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Morris G, Maliqi B, Lattof SR, Strong J, Yaqub N. Private sector quality of care for maternal, new-born, and child health in low-and-middle-income countries: a secondary review. Front Glob Womens Health 2024; 5:1369792. [PMID: 38707636 PMCID: PMC11066217 DOI: 10.3389/fgwh.2024.1369792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/21/2024] [Indexed: 05/07/2024] Open
Abstract
The private sector has emerged as a crucial source of maternal, newborn, and child health (MNCH) care in many low- and middle-income countries (LMICs). Quality within the MNCH private sector varies and has not been established systematically. This study systematically reviews findings on private-sector delivery of quality MNCH care in LMICs through the six domains of quality care (QoC) (i.e., efficiency, equity, effectiveness, people-centered care, safety, and timeliness). We registered the systematic review with PROSPERO international prospective register of systematic reviews (registration number CRD42019143383) and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses. Searches were conducted in eight electronic databases and two websites. For inclusion, studies in LMICs must have examined at least one of the following outcomes using qualitative, quantitative, and/or mixed-methods: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, quality of care, and/or experience of care including respectful care. Outcome data was extracted for descriptive statistics and thematic analysis. Of the 139 included studies, 110 studies reported data on QoC. Most studies reporting on QoC occurred in India (19.3%), Uganda (12.3%), and Bangladesh (8.8%). Effectiveness was the most widely measured quality domain with 55 data points, followed by people-centered care (n = 52), safety (n = 47), timeliness (n = 31), equity (n = 24), and efficiency (n = 4). The review showed inconsistencies in care quality across private and public facilities, with quality varying across the six domains. Factors such as training, guidelines, and technical competence influenced the quality. There were also variations in how domains like "people-centered care" have been understood and measured over time. The review underscores the need for clearer definitions of "quality" and practical QoC measures, central to the success of Sustainable Development Goals (SDGs) and equitable health outcomes. This research addresses how quality MNCH care has been defined and operationalized to understand how quality is delivered across the private health sector and the larger health system. Numerous variables and metrics under each QoC domain highlight the difficulty in systematizing QoC. These findings have practical significance to both researchers and policymakers. Systematic Review Registration https://bmjopen.bmj.com/content/10/2/e033141.long, Identifier [CRD42019143383].
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Affiliation(s)
- Georgina Morris
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Joe Strong
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Nuhu Yaqub
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
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Wagner Z, Mohanan M, Zutshi R, Mukherji A, Sood N. What drives poor quality of care for child diarrhea? Experimental evidence from India. Science 2024; 383:eadj9986. [PMID: 38330118 DOI: 10.1126/science.adj9986] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/08/2023] [Indexed: 02/10/2024]
Abstract
Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.
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Affiliation(s)
- Zachary Wagner
- Department of Economics, Sociology and Statistics, RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Rushil Zutshi
- Department of Economics, Sociology and Statistics, RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Arnab Mukherji
- Center for Public Policy, Indian Institute of Management Bangalore, Bangalore, Karnataka, India
| | - Neeraj Sood
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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Wagner Z, Banerjee S, Mohanan M, Sood N. Does the market reward quality? Evidence from India. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:467-505. [PMID: 36477343 DOI: 10.1007/s10754-022-09341-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
There are two salient facts about health care in low and middle-income countries; (1) the private sector plays an important role and (2) the care provided is often of poor quality. Despite these facts we know little about what drives quality of care in the private sector and why patients seek care from poor quality providers. We use two field studies in India that provide insight into this issue. First, we use a discrete choice experiment to show that patients strongly value technical quality. Second, we use standardized patients to show that better quality providers are not able to charge higher prices. Instead providers are able to charge higher prices for elements of quality that the patient can observe, which are less important for health outcomes. Future research should explore whether accessible information on technical quality of local providers can shift demand to higher quality providers and improve health outcomes.
