A total of 798 papers were identified through searching PubMed, Web of Science, Embase and other sources (Google Scholar, websites and reference lists of articles). After removal of duplicates, 664 records were screened for eligibility by reviewing the titles and abstracts. The full text was reviewed for 362 papers and 43 papers were finally included in the synthesis. See the flow diagram in figure 1, for more information on the process of identification of articles included in this scoping review.
Extent of utilisation of private providers for maternal and child health services in LMIC
Our findings confirm the dominant use of private health providers for outpatient care seeking, and substantial utilisation of these providers for inpatient services including child birth. Table 1 shows the studies included, and the extent of utilisation of private health providers for specific maternal and child health services including family planning services, antenatal care, delivery services and management of fever, malaria and pneumonia in children. Most of this data are multicountry data, aggregated from Demographic Health Surveys (DHS) between 2010 and 2019; and a few health facility surveys.
Using both DHS and Multiple Indicator Survey data from 65 LMIC between 2010 and 2019, Montagu and Chakraborty showed that the private sector provides nearly 40% of all healthcare in the WHO PAHO, AFRO and WPRO regions as well as 57% in the SEARO and 62% in the EMRO regions. They also showed that public and private care vary less by wealth levels for outpatient care. For inpatient care, this is predominantly used by the wealthy.6 Similarly,5 Grépin showed using aggregate data from 70 DHS surveys in LMIC that the private sector was the dominant source of care for diarrhoea and fever or cough treatment for sick children (67% and 63%, respectively); and institutional delivery—38%; antenatal care (ANC)—30%; modern contraceptives—39%.5 These findings are quite similar between all the other results from DHS surveys as in table 1, irrespective of the period of review, that about 20%–40% of deliveries occur in the private health sector12–16 and 30%–50% of all family planning commodities are obtained from private health providers.5 7 14
While the poor and wealthy equally seek outpatient care from private health providers,6 this is not the same for inpatient care, which is predominantly used by the wealthy in the private health sector.6 17 In general, as wealth levels increase, private sector utilisation increases for almost all services.5 7 15 17 18
Using world health survey data from 39 LMIC,19 Saksenaw et al determined the utilisation rates, out of pocket payment (OOP) and per visit charges for outpatient and inpatient stays in both the public and private sectors. They found that 65% of total OOP for inpatient services was paid at public health facilities and 45% of total OOP for outpatient services was also paid to public providers.19 This high OOP payment at public facilities was mainly for the purchase of medicines (and less for consultation fees), showing problems with the existing policies in many LMIC where user fees were abolished at public health facilities.
Effective private provider engagement strategies for maternal and child health services at the primary healthcare level
In general, private health providers are engaged by the public sector using two overarching approaches: either through voluntary public–private partnerships,20 21 or through mandatory approaches, for example, licensing of private providers/facilities or mandatory reporting of notifiable diseases, particularly the case of tuberculosis diagnosis, treatment and reporting (using the Global TB programme public–private mix approach).22 Various private sector engagement strategies and tools exist in the literature. Based on key literature, the consolidated scientific evidence on the strategies is presented in online supplemental table 1 as well as recommendations on how to effectively use the specific strategy. The table also provides details on the level of success with different strategies.
The results in online supplemental table 1 are mainly from published papers, particularly review papers on specific private sector engagement approaches; additional individual peer-reviewed studies as well as a few key reports from agencies and organisations that specialise in private health sector work. The literature congregates towards macrolevel (national) meso (intermediary level) and micro (individual level) influences on private health providers. The key strategies for private provider engagement identified through this review can be grouped under: financing strategies, regulatory strategies and policy (including policy development) strategies.
The financing strategies particularly include supply side strategies like contracting out, grants and loans as well as demand side strategies like vouchers and (social) health insurance. The regulatory strategies include licensing and accreditation, which are the most common as well as the less implemented but extremely effective strategies of monitoring and supervision, particularly support supervision. The policy strategies include existence of policy and/or guidelines for public private engagement, participatory policy development and effective dialogue mechanisms. Figure 2 provides a summary of the effective strategies for engaging the private sector for maternal and child health service provision, based on our evidence review and synthesis.
Figure 2Effective strategies for engaging the private sector for maternal and child health service provision.
Intermediary organisations are a dominant model used for coordination and engagement of private health providers. These are organisations that form networks between small-scale private providers in order to interact with governments, patients and vendors while performing key health systems functions that are challenging for individual private providers to do on their own. Many and diverse examples of intermediary organisations exist in the literature, and the key ones identified are social franchising networks, NGOs and faith-based organisations (FBOs), which typically create strong networks of private healthcare providers for service quality improvement, regulatory compliance and provider representation.23 24
The importance of data for understanding the private sector, its users (patients) and suppliers (providers) as well as the contextual and regulatory environment in which they operate cannot be over emphasised. Data allow policymakers to understand the private health sector, its contribution to national health goals and opportunities for better collaboration. Information exchange between the providers and regulators is, therefore, a key requirement for effective engagement. Additionally, provision of information to communities in order to empower them to make correct health choices and purchase quality health products is important. This has been done extensively through commodity social marketing (eg, for purchase of bed nets or condoms), which is the most common approach that has been used to engage private providers to sell quality products. Details of all these strategies are provided further below.
