Health Policy and Planning, Vol 13, 107-120, Copyright © 1998 by Oxford University Press
R Brugha and A Zwi
Despite significant successes in controlling a number of communicable
diseases in low and middle income countries, important challenges remain,
one being that a large proportion of patients with conditions of public
health significance, such as tuberculosis, malaria, or sexually transmitted
diseases, seek care in the largely unregulated 'for profit' private sector.
Private providers (PPs) often offer services which are perceived by users
to be more attractive. However, the available evidence suggests that
serious deficiencies in technical quality are often present. Evaluations of
interventions to promote evidence-based care in high income countries have
shown that multi-faceted strategies which increase provider knowledge have
had some success in improving service quality. A wider range of factors
need to be considered in low and middle income countries (LMICs),
especially factors which contribute to discrepancies between provider
knowledge and practice. Studies have shown that PPs, especially, perceive
or experience patient and community pressures to provide inappropriate
treatments. LMIC governments also lack the capacity to enforce regulatory
controls. Context-specific multi-faceted strategies are needed, including
the local adaptation and dissemination to providers of relevant evidence,
the education of patients and communities to adopt effect treatment-seeking
and treatment-taking behaviour, and feasible mechanisms for ensuring and
monitoring service quality, which may include a role for self-regulation by
provider organizations or provider accreditation. Developing, implementing
and evaluating strategies to improve the quality of service provision will
depend on the involvement of the key stakeholders, including policy makers
and PPs. Focusing on studies from Asia, Africa and Latin America, this
paper develops a model for identifying the influences on PPs, mainly
private medical practitioners, in their management of conditions of public
health significance. Based on this, multi-faceted strategies for improving
the quality of treatment provision are suggested. Interventions need to be
inexpensive, practical, efficient, effective and sustainable over the
medium to long term. Achieving this is a significant challenge.
ARTICLES
Improving the quality of private sector delivery of public health services: challenges and strategies
Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Correspondence to R Brugha, Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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