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Affiliation(s)
| | | | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Neeraj Sood
- Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
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Lall D, Balachandra SS, Prabhu P, Kumar D, Mokashi T, Devadasan N. Lessons for the Design of Comprehensive Primary Healthcare in India: A Qualitative Study. JOURNAL OF HEALTH MANAGEMENT 2022. [DOI: 10.1177/09720634221076238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health systems with strong comprehensive primary health care (CPHC) are known to result in better health outcomes for people. In India, there is a recent push to strengthen CPHC through Ayushman Bharat. This study aimed to document lessons from successful CPHC initiatives in rural and urban India using a qualitative case study approach. A total of 72 CPHC initiatives were identified through desk review and 12 of these were studied as cases. The following two main models of CPHC delivery were seen in India: (a) a hospital or health centre with outreach and (b) social franchising model, prevalent in rural and urban contexts, respectively. Themes identified were related to organisation of services, workforce, financing and challenges in practice. Services being comprehensive, dialoguing with the community, addressing social determinants were themes under organisation of services. There is need for more generalists and training health professionals towards CPHC. Financing of CPHC especially in the rural context remains a major challenge and cannot be sustained with user fees. Leadership, values, team-based care and organisational culture play a vital role in the delivery of good quality CPHC. These findings contribute to the literature on what works and why, which could be used to design CPHC in India.
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Affiliation(s)
- Dorothy Lall
- Department of Community Health, Christian Medical College Vellore, Chittoor, Andhra Pradesh, India
- Institute of Public Health, Bengaluru, Karnataka, India
| | | | - Priya Prabhu
- Institute of Public Health, Bengaluru, Karnataka, India
| | | | | | - N Devadasan
- Institute of Public Health, Bengaluru, Karnataka, India
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Novel Privacy Preserving Non-Invasive Sensing-Based Diagnoses of Pneumonia Disease Leveraging Deep Network Model. SENSORS 2022; 22:s22020461. [PMID: 35062422 PMCID: PMC8781561 DOI: 10.3390/s22020461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/21/2022]
Abstract
This article presents non-invasive sensing-based diagnoses of pneumonia disease, exploiting a deep learning model to make the technique non-invasive coupled with security preservation. Sensing and securing healthcare and medical images such as X-rays that can be used to diagnose viral diseases such as pneumonia is a challenging task for researchers. In the past few years, patients’ medical records have been shared using various wireless technologies. The wireless transmitted data are prone to attacks, resulting in the misuse of patients’ medical records. Therefore, it is important to secure medical data, which are in the form of images. The proposed work is divided into two sections: in the first section, primary data in the form of images are encrypted using the proposed technique based on chaos and convolution neural network. Furthermore, multiple chaotic maps are incorporated to create a random number generator, and the generated random sequence is used for pixel permutation and substitution. In the second part of the proposed work, a new technique for pneumonia diagnosis using deep learning, in which X-ray images are used as a dataset, is proposed. Several physiological features such as cough, fever, chest pain, flu, low energy, sweating, shaking, chills, shortness of breath, fatigue, loss of appetite, and headache and statistical features such as entropy, correlation, contrast dissimilarity, etc., are extracted from the X-ray images for the pneumonia diagnosis. Moreover, machine learning algorithms such as support vector machines, decision trees, random forests, and naive Bayes are also implemented for the proposed model and compared with the proposed CNN-based model. Furthermore, to improve the CNN-based proposed model, transfer learning and fine tuning are also incorporated. It is found that CNN performs better than other machine learning algorithms as the accuracy of the proposed work when using naive Bayes and CNN is 89% and 97%, respectively, which is also greater than the average accuracy of the existing schemes, which is 90%. Further, K-fold analysis and voting techniques are also incorporated to improve the accuracy of the proposed model. Different metrics such as entropy, correlation, contrast, and energy are used to gauge the performance of the proposed encryption technology, while precision, recall, F1 score, and support are used to evaluate the effectiveness of the proposed machine learning-based model for pneumonia diagnosis. The entropy and correlation of the proposed work are 7.999 and 0.0001, respectively, which reflects that the proposed encryption algorithm offers a higher security of the digital data. Moreover, a detailed comparison with the existing work is also made and reveals that both the proposed models work better than the existing work.
