Dominic Montagu

Where Do Poor Women in Developing Countries Give Birth? A Multi-Country Analysis of Demographic and Health Survey Data

Background In 2008, over 300,000 women died during pregnancy or childbirth, mostly in poor countries. While there are proven interventions to make childbirth safer, there is uncertainty about the best way to deliver these at large scale. In particular, there is currently a debate about whether maternal deaths are more likely to be prevented by delivering effective interventions through scaled up facilities or via community-based services. To inform this debate, we examined delivery location and attendance and the reasons women report for giving birth at home. Methodology/Principal Findings We conducted a secondary analysis of maternal delivery data from Demographic and Health Surveys in 48 developing countries from 2003 to the present. We stratified reported delivery locations by wealth quintile for each country and created weighted regional summaries. For sub-Saharan Africa (SSA), where death rates are highest, we conducted a subsample analysis of motivations for giving birth at home. In SSA, South Asia, and Southeast Asia, more than 70% of all births in the lowest two wealth quintiles occurred at home. In SSA, 54.1% of the richest women reported using public facilities compared with only 17.7% of the poorest women. Among home births in SSA, 56% in the poorest quintile were unattended while 41% were attended by a traditional birth attendant (TBA); 40% in the wealthiest quintile were unattended, while 33% were attended by a TBA. Seven per cent of the poorest women reported cost as a reason for not delivering in a facility, while 27% reported lack of access as a reason. The most common reason given by both the poorest and richest women for not delivering in a facility was that it was deemed “not necessary” by a household decision maker. Among the poorest women, “not necessary” was given as a reason by 68% of women whose births were unattended and by 66% of women whose births were attended. Conclusions In developing countries, most poor women deliver at home. This suggests that, at least in the near term, efforts to reduce maternal deaths should prioritize community-based interventions aimed at making home births safer.

What Is the Role of Informal Healthcare Providers in Developing Countries? A Systematic Review

Informal health care providers (IPs) comprise a significant component of health systems in developing nations. Yet little is known about the most basic characteristics of performance, cost, quality, utilization, and size of this sector. To address this gap we conducted a comprehensive literature review on the informal health care sector in developing countries. We searched for studies published since 2000 through electronic databases PubMed, Google Scholar, and relevant grey literature from The New York Academy of Medicine, The World Bank, The Center for Global Development, USAID, SHOPS (formerly PSP-One), The World Health Organization, DFID, Human Resources for Health Global Resource Center. In total, 334 articles were retrieved, and 122 met inclusion criteria and chosen for data abstraction. Results indicate that IPs make up a significant portion of the healthcare sector globally, with almost half of studies (48%) from Sub-Saharan Africa. Utilization estimates from 24 studies in the literature of IP for healthcare services ranged from 9% to 90% of all healthcare interactions, depending on the country, the disease in question, and methods of measurement. IPs operate in a variety of health areas, although baseline information on quality is notably incomplete and poor quality of care is generally assumed. There was a wide variation in how quality of care is measured. The review found that IPs reported inadequate drug provision, poor adherence to clinical national guidelines, and that there were gaps in knowledge and provider practice; however, studies also found that the formal sector also reported poor provider practices. Reasons for using IPs included convenience, affordability, and social and cultural effects. Recommendations from the literature amount to a call for more engagement with the IP sector. IPs are a large component of nearly all developing country health systems. Research and policies of engagement are needed.

Private sector, human resources and health franchising in Africa

In much of the developing world, private health care providers and pharmacies are the most important sources of medicine and medical care and yet these providers are frequently not considered in planning for public health. This paper presents the available evidence, by socioeconomic status, on which strata of society benefit from publicly provided care and which strata use private health care. Using data from The World Banks Health Nutrition and Population Poverty Thematic Reports on 22 countries in Africa, an assessment was made of the use of public and private health services, by asset quintile groups, for treatment of diarrhoea and acute respiratory infections, proxies for publicly subsidized services. The evidence and theory on using franchise networks to supplement government programmes in the delivery of public health services was assessed. Examples from health franchises in Africa and Asia are provided to illustrate the potential for franchise systems to leverage private providers and so increase delivery-point availability for public-benefit services. We argue that based on the established demand for private medical services in Africa, these providers should be included in future planning on human resources for public health. Having explored the range of systems that have been tested for working with private providers, from contracting to vouchers to behavioural change and provider education, we conclude that franchising has the greatest potential for integration into large-scale programmes in Africa to address critical illnesses of public health importance.

