Strategies for engaging the private sector in sexual and reproductive health: how effective are they?

Abstract

The private health sector provides a significant portion of sexual and reproductive health (SRH) services in developing countries. Yet little is known about which strategies for intervening with private providers can improve quality or coverage of services. We conducted a systematic review of the literature through PubMed from 1980 to 2003 to assess the effectiveness of private sector strategies for SRH services in developing countries. The strategies examined were regulating, contracting, financing, franchising, social marketing, training and collaborating. Over 700 studies were examined, though most were descriptive papers, with only 71 meeting our inclusion criteria of having a private sector strategy for one or more SRH services and the measurement of an outcome in the provider or the beneficiary. Nearly all studies (96%) had at least one positive association between SRH and the private sector strategy. About three-quarters of the studies involved training private providers, though combinations of strategies tended to give better results. Maternity services were most commonly addressed (55% of studies), followed by prevention and treatment of sexually transmitted diseases (32%). Using study design to rate the strength of evidence, we found that the evidence about effectiveness of private sector strategies on SRH services is weak. Most studies did not use comparison groups, or they relied on cross-sectional designs. Nearly all studies examined short-term effects, largely measuring changes in providers rather than changes in health status or other effects on beneficiaries. Five studies with more robust designs (randomized controlled trials) demonstrated that contraceptive use could be increased through supporting private providers, and showed cases where the knowledge and practices of private providers could be improved through training, regulation and incentives. Although tools to work with the private sector offer considerable promise, without stronger research designs, key questions regarding their feasibility and impact remain unanswered.

Assessing public and private sector contributions in reproductive health financing and utilization for six sub-Saharan African countries

“…However, it is worth noting a few variations in the DHS format that impact our analysis. First, while most surveys asked about condom use among men, some did not (Malawi, 2004;Rwanda, 2000 andTanzania, 1999 and2004). To ensure consistency, the information on source of condoms in our analysis is based only on women's reporting.…”

“…Following the practice in the literature, the formal private sector in this analysis includes private facilities (hospitals and clinics), whereas the informal private sector includes a wide array of unqualified providers, such as pharmacies, drug vendors, traditional healers, traditional birth attendants (TBAs) and village doctors. [18][19][20] Table 2 gives background statistics for the six countries. All six have a high proportion of rural residents, a high population growth rate, and high maternal mortality ratios.…”

International health policy and stagnating maternal mortality: is there a causal link?

“…Peters et al 77 evaluated some 700 studies of contracting-out schemes for sexual and reproductive health services carried out between 1980 and 2003 in different regions (including maternity care, abortion, prevention or treatment of STIs and family planning). Although contracts with private sector agencies were used most frequently for maternity services (in 55% of studies analysed), these were in most cases limited to the training of traditional birth attendants (TBAs).…”

“…83 Yet public-private partnerships in reproductive and maternal health care continue to be advocated, especially in Asia. 77 Without evidence, it is possible to formulate hypotheses about other negative consequences of contracting out obstetric care. In theory, the separation of health care delivery and disease control programmes could have been avoided by contracting out both comprehensive care delivery and disease control interventions.…”

Preference for private hospital-based maternity services in inner-city Lagos, Nigeria: An observational study

“…In many of these countries especially in sub-Saharan Africa and South Asia majority of the women deliver outside health facilities without skilled attendants [4]. International efforts aimed at redressing this trend and the associated risks have largely focused on strengthening the public health systems to provide more affordable services while private health facilities are rarely targeted despite substantial evidence on the role of the private health care providers in developing countries [5][6][7][8][9]. Undoubtedly, the relative effectiveness of public and private providers for maternal and child health in developing countries has been a subject of debate for many years [5][6][7].…”