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Cheng W, Zhang Z, Hoelzer S, Tang W, Liang Y, Du Y, Xue H, Zhou Q, Yip W, Ma X, Tian J, Sylvia S. Evaluation of a village-based digital health kiosks program: A protocol for a cluster randomized clinical trial. Digit Health 2022; 8:20552076221129100. [PMID: 36211797 PMCID: PMC9537487 DOI: 10.1177/20552076221129100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background To address disparities in healthcare quality and access between rural and
urban areas in China, reforms emphasize strengthening primary care and
digital health utilization. Yet, evidence on digital health approaches in
rural areas is lacking. Objective This study will evaluate the effectiveness of Guangdong Second Provincial
General Hospital's Digital Health Kiosk program, which uses the Dingbei
telemedicine platform to connect rural clinicians to physicians in
upper-level health facilities and provide access to artificial
intelligence-enabled diagnostic support. We hypothesize that our
interventions will increase healthcare utilization and patient satisfaction,
decrease out-of-pocket costs, and improve health outcomes. Methods This cluster randomized control trial will enroll clinics according to a
partial factorial design. Clinics will be randomized to either a control arm
with clinician medical training, a second arm additionally receiving Dingbei
telemedicine training, or a third arm with monetary incentives for patient
visits conducted through Dingbei plus all prior interventions. Clinics in
the second and third arm will then be orthogonally randomized to a social
marketing arm that targets villager awareness of the kiosk program. We will
use surveys and Dingbei administrative data to evaluate clinic utilization,
revenue, and clinician competency, as well as patient satisfaction and
expenses. Results We have received ethical approval from Guangdong Second Provincial General
Hospital (IRB approval number: GD2H-KY IRB-AF-SC.07-01.1), Peking University
(IRB00001052-21007), and the University of North Carolina at Chapel Hill
(323385). Study enrollment began April 2022. Conclusions This study has the potential to inform future telemedicine approaches and
assess telemedicine as a method to address disparities in healthcare
access. Trial registration number: ChiCTR2100053872
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Affiliation(s)
- Weibin Cheng
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China.,School of Data Science, City University of Hong Kong, Kowloon, Hong Kong
| | - Zhang Zhang
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Samantha Hoelzer
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Weiming Tang
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Institute for Global Health and Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Yizhi Liang
- University of North Carolina at Chapel Hill Project-China, Guangzhou, China.,Department of Global Health and Population, Harvard University, Boston, USA
| | - Yumeng Du
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China.,University of North Carolina at Chapel Hill Project-China, Guangzhou, China
| | - Hao Xue
- Stanford Center for China's Economy and Institutions, Stanford University, Stanford, USA
| | - Qiru Zhou
- Internet Hospital, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Winnie Yip
- Department of Global Health and Population, Harvard University, Boston, USA
| | - Xiaochen Ma
- China Center for Health Development Studies, Peking University, Beijing, China
| | - Junzhang Tian
- Institute for the Application of Artificial Intelligence in Healthcare, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Sean Sylvia
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Mumtaz Z. Midwives providing maternal health services to poor women in the private sector: is it a financially feasible model? Health Policy Plan 2021; 36:913-922. [PMID: 33942090 DOI: 10.1093/heapol/czab035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 11/15/2022] Open
Abstract
Governments in many low- and middle-income countries have increasingly turned to the private sector to address the gap in skilled birth attendance in rural areas. They draw on limited, but emerging evidence that the poor also seek private healthcare services. A question not addressed in this policy and strategy is: Can poor women pay the fees required for private-sector maternity care providers to financially sustain their practices? This article examined the financial viability of private-sector midwifery practices established to provide skilled birth services to Afghan refugee women in Baluchistan, Pakistan. An international non-governmental organization established 45 midwifery practices as part of a poverty alleviation project aimed at providing market-based solutions for female poverty. A retrospective micro-cost analysis was conducted on a sample of 11 practices. In-depth interviews were conducted with 33 stakeholders to explore the midwives' experiences of operating private practices, and the facilitators and barriers they experienced. The single midwife-practices saw a mean of 8.7 ANC patients (range 1-19), attended 2.9 births (range 0-10) and provided care to 1.6 postnatal patients (range 0-7). The average net income of the 11 practices in May 2014 was US$81, but the median was just US$12. To contextualize these incomes, the midwives earned, on average, 25% of Pakistan's minimum monthly living wage. The financial analysis showed only 3 out of 11 sampled practices could be considered financially viable. The qualitative data revealed that even in practices with reasonable client volumes, the patients' inability to pay was the critical factor in the midwife practices' low net incomes. The research provides empirical evidence of a potential pitfall of private funding models in resource-poor settings where providers rely on impoverished clients to pay user-fees. Such financial models essentially shift the government's responsibility to provide safe childbirth services onto providers who can least afford to offer such care.
