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Engaging private sector providers around universal health coverage:

a qualitative study of motivations and entry points in three cities of Bangladesh

Alayne Adams

Senior Social Scientist

Centre for Equity and Health Systems, icddr,b

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The Lancet Series 2014

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The urban healthcare landscape

Rapid urbanization and expanding health service needs among urban residents

No public provision of urban primary care services: limited to tertiary facilities, EPI outreach, MNCH services contracted out by local government

Private sector dominates urban healthcare landscape: private hospitals represent 80% of >3500 hospitals in Bangladesh

YET largely undocumented given weak implementation of regulation around licensing or integration into routine health information systems.

2%

12%

86%*

Formal healthcare facilities in Dhaka

n=7350

Public

NGO

Private

*Excluding pharmacies & optical shops

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Profile of the private-for-profit healthcare sector in Dhaka City (North & South)

4

11

106

140

216

274

279

364

1780

3436

5181

0 1000 2000 3000 4000 5000 6000

Others

Blood Bank

Traditional/Spiritual

Hospital

Optical Shop attached with Doctor’s Chamber

Diagnostic Centre

Optical Shop

Clinic

Doctor’s Chamber

Pharmacy attached with Doctor’s Chamber

Pharmacy

Static (n= 11,791)

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Where do the urban poor seek care?

Largely reliant on the informal private sector - pharmacies -due to proximity and desire for rapid treatment

Almost 30% of slum dwellers and 58% of non-slum dwellers went to private sector for ANC (BUHS, 2013)

65% of poor urban respondents cite proximity as a factor motivating choice (icddr,b, 2104)

Health seeking for last acute health episode among the urban poor in Tongi

Source:, icddr,b, 2014

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Not without costs

Rising out-or pocket expenditures impact the

urban poor, leading to medical impoverishment

- Out-of-pocket payments constitute 64% of total

health expenditure

- 3.5% population falls into poverty in 2010 due to

catastrophic health expenditure (HIES, 2010)

Concerns about quality and high service costs of

private sector provision

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Universal Health Coverage in Bangladesh

The goal of Universal Health Coverage (UHC) is to

“ensure that all people obtain the health services that they need without

suffering financial hardship when paying them” (WHO, 2014)

Publically financed free services are typically preferred to address inequity and ensure UHC

HOWEVER, increasing pluralism of health care provision challenges this assumption, especially in urban areas

Less than 1% covered by any health protection scheme

With rapid growth of urban populations, especially in poor urban settlements, health systems in Bangladesh must respond

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Moving towards UHC in Bangladesh

Population: who is covered?

Current pooled funds

Direct cost:proportion of costs covered

Extend to non-covered

Reduce cost sharing and fees

Include other services

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National health financing strategy

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Private sector readiness for UHC

In urban areas, UHC is unlikely without private sector engagement - needed for population coverage of quality, affordable services

QUESTION: how feasible is this in the context of private sector motivations and interests?

Objectives of private sector study:

1. To understand the private sector motivations, business strategies and incentives in urban areas

2. To identify areas of potential intervention to improve service quality and access to the urban poor that also serve the business interests of this sector

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Methods

Qualitative study in Khulna, Dhaka and Sylhet City Corporations

47 in-depth interviews with private clinic/hospital owners, and formal and informal providers

20 key informant interviews with health managers, clinic owners association leaders

30 exit interviews with patients

30 facility observations

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Key findings

Subsidies for the poor are widespread

Multiple motivations underlie business

Concerns about quality and regulation

Some interest in insurance!

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Reported provision for the poor by private-for-profit health facilities in Dhaka

While relatively high service costs are charged by the private sector, reports of discounted services to the poor were widespread:

“My visit is 500 taka, if anyone tell me patient is poor or garments worker, I take only 120 taka or less in different situations” (Formal Provider, Dhaka)

*Multiple responses

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What motivates the private sector?Not just profit

Motivating FactorFormal Owner

Informal Provider

Formal Provider

Quality of care √√√ √ √

Service √√√ √√√ √√

Personal desire √ √ √√

Family influence √ √√√√ √

Profit √√ √

Making a living √

Honourable profession √ √√√

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Concerns about quality of care

Almost 40% of private sector respondents noted that variable service costs affect their business interests as well as consumer access to services, and many indicated that Government should intervene

Over a quarter of private sector respondents expressed concern about HR issues:

- Unavailability of specialized full-time consultants- Poorly trained newly graduated MBBS doctors- Lack of qualified nurses

“The number of diploma nurse is insufficient. So, nurses are not available

even after giving money. Without qualified nurse, providing service becomes tough.” (Clinic owner, Sylhet)

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Concerns about regulation

Over a quarter of private sector respondents emphasized the need for greater regulation and enforcement of existing law to increase accountability and quality:

“They (Government) have made the laws for everything…in case of miss-enforcement, good law becomes useless.” (Key informant, Khulna)

Confusion and frustration expressed about multiple and uncoordinated regulatory bodies making compliance difficult

The current punitive approach of mobile courts is not appreciated:

“…now if it is seen that mobile court has come and we are running away closing our store, then how can monitoring be done? But if monitoring is done in a way that (helps us) correct our mistakes - If they help us in this way, then it will be good.” (Informal provider, Dhaka)

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Private sector readiness for health insurance

Almost 15% of private sector respondents suggested the introduction of health insurance as a strategy to help increase access and utilization of services by the poor.

“Insurance should be made obligatory. To bring each and every person under the medical services, be it rickshaw puller, farmer or even your housemaid, insurance is the only option. If these people can pay mobile phone bills per month, then I don’t believe they can’t pay the premium for insurance every month.” (Formal private clinic

owner, Dhaka)

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Challenges in engaging the private sector

Formal private sector facilities tend to specialize in diagnostics or high volume services – primary care functions are provided by thousands of private doctors chambers, and pharmacies but with little regulation

The dualism dilemma - shortage of qualified health human resources available 24/7 both private and public sectors

Stewardship function of government around quality improvement and regulatory oversight is weak

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Conclusions

Need to formally engage the private sector around effective coverage of quality services given its massive presence in the urban healthcare market

Indications of readiness to engage with UHC solutions such as health insurance schemes - may provide an entry point to increasing coverage

Achieving UHC objectives with private sector engagement requires the enforcement of regulatory frameworks around pricing, quality, and standards of care

The informal private sector can’t be ignored

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Recommendations

Take advantage of multiple private sector motivations around

service and quality (not just profit) in leveraging involvement

Explore different modalities of formalizing support to the poor

through subsidies or the design of insurance schemes that measure

and reward quality provision of services by the private sector

Strengthen government capacity to develop and implement

appropriate policy frameworks to engage with the private sector,

especially with respect to costs, standards of care and MIS

Explore ways to improve quality and minimize harm of informal

private sector i.e. ICT innovations, franchising