By Atsumi Hirose (Karolinska Institutet), Julia Hussein (University of Aberdeen), Ibrahim Yisa (Partnership for Transforming Health Systems II)
Private sector for universal health coverage
One of the targets of Sustainable Development Goal (SDG) 3 is to achieve universal health coverage, which includes ensuring access to quality maternal health care services for every pregnant woman. Universal coverage of quality maternal health care such as skilled attendance is key to reducing maternal and newborn mortality. In Sub-Saharan Africa, where resources are insufficient in the public sector, coverage of skilled attendance is generally low, at about 52% in 2014 and maternal mortality remains high, hovering at 547 deaths per 100,000 live births in 2015. To tackle this problem, health ministries, donors and programme planners are considering engaging the private sector in their efforts to increase coverage of skilled attendance as a strategy because the private sector plays a significant part in the health systems in many settings.
We know that women across a range of settings use private providers for antenatal and delivery care because the private sector usually provides more flexible services. Better hospitality or birth companionship may be more easily found in the private sector. So, the adaptation of the SDG targets has increased interest in how private healthcare providers should contribute to attaining the SDG target. Among key discussions are questions on how efforts to increase coverage can ensure equitable access to care in the public-private mixed health systems, and whether the private sector provides good quality maternal health care.
Our team conducted operational research in two southern states of Lagos and Enugu in Nigeria to find out how technical quality of maternal health care services provided by private providers compares to that provided by public sector providers in public-private mixed health systems. The research indicated that technical quality of for-profit maternal health care providers was better than that of public sector providers in Lagos State, however, in Enugu State, the opposite was true. Is there any reason for these seemingly contradictory findings?
Strong public sector and regulatory frameworks may be key?
We think that the differing contexts between Enugu and Lagos states could explain the findings. In particular, a stronger public sector in Lagos in contrast to a weaker one in Enugu may provide reasons for the findings. Lagos State is a prime contributor to Nigeria’s economy with a vibrant private sector. In 2006, the Health Facility Monitoring and Accreditation Agency (HEFAMAA) was established by the Lagos State Health Sector Reform Law to improve the performance of the health system. The programme known as Partnership for Transforming Health Systems Phase II (PATHS2) further provided support to strengthen HEFAMAA in its final two years of the 8-year (2008-2016) programme, as part of its public-private partnership strategy. Lagos State’s stronger public sector may have helped to ensure that services in both the private sector and the public sector are provided with acceptable standards. In Enugu State on the other hand, provision of essential maternal health care in the public sector has been inadequate and there has not been a robust institutional framework to regulate private health provision and to ensure quality of care. As a consequence, services in the private sector were found to be even poorer than the public sector. PATHS2 only recently intervened to help expand the role of the Joint Inspectorate Division of the Ministry of Health in Enugu State.
Our explanations seem to be supported by existing literature as discussed in our paper. Literature suggests that broader structural and contextual factors such as the nature of the public sector and presence of effective regulatory practices contribute to the performance of the private sector and how it affects the entire health care system. In a setting where the public sector is strong and the private sector is regulated, the quality of care in the private sector can be as good as the public sector.
What are the implications of the study?
An important consideration emerges from our study. We think that our study tells us that good governance at local and national ministries of health and regulatory frameworks are crucial in global efforts to ensure access to quality maternal health care. To achieve universal coverage, context-sensitive, multifaceted approaches ranging from specific clinical best practices to more broad system-wide considerations may be needed.
It seems that quality of maternal health care in the private and public sectors are mutually dependent: in a setting where there is reasonably strong governance and regulatory frameworks, quality of care in the private sector appears as good as that of the public sector. In global efforts to ensure access to quality maternal health care, it may not be enough to simply implement interventions to promote best clinical practice but also those to support local governments to adapt regulatory frameworks may be necessary in public-private mixed health systems.
Image credit: Robert