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Affiliation(s)
- Zubia Mumtaz
- School of Public Health, University of Alberta, 3-309 Edmonton Clinic Health Academy, 11405-87 Ave, Edmonton, AB T6G 1C9, Canada
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8
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Rao KD, Kaur J, Peters MA, Kumar N, Nanda P. Pandemic response in pluralistic health systems: a cross-sectional study of COVID-19 knowledge and practices among informal and formal primary care providers in Bihar, India. BMJ Open 2021; 11:e047334. [PMID: 33931411 PMCID: PMC8098292 DOI: 10.1136/bmjopen-2020-047334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Responding to pandemics is challenging in pluralistic health systems. This study assesses COVID-19 knowledge and case management of informal providers (IPs), trained practitioners of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy (AYUSH) and Bachelor of Medicine, Bachelor of Surgery (MBBS) medical doctors providing primary care services in rural Bihar, India. DESIGN This was a cross-sectional study of primary care providers conducted via telephone between 1 and 15 July 2020. SETTING Primary care providers from 224 villages in 34 districts across Bihar, India. PARTICIPANTS 452 IPs, 57 AYUSH practitioners and 38 doctors (including 23 government doctors) were interviewed from a census of 1138 primary care providers used by community members that could be reached by telephone. PRIMARY OUTCOME MEASURES Providers were interviewed using a structured questionnaire with choice-based answers to gather information on (1) change in patient care seeking, (2) source of COVID-19 information, (3) knowledge on COVID-19 spread, symptoms and methods for prevention and (4) clinical management of COVID-19. RESULTS During the early days of the COVID-19 pandemic, 72% of providers reported a decrease in patient visits. Most IPs and other private primary care providers reported receiving no COVID-19 related engagement with government or civil society agencies. For them, the principal source of COVID-19 information was television and newspapers. IPs had reasonably good knowledge of typical COVID-19 symptoms and prevention, and at levels similar to doctors. However, there was low stated compliance among IPs (16%) and qualified primary care providers (15% of MBBS doctors and 12% of AYUSH practitioners) with all WHO recommended management practices for suspect COVID-19 cases. Nearly half of IPs and other providers intended to treat COVID-19 suspects without referral. CONCLUSIONS Poor management practices of COVID-19 suspects by rural primary care providers weakens government pandemic control efforts. Government action of providing information to IPs, as well as engaging them in contact tracing or public health messaging can strengthen pandemic control efforts.
