Working with private health providers to improve quality

The characteristics of healthcare providers, the demands of users and the policy environment can all influence the quality of private healthcare provision.

Private providers, especially in highly competitive environments, as in urban India, are responsive to patients' demands. Patients look for private providers who can provide those aspects of care that signal a quality service - short waiting times, respectful provider attitude, injections, and who can supply drugs at a price patients can afford.

However, limited evidence shows that technical quality is often poor, particularly among informal providers. An example is the provision of incomplete courses of treatments because poor people are less able or willing to pay for complete courses.

Studies demonstrate that a range of factors influence private providers' behaviour, including:

• a lack of essential knowledge and skills about the services that they provide. Private medical practitioners (PMPs) are usually overlooked by the public sector when disseminating information and conducting in-service training on disease management
• pharmaceutical company representatives, whose principal aim is to increase drug sales, readily fill the information vacuum. Informal providers, such as drug pedlars who often dispense drugs illegally, lack basic training to provide safe and effective treatments
• a lack of resources such as, access to laboratory services and essential drugs that are affordable to their patients.

When attempting to work with private providers, policy-makers must decide on their overall policy aims. They may wish to use the private sector to increase coverage of under-provided services, for example in supervising tuberculosis treatment. Or they may focus on improving the quality of care for services private providers are already delivering, for example treatment of suspected malaria or sexually transmitted diseases. Where private providers have a dominant role in the healthcare market, as in India where they provide about 80 per cent of ambulatory services, finding ways to work with them - to reduce harmful practices and improve quality - is a policy imperative, not an option.

Strategies for working with private providers vary by their level of complexity. One important simple strategy is information and training. This is usually the only feasible and affordable strategy for working with the informal private sector. However, its effectiveness is limited if not reinforced by more expensive strategies such as visits to providers' practices and feedback on performance. How training is conducted is likely to be important. For example, involving service users in training is effective. Insufficient attention has been given to training, given its importance in all quality assurance strategies.

Complex strategies involve major inputs of resources and include:

• direct policies like contracting and financing PMPs to provide packages of care
• indirect approaches through advertising and promoting private provider services in the community e.g. social marketing, franchising and accreditation, where an agent takes responsibility to assure the quality of the product or service provided.

The use of scarce public sector resources to promote or directly finance private sector care can provide a leverage to promote quality. However, recognising, promoting and assuring quality is more easily done with simple products, such as a condom or bednet, where the quality of the product is monitored and assured by an external body, and then can be marketed, using a recognised and trusted brand name. Complex clinical services require more sophisticated monitoring and assurance mechanisms. For example, in accreditation, private providers are expected to supply detailed information on the services provided and facilities are routinely inspected for evidence of quality indicators.

While best kept simple, reporting on these indicators requires a high level of capacity on the part of the private providers and the organisations responsible for monitoring them. In poorer countries, where the private sector is least well controlled, both it and the public sector usually lack the ability to supply, analyse and utilise the necessary information for monitoring and assuring these aspects of quality of care. Building this capacity is one of the main challenges facing policy-makers.

Ruairi Brugha
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel St
London WC1E 7HT
UK

T +44 (0)207 927 2072
Ruairi.Brugha@lshtm.ac.uk

See also
'Quality and equity of private sector care for sexually transmitted diseases in South Africa', Health Policy and Planning 17 (Suppl. 1): 40-46, by N. Chabikuli, H. Schneider, D. Blaauw, A. Zwi and R. Brugha, 202

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