The Impact of Clinical Social Franchising on Health Services in Low- and Middle-Income Countries: A Systematic Review

Background The private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access. Objectives and Methods We examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings. Results Of 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes. Conclusions Our review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system.

Moving towards in-depth knowledge on the private health sector in low- and middle-income countries.

The past two decades have seen a steady growth in attention to the private sector role within the overall health systems of lowand middle-income countries. Since the 1990s researchers have worked to call attention to the previously unrecognized scale of private medical services in the developing world (Berman and Rose 1996; Brugha and Zwi 1998; Hanson and Berman 1998; Preker et al. 2000; Uplekar 2000; Berman 2001; Mills et al. 2002; Harding and Preker 2003). As cross-country datasets have become available, the evidence has become increasingly clear that the private sector plays a major role in financing and provision of care in lowand middle-income countries (LMICs) (Zwi et al. 2001; Ha et al. 2002; Liu et al. 2006; Konde-Lule et al. 2010). In parallel, a half-dozen multi-centre projects supporting research on the private sector in LMICs have been implemented (De Costa and Diwan 2007; Access Health International, n.d.; PSP, n.d.; PSP-One, n.d.; Results for Development Institute, n.d.). Evidence and analysis has also pointed to the challenges and opportunities that the private sector poses to health and health sector development (Lonnroth et al. 1998; Lonnroth et al. 2001; Travis and Cassels 2006). The result of this growth in evidence is a general acknowledgement of the private sector and acceptance of its existence and important role in health care for many people in lowand middle-income countries. Consequently, the focus in research and policy development has moved from measurement to nuanced assessment of policy options and interventions for engagement of the private sector in public policy goal attainment (Montagu 2002; De Costa et al. 2008; Dimovska 2009; Lagomarsino 2009; Kangwana et al. 2011). As a result, in 2010 the World Health Assembly passed a resolution calling on countries to ‘constructively engage the private sector in providing essential health-care services’ (WHO 2010). The British development agency, DFID (Department for International Development), has supported a series of recent systematic reviews addressing voucher-based payments for care, the quality of private provision, and health outcomes in public vs private facilities in LMICs (Madhavan 2010; Montagu 2010; Meyer 2011). Health system thinking is increasingly acknowledging, and measuring, the scale of private provision. While documentation and guidance on policies and analysis are still in limited supply, the field is expanding. A further indication of this is the growing body of researchers addressing issues of private health care in LMICs and sharing their evidence in public fora and in peer-reviewed journals. In 2007 an informal gathering of researchers on the private sector met for lunch at the VIth World Congress of the International Health Economics Association (iHEA) in Copenhagen. From this group a small committee was formed to organize a symposium on the Role of the Private Sector in Health Care in conjunction with the 2009 VIIth iHEA congress. Around 100 participants attended the symposium. The papers in this supplement were presented at that 2009 Symposium. They are indicative of the growing sophistication and depth of research being conducted on issues of private health care provision in LMICs. Ann Levin and Miloud Kaddar have conducted a literature review on the role of the private sector in lowto middle-income countries in the delivery of immunization services. Overall, there are few studies of the subject but the authors find that the private sector is contributing to immunization service delivery and helping to improve access to basic vaccines in some low-income countries. They find that not-for-profit facilities are more likely to be coordinated with public services than the private for-profit sector. The contribution of this sector is poorly documented, leading to a lack of recognition of its role at national and global levels. The study Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine The Author 2011; all rights reserved. Health Policy and Planning 2011;26:i1–i3 doi:10.1093/heapol/czr050

Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector?

The private for-profit sectors prominence in health-care delivery, and concern about its failures to deliver social benefit, has driven a search for interventions to improve the sectors functioning. We review evidence for the effectiveness and limitations of such private sector interventions in low-income and middle-income countries. Few robust assessments are available, but some conclusions are possible. Prohibiting the private sector is very unlikely to succeed, and regulatory approaches face persistent challenges in many low-income and middle-income countries. Attention is therefore turning to interventions that encourage private providers to improve quality and coverage (while advancing their financial interests) such as social marketing, social franchising, vouchers, and contracting. However, evidence about the effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate. Other challenges concern scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage, though interventions can address focused problems on a restricted scale.

Validation of a new method for testing provider clinical quality in rural settings in low- and middle-income countries: the observed simulated patient.

