International Journal for Equity in Health BioMed Central Research Open Access Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature Edith Patouillard*1, Catherine A Goodman1,2, Kara G Hanson1 and Anne J Mills1 Address: 1Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, London, UK and 2Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya Email: EdithPatouillard*[email protected]; [email protected]; [email protected]; [email protected] * Corresponding author Published: 7 November 2007 Received: 31 January 2007 Accepted: 7 November 2007 International Journal for Equity in Health 2007, 6:17 doi:10.1186/1475-9276-6-17 This article is available from: http://www.equityhealthj.com/content/6/1/17 © 2007 Patouillard et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor. Methods: The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations. Results: A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions. Conclusion: Few studies provided evidence on the impact of private sector interventions on quality and/ or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn. Page 1 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 Background interventions improve equity has not yet been clearly Recent years have seen increasing interest in the role of the made [13]. Moreover, one might fear that working with private sector in health service provision in low- and mid- private for-profit providers may disproportionately bene- dle-income countries. Many countries have a vibrant and fit the wealthier members of the community who can growing private sector, which is perceived by some to afford their charges, and thus exacerbate inequity [14]. respond to public sector failures. Private providers are This paper addresses this knowledge gap by presenting the argued to deliver services which are more accessible, results of a systematic review of the impact of private sec- affordable (particularly where public providers charge tor interventions on the poor. Section 1 sets the scope of official or unofficial user fees) and responsive to the needs the literature review, providing definitions of key terms and preferences of users [1]. and concepts and describes the review methods. Section 2 presents the findings, which are discussed in the final sec- The private sector is also an important source of care for tion. poor and disadvantaged groups within low- and middle- income countries. For instance, in Guatemala, 40 to 45% Methods of the population in the two lower income quintiles The scope of the review was defined as follows: sought care in the private sector and in South Africa over 33% of each of the three lower quintiles did so [2]. Simi- Scope of the review larly, in Nepal, the private sector provided care to more Private sector than a third of the lowest income quartile [3]. A review of The private health sector is commonly defined as all pro- Demographic Health Survey (DHS) data from 38 coun- viders outside the public sector. This includes a heteroge- tries found high levels of private sector use by those in the neous mix of for-profit and not-for profit providers, with lowest socioeconomic quintile for childhood diarrhea varying degrees of formality and qualifications. Our focus (34–96% of children) and acute respiratory infections was on interventions that work with existing for-profit (37–99% of children) [4]. In seeking to extend coverage of providers, both formal and informal. While we recognize priority interventions, there are numerous operational the importance of private not-for-profit providers, their advantages to working with pre-existing, self-sustaining characteristics and incentives are likely to differ from outlets that are widely used by target populations. For those of commercial providers, and they were considered these reasons the private sector represents an important beyond the scope of this review. In practice, boundaries potential partner in efforts to scale up coverage of effective between public and private provision may be blurred; health interventions among the poor. both formal and informal cost recovery schemes operate at public facilities [15] and dual practice, where providers However, there is a growing body of evidence that the care work in both the public and private sectors, is widespread provided in the private sector is often of low technical [16]. We have not set out to include these mixes of public quality [5]. For example, private sector treatment of sexu- and private operations, though it is possible that some ally transmitted infections (STIs) [6], tuberculosis [7] and private outlets involved in the reviewed interventions are malaria [8] have been demonstrated to have significant run by public sector staff. shortcomings in terms of quality of diagnosis and correct prescription of medications. Concern about the potential Health services and public health products harm caused by private providers, combined with recog- In this paper, health services refer to all in-patient and nition that public sector technical quality is often also ambulatory care services [17], and public health products poor, has led to interest in developing interventions are "those commodities used for treatment of diseases of which will take advantage of the potential offered by the public health importance or for the promotion of health, private sector while at the same time addressing its techni- which can be provided at the retail level without a 'service' cal failures. There is now a substantial literature on ways attached to