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Affiliation(s)
- Krishna D Rao
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Japneet Kaur
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Michael A Peters
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Priya Nanda
- Bill and Melinda Gates Foundation India, New Delhi, Delhi, India
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Fry MW, Saidi S, Musa A, Kithyoma V, Kumar P. "Even though I am alone, I feel that we are many" - An appreciative inquiry study of asynchronous, provider-to-provider teleconsultations in Turkana, Kenya. PLoS One 2020; 15:e0238806. [PMID: 32931503 PMCID: PMC7491713 DOI: 10.1371/journal.pone.0238806] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 08/23/2020] [Indexed: 01/29/2023] Open
Abstract
Non-physician clinicians (NPCs) in low and middle-income countries (LMICs) often have little physical proximity to the resources-equipment, supplies or skills-needed to deliver effective care, forcing them to refer patients to distant sites. Unlike equipment or supplies, which require dedicated supply chains, physician/specialist skills needed to support NPCs can be sourced and delivered through telecommunication technologies. In LMICs however, these skills are scarce and sparsely distributed, making it difficult to implement commonly used real-time (synchronous), hub-and-spoke telemedicine paradigms. An asynchronous teleconsultations service was implemented in Turkana County, Kenya, connecting NPCs with a volunteer network of remote physicians and specialists. In 2017-18, the service supported over 100 teleconsultations and referrals across 20 primary healthcare clinics and two hospitals. This qualitative study aimed to explore the impact of the telemedicine intervention on health system stakeholders, and perceived health-related benefits to patients. Data were collected using Appreciative Inquiry, a strengths-based, positive approach to assessing interventions and informing systems change. We highlight the impact of provider-to-provider asynchronous teleconsultations on multiple stakeholders and healthcare processes. Provider benefits include improved communication and team work, increased confidence and capacity to deliver services in remote sites, and professional satisfaction for both NPCs and remote physicians. Health system benefits include efficiency improvements through improved care coordination and avoiding unnecessary referrals, and increased equity and access to physician/specialist care by reducing geographical, financial and social barriers. Providers and health system managers recognised several non-health benefits to patients including increased trust and care seeking from NPCs, and social benefits of avoiding unnecessary referrals (reduced social disruption, displacement and costs). The findings reveal the wider impact that modern teleconsultation services enabled by mobile technologies and algorithms can have on LMIC communities and health systems. The study highlights the importance of viewing provider-to-provider teleconsultations as complex health service delivery interventions with multiple pathways and processes that can ultimately improve health outcomes.
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Affiliation(s)
| | | | - Abdirahman Musa
- Ministry of Health Services & Sanitation, Turkana County, Kenya
| | | | - Pratap Kumar
- Health-E-Net Limited, Nairobi, Kenya
- Institute of Healthcare Management, Strathmore University Business School, Nairobi, Kenya
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Penn-Kekana L, Powell-Jackson T, Haemmerli M, Dutt V, Lange IL, Mahapatra A, Sharma G, Singh K, Singh S, Shukla V, Goodman C. Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India. Implement Sci 2018; 13:124. [PMID: 30249294 PMCID: PMC6154932 DOI: 10.1186/s13012-018-0813-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A prominent strategy to engage private sector health providers in low- and middle-income countries is clinical social franchising, an organisational model that applies the principles of commercial franchising for socially beneficial goals. The Matrika programme, a multi-faceted social franchise model to improve maternal health, was implemented in three districts of Uttar Pradesh, India, between 2013 and 2016. Previous research indicates that the intervention was not effective in improving the quality and coverage of maternal health services at the population level. This paper reports findings from an independent external process evaluation, conducted alongside the impact evaluation, with the aim of explaining the impact findings. It focuses on the main component of the programme, the "Sky" social franchise. METHODS We first developed a theory of change, mapping the key mechanisms through which the programme was hypothesised to have impact. We then undertook a multi-methods study, drawing on both quantitative and qualitative primary data from a wide range of sources to assess the extent of implementation and to understand mechanisms of impact and the role of contextual factors. We analysed the quantitative data descriptively to generate indicators of implementation. We undertook a thematic analysis of the qualitative data before holding reflective meetings to triangulate across data sources, synthesise evidence, and identify the main findings. Finally, we used the framework provided by the theory of change to organise and interpret our findings. RESULTS We report six key findings. First, despite the franchisor achieving its recruitment targets, the competitive nature of the market for antenatal care meant social franchise providers achieved very low market share. Second, all Sky health providers were branded but community awareness of the franchise remained low. Third, using lower-level providers and community health volunteers to encourage women to attend franchised antenatal care services was ineffective. Fourth, referral linkages were not sufficiently strong between antenatal care providers in the franchise network and delivery care providers. Fifth, Sky health providers had better knowledge and self-reported practice than comparable health providers, but overall, the evidence pointed to poor quality of care across the board. Finally, telemedicine was perceived by clients as an attractive feature, but problems in the implementation of the technology meant its effect on quality of antenatal care was likely limited. CONCLUSIONS These findings point towards the importance of designing programmes based on a strong theory of change, understanding market conditions and what patients value, and rigorously testing new technologies. The design of future social franchising programmes should take account of the challenges documented in this and other evaluations.