Background Assessing the quality of care provided by individual health practitioners is critical to identifying possible risks to the health of the public. However, existing assessment methods can be inaccurate, expensive, or infeasible in many developing country settings, particularly in rural areas and especially for children. Following an assessment of the strengths and weaknesses of the existing methods for provider assessment, we developed a synthesis method combining components of direct observation, clinical vignettes, and medical mannequins which we have termed “Observed Simulated Patient” or OSP. An OSP assessment involves a trained actor playing the role of a ‘mother’, a life-size doll representing a 5-year old boy, and a trained observer. The provider being assessed was informed in advance of the role-playing, and told to conduct the diagnosis and treatment as he normally would while verbally describing the examinations. Methodology/Principal Findings We tested the validity of OSP by conducting parallel scoring of medical providers in Myanmar, assessing the quality of their diagnosis and treatment of pediatric malaria, first by direct observation of true patients and second by OSP. Data were collected from 20 private independent medical practitioners in Mon and Kayin States, Myanmar between December 26, 2010 and January 12, 2011. All areas of assessment showed agreement between OSP and direct observation above 90% except for history taking related to past experience with malaria medicines. In this area, providers did not ask questions of the OSP to the same degree that they questioned real patients (agreement 82.8%). Conclusions/Significance The OSP methodology may provide a valuable option for quality assessment of providers in places, or for health conditions, where other assessment tools are unworkable.

SMS messages increase adherence to rapid diagnostic test results among malaria patients: Results from a pilot study in Nigeria

BackgroundThe World Health Organization now recommends parasitological confirmation for malaria case management. Rapid diagnostic tests (RDTs) for malaria are an accurate and simple diagnostic to confirm parasite presence in blood. However, where they have been deployed, adherence to RDT results has been poor, especially when the test result is negative. Few studies have examined adherence to RDTs distributed or purchased through the private sector.MethodsThe Rapid Examination of Malaria and Evaluation of Diagnostic Information (REMEDI) study assessed the acceptability of and adherence to RDT results for patients seeking care from private sector drug retailers in two cities in Oyo State in south-west Nigeria. In total, 465 adult participants were enrolled upon exit from a participating drug shop having purchased anti-malaria drugs for themselves. Participants were given a free RDT and the appropriate treatment advice based on their RDT result. Short Message Service (SMS) text messages reiterating the treatment advice were sent to a randomly selected half of the participants one day after being tested. Participants were contacted via phone four days after the RDT was conducted to assess adherence to the RDT information and treatment advice.ResultsAdherence to RDT results was 14.3 percentage points (P-val <0.001) higher in the treatment group who were sent the SMS. The higher adherence in the treatment group was robust to several specification tests and the estimated difference in adherence ranged from 9.7 to 16.1 percentage points. Further, the higher adherence to the treatment advice was specific to the treatment advice for anti-malarial drugs and not other drugs purchased to treat malaria symptoms in the RDT-negative participants who bought both anti-malarial and symptom drugs. There was no difference in adherence for the RDT-positive participants who were sent the SMS.ConclusionsSMS text messages substantially increased adherence to RDT results for patients seeking care for malaria from privately owned drug retailers in Nigeria and may be a simple and cost-effective means for boosting adherence to RDT results if and when RDTs are introduced as a commercial retail product.

Pay-for-performance and the Millennium Development Goals

Only 23 countries are on course to reach Millennium Development Goal (MDG) 5: to reduce the maternal mortality ratio by 75% by 2015 [1]. One reason for this slow progress is that, in many low-income and middle-income countries, most poor women deliver at home without skilled attendance, and thus face a high rate of obstetric complications. Our recent analysis, for example, found that in sub-Saharan Africa, from 2003 to the present, 78% of births among the poorest women occurred at home, of which 56% were unattended [2]. Reasons for this high rate of unattended home births include poor availability of health facilities, and social and cultural preferences for home delivery [2,3]. Increasing the proportion of poor women receiving skilled obstetric care is a complex public health challenge that defies easy solutions. Innovative approaches are desperately needed. References 1. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23. 2. Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One 2011; 6: e17155. 3. Koblinsky M, Matthews Z, Hussein J, et al, on behalf of The Lancet Maternal Survival Series steering group. Going to scale with professional skilled care. Lancet 2006; 368: 1377–86.

Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: An evaluation of incentive schemes among informal private healthcare providers

BackgroundAs efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar.MethodsThe study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms.ResultsThe pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy.ConclusionsResults show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.