them" [18]. Examples of the latter include that government and non-governmental organizations condoms and mosquito nets. We addressed only those (NGOs) can work with private health care providers, services and interventions which fall under the classifica- including social marketing, regulation, training, franchis- tion of biomedical/allopathic, and excluded interventions ing, accreditation and contracting-out [1,4,5,8-11]. to improve the quality of "traditional" care. It has been argued that there is "evidence that effective Outcome Measures public-private partnerships can increase access, improve We included studies focusing on the impact on either uti- equity, and raise quality of health services"[12] and that lization or quality of care. We focused on utilization governments should "urgently engage with private stake- because it reflects the degree to which multiple barriers to holders to. .... facilitate increased private sector participa- access (e.g. geographic, financial, social) are overcome. In tion" [12]. However, the case that private sector terms of quality, our focus was on both the technical and Page 2 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 perceived dimensions of quality. We considered technical ment or donor-sponsored NGO which subsidises the net- quality to be assessed through observation of provider work [22]. behaviour and of the physical attributes of the practice [18]. For example, we included studies that evaluated pro- Accreditation is a strategy to improve and control the qual- viders' practical performance against training or national ity of services provided at organisational or facility level guidelines (e.g. proportion of cases correctly managed), through oversight by an independent quality control eval- and those that assessed the adequacy of the premises for uation body which may be the government or an NGO. It the services and products provided (e.g. range of essential may include training providers in standardised practices drugs available). We also included studies on the more [1]. While accreditation is similar to franchising, the controversial dimension of quality based on patients' per- nature of the relationship between the provider/accreditor ceptions and considered perceived quality as measured by is often voluntary, compared with the contractual rela- the level of satisfaction expressed by patients. Our review tionship between the franchisee/franchise organization. excluded studies that reported intervention impacts in terms of providers' qualifications and knowledge alone. Training interventions can take various forms including formal training sessions, vendor-to-vendor education, dis- Private sector interventions tribution of guidelines and job-aids. Training is often inte- A preliminary review identified eight areas of intervention grated into other interventions, such as franchising, involving the government or NGOs working with the pri- accreditation and social marketing. vate for-profit sector: social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, Regulatory interventions aim to set up and ensure ade- accreditation and contracting-out. quate technical quality of the services provided [18]. They take the form of rules, enforcement systems and sanction Social marketing is the application of the tools and con- mechanisms, and can be applied at the levels of health cepts of commercial marketing to social and health prob- care provider, organisation or facility. At the provider level lems [19], in order to increase population coverage of regulation may include requirements for pre-service train- effective and affordable interventions [10]. Social market- ing, continuing education, licensing and certification of ing interventions may include a combination of promo- providers [23]. At the organisational or facility level, regu- tional activities, branding, labelling, pre-packaging and lation may aim to control the location of facilities, their subsidy of public health products. registration and minimum complement of staff or facili- ties [18]. In addition, consumer protection legislation A voucher is a form of demand-side subsidy that the recip- may be used to oversee medical practices and influence ient can use as part or full-payment for a product or service provider behaviour. Pharmaceutical market regulation from identified providers. The distribution of vouchers aims to limit the availability of harmful drugs and unreg- can be targeted, to improve access for an identified popu- istered products, minimize drug misuse, control the sale lation group such as the poorest households or pregnant of specific drugs through prescriptions, and regulate drug women. Vouchers can either be competitively redeemed manufacture and importation [20]. where they are exchangeable at a number of different pro- viders [10], or non-competitive where they are assigned to Contracting out is a purchasing mechanism used to acquire one particular provider [9]. specified services of a defined quality at an agreed price from a specific private provider and for a specific period of Pre-packaging is a strategy to improve provider and patient time. Governments may purchase clinical or non-clinical adherence to treatment regimens, and involves packaging services from private providers to complement public pro- drugs in pre-defined doses adequate for the targeted pop- vision [24]. ulation group and length of treatment regimen [20]. Where interventions employed a mix of strategies we clas- A franchise is a contractual