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Affiliation(s)
- Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Varun Dutt
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Isabelle L. Lange
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Gaurav Sharma
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Kultar Singh
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | | | - Vasudha Shukla
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Mumtaz Z. Setting the record straight on social franchising – Author's reply. THE LANCET GLOBAL HEALTH 2018; 6:e612. [DOI: 10.1016/s2214-109x(18)30191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/14/2018] [Indexed: 10/16/2022] Open
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Mohanan M, Hay K, Mor N. Quality Of Health Care In India: Challenges, Priorities, And The Road Ahead. Health Aff (Millwood) 2018; 35:1753-1758. [PMID: 27702945 DOI: 10.1377/hlthaff.2016.0676] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
India's health care sector provides a wide range of quality of care, from globally acclaimed hospitals to facilities that deliver care of unacceptably low quality. Efforts to improve the quality of care are particularly challenged by the lack of reliable data on quality and by technical difficulties in measuring quality. Ongoing efforts in the public and private sectors aim to improve the quality of data, develop better measures and understanding of the quality of care, and develop innovative solutions to long-standing challenges. We summarize priorities and the challenges faced by efforts to improve the quality of care. We also highlight lessons learned from recent efforts to measure and improve that quality, based on the articles on quality of care in India that are published in this issue of Health Affairs The rapidly changing profile of diseases in India and rising chronic disease burden make it urgent for state and central governments to collaborate with researchers and agencies that implement programs to improve health care to further the quality agenda.
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Affiliation(s)
- Manoj Mohanan
- Manoj Mohanan is an assistant professor of public policy and economics in the Sanford School of Public Policy at Duke University, an assistant research professor at the Duke Global Health Institute, and faculty research scholar at the Duke Population Research Institute, all in Durham, North Carolina
| | - Katherine Hay
- Katherine Hay is deputy director of the Bill & Melinda Gates Foundation India, in New Delhi
| | - Nachiket Mor
- Nachiket Mor is director of the Bill & Melinda Gates Foundation India
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Effect of a multifaceted social franchising model on quality and coverage of maternal, newborn, and reproductive health-care services in Uttar Pradesh, India: a quasi-experimental study. LANCET GLOBAL HEALTH 2018; 6:e211-e221. [DOI: 10.1016/s2214-109x(17)30454-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 10/26/2017] [Accepted: 11/10/2017] [Indexed: 11/23/2022]
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Kostyak L, Shaw DM, Elger B, Annaheim B. A means of improving public health in low- and middle-income countries? Benefits and challenges of international public-private partnerships. Public Health 2017; 149:120-129. [PMID: 28595064 DOI: 10.1016/j.puhe.2017.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/08/2017] [Accepted: 03/09/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE In the last two decades international public-private partnerships have become increasingly important to improving public health in low- and middle-income countries. Governments realize that involving the private sector in projects for financing, innovation, development, and distribution can make a valuable contribution to overcoming major health challenges. Private-public partnerships for health can generate numerous benefits but may also raise some concerns. To guide best practice for public-private partnerships for health to maximize benefits and minimize risks, the first step is to identify potential benefits, challenges, and motives. We define motives as the reasons why private partners enter partnerships with a public partner. STUDY DESIGN We conducted a systematic review of the literature using the PRISMA guidelines. METHOD We reviewed the literature on the benefits and challenges of public-private partnerships for health in low- and middle-income countries provided by international pharmaceutical companies and other health-related companies. We provide a description of these benefits, challenges, as well as of motives of private partners to join partnerships. An approach of systematic categorization was used to conduct this research. RESULT We identified six potential benefits, seven challenges, and three motives. Our main finding was a significant gap in the available academic literature on this subject. Further empirical research using both qualitative and quantitative approaches is required. From the limited information that is readily available, we conclude that public-private partnerships for health imply several benefits but with some noticeable and crucial limitations. CONCLUSION In this article, we provide a description of these benefits and challenges, discuss key themes, and conclude that empirical research is required to determine the full extent of the challenges addressed in the literature.