As in figure 2, engagement with private healthcare providers for effective service delivery should be undertaken at all the system levels including the macrolevel, meso and microlevels. At the macro (national) where policy development and decisions are made, these policy guidelines should be developed in collaboration with private providers and an attempt should be made to include the diverse groups of private health providers through the intermediary organisations that they subscribe to (NGOs, FBOs, Franchise organisations etc); or through their direct representatives, for example, health professional bodies. Clear mechanisms for dialogue between the providers, regulators and decision-makers are important.
At the meso (regional and district) level, it is important to again involve the private providers in the decision-making and particularly negotiation and ownership and implementation of contracts and other financial tools that are available in the system. At the individual or microlevel, various options are available for influencing the provider behaviour and service quality. These include strict enforcement of regulatory tools, for example, licensing and accreditation of providers, as well as training and support supervision.
Contracting out
Contracting out is a purchasing mechanism used to acquire specified services, of defined quality, at an agreed price, from a specific private provider and for a specific period of time. Governments may purchase clinical or non-clinical services from private providers to complement public provision. Contracting out has been shown to be effective at increasing access and use of health services, and in reducing out of pocket health expenditure in conflict or fragile states as well as in stable environments.25–28 Contracting out is no better or no worse than government health-provided services.29 See online supplemental table 1 for more detailed information based on the studies on contracting out.
Social franchising
A franchise is a contractual arrangement between a health service provider and a franchise organisation, which aims to improve access to quality and price-controlled services. Franchisees are trained in standardised practices for which prices are predefined, and they benefit from advertising the logo or franchise name. Franchising is associated with increased numbers of clients, patient satisfaction, physical accessibility and improved quality.30 Further research is needed to elucidate the effect of franchising for quality, health impact, equity, cost effectiveness, and the value of franchising in other healthcare sectors like child health.30–32
Numerous social franchising programmes already exist around the world, providing an opportunity to expand access to care rapidly and to standardise and improve the quality of care.9 32–34 This could form the basis for evaluation of private sector initiatives, provided that evaluation is built into further expansion of the social franchises.
Regulation
Regulatory interventions are used to set up and ensure adequate technical quality of service providers. Regulation involves setting rules, sanctions and ensuring adequate enforcement. Basic regulatory frameworks exist in most countries, particularly for preservice training, registration and licensing requirements for health workers and premises.35 Pharmaceutical market regulation aims to limit the availability of harmful drugs and unregistered products, minimise drug misuse, control the sale of specific drugs through prescriptions and regulate drug manufacture and importation. Regulation has a crucial balancing role within the private sector, although, inadequate resources are typically allocated for monitoring and enforcing regulations.28 36–38 Coregulation with professional associations, civil society and communities provides additional benefit.4 35 38 See online supplemental table 1 for more detailed information on the studies and recommendations related to regulation.
Drug shops as a provider of maternal and child health services
As shown in table 1, drug shops are a dominant provider of medicines and healthcare services for adults and children in LMIC, particularly antimalarial medicines, fever medication and family planning commodities. This group of providers has been effectively engaged through various ways. Training, accreditation, supervision and monitoring are effective ways of improving knowledge and compliance to guidelines when working with drug shops for improved primary healthcare outcomes.9 38–40 Organising these drug shops through intermediary organisations like franchise networks and accreditation bodies has also been effective.39 41 Programmes that include price subsidies, for example, for ACT commodities, ORS Zinc, other child health commodities and programmes which have used the integrated community case management strategy at drug shops have also been shown to be extremely effective.9 42–47 See online supplemental table 1 for detailed information on studies and recommendations on utilising drug shops for stronger health systems.
Social health insurance and maternal and child health service provision in the private sector
Through this review, we identified some papers on the role of state led and state-funded social health insurance programmes, which expand access to maternal and child health services through the private sector. The evidence provided is from eight countries in Asia based on a review, and two additional papers were from India and another paper comparing North and South Korea PHC interventions. Inclusion of private obstetricians and private health providers in public–private partnerships for provision of child birth and other health services to people with social health insurance cover has been shown to greatly increase access to healthcare at the PHC level.48–50 Government subsidised health insurance type arrangements can be effective mechanism to help countries progress towards UHC, although there is room to improve the design of these schemes.51
The role of the private sector in the provision of immunisation services
While the public sector offers vaccination services to the majority of the population in LMIC, there is some evidence on the role of the private sector in immunisation service delivery. In the low-income countries, the private-for-profit sector and the not-for-profit (NGO) sector is contributing to expanded immunisation service delivery of the traditional vaccines. In the LMICs, the for-profit sector often acts to facilitate early adoption of new vaccines and technologies before introduction by the public sector.52 53
There is one key limitation of this review. While we have searched multiple databases and other sources, the review is limited to only English-language publications. It is, therefore, possible that we have excluded relevant publications that are in other languages.