arrangement between a health sified them by the primary or main intervention, based on service provider and a franchise organisation. It aims to the emphasis given in the paper or report. improve access to quality- and price-controlled services. Franchisees are trained in standardized practices for which Poverty prices are predefined [21] and benefit from advertising of The main focus of this paper was the extent to which the the logo or franchise name. In return, franchisees may be effects of private sector interventions reach the poor. Pov- required to comply with minimum sales volume and erty is a multidimensional construct, notoriously difficult quality standards and pay a membership fee to the fran- to measure [25]. Various tools are used to assess the pov- chisor [22]. Providers are monitored by the franchise erty status of population groups, in either absolute or rel- organisation, which in public health is generally a govern- ative terms. For instance, household income or Page 3 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 consumption, asset ownership and housing conditions, Table 1: Search strategy: key terms and limits residence status and the level of education attained, are all Key terms Limits relevant dimensions. We included in the review all studies that examined the effects of interventions on the poor as Private Sector* Geographic measured by any of these indicators, for example those Delivery of Health Care† Developing countries with low household income, lower levels of education, or Health Care Sector† Low income countries those living in rural areas. It is recognised that all of these Social marketing* Middle income countries proxies suffer from imperfections, in terms both of meas- Marketing of health services† Linguistic urement and interpretation [26,27]. Voucher‡ English Vouchers‡ French Franchising‡ Publication period To determine whether an intervention reaches the poor Franchise‡ 01/1990 to 05/2006 we took two approaches. First, interventions were deemed Accreditation* to have reached the poor if they benefited generally poor Accredited‡ areas based on the study site information provided in the Education, Pharmacy† original papers. This was termed an average SES measure. Training‡ Secondly, interventions were deemed to have reached the Contracting out‡ Contract services‡ poor if the socioeconomic distribution of benefits Contracting‡ favoured the most disadvantaged groups within a given Facility regulation and control ^† population. This was termed a relative SES measure. The Regulation‡ distinction between these two criteria is important, and is Drugs, Non-Prescription† linked to the difference between measures of absolute and Antimalarials† relative poverty. For instance, an intervention that is Drug Labeling† implemented among private providers in a predomi- Drug Packaging† nantly rural district of a poor country may improve the *MeSH and free text quality of care received by all socioeconomic groups in † MeSH only that area (i.e. may have no effect on the relative distribu- ‡ free text only tion of access to quality services). However, because most ^legislation and jurisprudence subheading only of the population is disadvantaged, it can be judged to be successful in reaching the poor based on an average SES measure. Alternatively, an intervention that generates a greater improvement in utilization of quality care for Development. The bibliographies of selected papers were those in the lowest income quintile compared with the also checked for additional papers. highest, for example by targeting providers who are pref- erentially used by the poorest, would be judged to have When all searches were complete, document titles and reached the poor based on a relative SES measure. available abstracts were read and potential sources selected based on the following inclusion criteria. Search methodology Published, grey and unpublished literature was systemat- We included all impact evaluations of interventions work- ically searched. The search topic was defined as evidence ing with private for-profit providers in low and middle- on the effectiveness of different strategies of working with income countries that measured the effect of the interven- existing private-for-profit providers to improve utilization tion on either utilization or quality of services. An impact and quality of health services and public heath products evaluation was defined as a study documenting changes for the poor. over time (pre-post), or comparing an intervention area with a control area (controlled), or comparing changes The search for published literature used the electronic over time in an intervention area with changes over time databases PubMed, Popline, HMIC and CabHealth Glo- in a control area (pre-post with control), with or without bal Health applying both controlled vocabulary and free randomisation. We excluded studies using national sur- text key terms, and limiting the review to articles pub- vey data on aggregate changes in utilization of a service or lished after 1990, in English and French (Table 1). a product that could not be related to a specific interven- tion. The search for grey and unpublished literature focused on reports and documents available on the World Wide Web. We then identified interventions with average socioeco- Using key terms in Table 1, we searched the sites of Eldis nomic status (SES) information on the recipient popula- Gateway to Development Information, USAID PSP-One, tion, and those which documented