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Affiliation(s)
- L Kostyak
- Institute for Biomedical Ethics, University of Basel, Spalenring 73, CH-4055, Basel, Switzerland.
| | - D M Shaw
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, CH-4056, Basel, Switzerland.
| | - B Elger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, CH-4056, Basel, Switzerland.
| | - B Annaheim
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, CH-4056, Basel, Switzerland.
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Mohanan M, Giardili S, Das V, Rabin TL, Raj SS, Schwartz JI, Seth A, Goldhaber-Fiebert JD, Miller G, Vera-Hernández M. Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India. Bull World Health Organ 2017; 95:343-352E. [PMID: 28479635 PMCID: PMC5418816 DOI: 10.2471/blt.16.179556] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 12/20/2016] [Accepted: 01/31/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke University, 302 Towerview Drive, 128 Rubenstein Hall, Durham, North Carolina, NC 27708, United States of America (USA)
| | - Soledad Giardili
- Department of Economics, Queen Mary University of London, London, England
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Tracy L Rabin
- Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Sunil S Raj
- Indian Institute of Public Health, New Delhi, India
| | - Jeremy I Schwartz
- Department of Internal Medicine, Yale University School of Medicine, New Haven, USA
| | - Aparna Seth
- Sambodhi Research and Communications Pvt. Ltd., New Delhi, India
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA
| | - Grant Miller
- Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, USA
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Mohanan M, Goldhaber-Fiebert JD, Giardili S, Vera-Hernández M. Providers' knowledge of diagnosis and treatment of tuberculosis using vignettes: evidence from rural Bihar, India. BMJ Glob Health 2016; 1:e000155. [PMID: 28588984 PMCID: PMC5321391 DOI: 10.1136/bmjgh-2016-000155] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/03/2016] [Accepted: 11/13/2016] [Indexed: 12/04/2022] Open
Abstract
Background Almost 25% of all new cases of tuberculosis (TB) worldwide are in India, where drug resistance and low quality of care remain key challenges. Methods We conducted an observational, cross-sectional study of healthcare providers' knowledge of diagnosis and treatment of TB in rural Bihar, India, from June to September 2012. Using data from vignette-based interviews with 395 most commonly visited healthcare providers in study areas, we scored providers' knowledge and used multivariable regression models to examine their relationship to providers' characteristics. Findings 80% of 395 providers had no formal medical qualifications. Overall, providers demonstrated low levels of knowledge: 64.9% (95% CI 59.8% to 69.8%) diagnosed correctly, and 21.7% (CI 16.8% to 27.1%) recommended correct treatment. Providers seldom asked diagnostic questions such as fever (31.4%, CI 26.8% to 36.2%) and bloody sputum (11.1%, CI 8.2% to 14.7%), or results from sputum microscopy (20.0%, CI: 16.2% to 24.3%). After controlling for whether providers treat TB, MBBS providers were not significantly different, from unqualified providers or those with alternative medical qualifications, on knowledge score or offering correct treatment. MBBS providers were, however, more likely to recommend referrals relative to complementary medicine and unqualified providers (23.2 and 37.7 percentage points, respectively). Interpretation Healthcare providers in rural areas in Bihar, India, have low levels of knowledge regarding TB diagnosis and treatment. Our findings highlight the need for policies to improve training, incentives, task shifting and regulation to improve knowledge and performance of existing providers. Further, more research is needed on the incentives providers face and the role of information on quality to help patients select providers who offer higher quality care.
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Affiliation(s)
- Manoj Mohanan
- Sanford School of Public Policy, Duke Global Health Institute, and Department of Economics, Duke University, Durham, North Carolina, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA
| | - Soledad Giardili
- School of Economics and Finance, Queen Mary University of London, London, UK
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