs) to enable pro-poor access to health services in post conflict Northern Uganda.Methods: Data collection was conducted in Gulu municipality in 2015 using Organisational survey of 45 registered formal private for-profit providers (FPFPs),10 life histories, and 13 key informant interviews. Descriptive statistics were generated for the quantitative findings whereas qualitative findings were analysed thematically.Results: FPFPs pragmatically employed various access mechanisms and these included fee exemptions and provision of free services, fee reductions, use of loan books, breaking down doses and partial payments. Most mechanisms were preceded by managers' subjective identification of the poor, while operationalisation heavily depended on the managers' availability and trust between the provider and the customer. For a few FPFPs, partnerships with Non-governmental organisations (NGOs) and government enabled provision of free, albeit mainly preventive services, including immunisation, consultations, screening for blood pressure and family planning. Challenges such as quality issues, information asymmetry and standardisation of charges arose during implementation of the mechanisms.Conclusion: The identification of the poor by the FPFPs was subjective and unsystematic. FPFPs implemented various innovations to ensure pro-poor access to health services. However, they face a continuous dilemma of balancing the profit maximization and altruism objectives. Implementation of some pro-poor mechanisms raises concerns included those related to quality and standardisation of pricing.

Utilization of Private Sector Family Planning Services in Malaysia

BACKGROUND

The private sector is playing an increasingly important role in family planning services globally. The active participation of private providers is associated with a higher contraceptive prevalence rate.

OBJECTIVES

To examine the differentials and determinants of the utilization of private providers for family planning services.

METHOD

This study used the 2014 Malaysian Population and Family Survey data. Cross-tabulations and logistic regression were performed on 1,817 current users of modern methods.

RESULTS

Overall, 26% of modern method users obtained their supplies from private clinics/pharmacies and 15.2% from other sources, such as drug stores and sundry shops. The odds of utilizing the private sector for family planning services differ significantly across regions and socio-economic groups. The odds of obtaining supply from the private clinics/pharmacies were higher among the Chinese and urban women (AOR > 1), and it was lower among those from the eastern region (AOR = 0.47, 95% CI = 0.30-0.73). Non-Bumiputera, urban, higher educated, and working women, and those whose husbands decided on family planning had higher odds of obtaining the supply from the other sources (AOR > 1).

CONCLUSION

The private sector complements and supplements the public sector in providing family planning services to the public.

Using the Demographic Health Survey wealth index to create family planning market segments based on absolute income levels

Family planning market segmentation approaches typically include analysis by wealth, particularly when considering whether individuals can afford out-of-pocket expenses in the private sector. Most commonly, this is done using the Demographic and Health Survey (DHS) wealth index, which uses a relative approach by summing household asset questions and categorising respondents into five groups from poorest to wealthiest within a country. In addition, the use of absolute measures, such as segmenting populations based on whether one lives below or above the International Poverty line, defined by the World Bank as US$1.90 per person per day, may provide further useful insights when designing strategies to ensure access to family planning. While such measures are not readily available in the DHS, a simple approach can be used to combine the wealth index and World Bank poverty lines to generate an absolute measure for an additional perspective when conducting family planning market segmentation. Family planning market size estimates were made for 24 low-income countries using wealth quintiles and World Bank poverty lines. The results show large variations in market size based on what measure is used, particularly for countries with a high density of poverty. Looking at both types of measures and understanding the reasons for the differences in market size estimates between the approaches can help lend a more nuanced understanding of the distribution of wealth and income in a country, leading to improved family planning market segmentation and ultimately to ensure more women have access to a method of their choice.

Factors Influencing Unintended Pregnancies amongst Adolescent Girls and Young Women in Cambodia

Background: Unintended pregnancies in Cambodian youth are a major reproductive health concern with detrimental personal and socioeconomic consequences. A social ecological model was used to identify sociodemographic factors potentially associated with unintended pregnancies, and an analysis of data from the 2014 Cambodian Demographic and Health Survey was used to determine associations. Methods: Weighted data were analysed using multiple logistic regression analyses for 3406 Cambodian sexually active single, in union or married females aged 15–29 years. Results: The prevalence of unintended pregnancy was 12.3%. Unintended pregnancy was significantly associated with younger age groups (15–24 years), multiparity, history of abortion, and current use of modern contraceptive methods. All women had an increased likelihood of unintended pregnancy when the husband alone or someone else in the household made decisions about their access to healthcare. Conclusion: The burden of unintended pregnancies is associated with young age, multiparity, history of abortions, unemployment, and low autonomy for accessing healthcare. Multi-pronged, holistic reproductive and sexual health program interventions are needed to increase literacy and accessibility to modern contraception and to raise awareness about women’s health and status in Cambodia.

Equitable coverage? The roles of the private and public sectors in providing maternal, newborn and child health interventions in South Asia

Introduction

The private sector accounts for an important share of health services available in South Asia. It is not known to what extent socioeconomic and urban–rural inequalities in maternal, newborn and child health (MNCH) interventions are being affected by the presence of private providers.

Methods

Nationally representative surveys carried out from 2009 to 2015 were analysed for seven of the eight countries in South Asia, as data for Sri Lanka were not available. The outcomes studied included antenatal care (four or more visits), institutional delivery, early initiation of breast feeding, postnatal care for babies, and careseeking for diarrhoea and pneumonia. Results were stratified according to quintiles of household wealth and urban–rural residence.

Results

At regional level, the public sector played a larger role than the private sector in providing antenatal (24.8% vs 15.6% coverage), delivery (51.9% vs 26.8%) and postnatal care (15.7% vs 8.2%), as well as in the early initiation of breast feeding (26.1% vs 11.1%). The reverse was observed in careseeking for diarrhoea (15.0% and 46.2%) and pneumonia (18.2% and 50.5%). In 28 out of 37 possible analyses of coverage by country, socioeconomic inequalities were significantly wider in the private than in the public sector, and in only four cases the reverse pattern was observed. In 20 of the 37 analyses, the public sector was also more likely to be used by the wealthiest women and children.

Conclusion

The private sector plays a substantial role in delivering MNCH interventions in South Asia but is more inequitable than the public sector.

Who Serves the Poor? An Equity Analysis of Public and Private Providers of Family Planning and Child Health Services in Kenya

Understanding differences in the wealth status of patients can inform planning decisions aimed at providing affordable access to high quality care to all. This study assesses differences in the wealth status of clients of family planning and child health services by health sector. It also describes reason for facility choice, cost of services, and the proportion of additional clients of these services, and assesses if there are any differences by health sector.

A cross-sectional survey of 2,173 clients from 96 health facilities in urban areas of 6 counties in Kenya was conducted, stratified by health facility type. The 4 strata were public, faith-based, private for profit, and social franchise. Client wealth was benchmarked to the national and urban population of the 2014 Kenya Demographic and Health Survey (DHS), and assessed using the EquityTool.

There were significant differences in the client wealth distribution between facility types, and public sector facilities served a significantly higher proportion of poor clients than other types of facilities. In all three non-public facility types, more than 25% of clients were from the poorest two wealth quintiles, without significant differences between facility types. No facility type stands out as expanding access to health services more than another.

Results show that social franchises do better at reaching the poor than earlier studies have indicated, though not as well as faith-based and public facilities. Findings suggest that private providers remain important within the larger health system, more so for family planning than childhood illness management. In urban areas with significant facility choice, this study quantifies differences in client wealth across four health sectors. Incorporating these findings into policy and programmatic interventions can improve equity in access to and use of quality health services.