relative effectiveness and World Bank Knowledge Services for Private Sector across SES groups. Page 4 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 Results tributed to pregnant women and mothers of under-five A total of 2483 references were retrieved, from which 52 children attending public clinics. evaluated interventions working with private for-profit providers were identified. The majority concerned train- Vouchers for free nets and treatment from retail outlets ing (26) and social marketing (14), with the remainder were used alongside measles vaccination in a campaign evaluating contracting-out (3), franchising (6), regulation approach in an urban Zambian district [35]. Two other (2) and accreditation (1) [see Additional file 1]. voucher schemes for sexual and reproductive health care (SRHC) were implemented in Nicaragua. The first tar- Social marketing, vouchers and pre-packaging of drugs geted adolescent girls at various sites, entitling the recipi- These interventions were grouped together because of ent to free SRHC at NGO, public and for-profit clinics their significant overlap. Fourteen evaluated interventions [36,37]. The second scheme provided free STI care at pri- were identified, eleven relating to social marketing one vate for-profit and NGO clinics for sex workers and their also including a voucher scheme, and 2 including pre- clients [38]. packaged treatments. A further 3 interventions focused purely on provision of vouchers. Two final interventions combined social marketing with prepackaged treatments – for STI treatment for male ure- Of the social marketing interventions, six involved con- thritis in Uganda [39] and prepackaged treatment for doms and/or other family planning commodities, and childhood malaria and acute respiratory infections in one each involved oral rehydration therapy (ORT), iron Nigeria [40]. supplements, insecticide treated nets (ITNs), STI treat- ment and malaria/acute respiratory infection (ARI) treat- Of the 14 interventions, data on the average SES of the ment. All showed significant increases in utilization of recipient community was provided for only one, the programme commodities and services, though of differ- KINET ITN project. This clearly benefited a generally poor ing magnitudes across interventions. For example, social population, with an estimated median household marketing increased condom use among women in urban monthly expenditure of $77–96 in 1997 [34]. For 12 Cameroon from 58% to 76% [28], coverage of iron-folic interventions, only general information on the urban/ acid supplementation from 6% to 99% in non-pregnant rural settings was available, and for 1 intervention there Filipino women [29], and ITN coverage in rural Tanza- was no information aside from location. nian children under 2 years from 10% to 61% [30]. Data on the distribution of benefits across socioeconomic The contraceptive social marketing programmes were groups was provided for 2 of these interventions. The implemented in urban settings and the majority targeted effect of KINET on the socioeconomic distribution of ITNs adolescent groups. A number of interventions included was documented in three studies. The first demonstrated peer educators as well as distribution of commodities positive changes in the ratio of net ownership in the low- through retail outlets (Soweto, Horizon Jeunes, Tsa est to the highest SES quintiles (the equity ratio) from 0.3 Banana, My Future First). in 1997 to 0.6 in 2000 [33]. The second reported a signif- icantly greater increase (of 51%) in household net owner- The social marketing programme for ORT in a rural Ken- ship among the poorest income quartile in the social yan district included sales of flavoured ORT sachets marketing area compared to 32% in the control area. Sim- through shops and a mass communication and education ilar information for households in village peripheries campaign [31]. In the Philippines, social marketing of (likely to be poorer) were 68% and 27% [19]. The third iron and folic acid supplements in rural municipalities study assessed the socioeconomic distribution of vouch- combined free distribution of iron-folic acid supplemen- ers and, in contrast to the other two, found that none of tation targeted to pregnant women through the public the households in the lowest quintile had used a voucher health system and sales of iron supplements to non-preg- towards the purchase of a net compared to 8% in the high- nant women by village health workers (VHWs) and drug est quintile [32]. This may be due to the low share of outlets, as well as training VHWs and school teachers in vouchers in total net sales, itself reflecting low knowledge counselling and information, education and communica- among mothers of vouchers, with only 28% of women tion (IEC) [29]. having ever heard of the voucher scheme [41]. The Kilombero and Ulanga Insecticide-Treated Net Poorer groups also benefited in relative terms in urban project (KINET) in Tanzania distributed branded ITNs Zambia, where the equity ratio for ITN coverage increased and net treatment kits through retail outlets, and included from 0.66 to 1.19, with no statistically significant associa- a comprehensive IEC campaign [19,30,32-34]. Vouchers tion between wealth and ownership found post-interven- reducing the price of nets at retail shops by 17% were dis- tion [35]. Page 5 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 Regulation vention pharmacies compared with 18% at control Of the two evaluated interventions identified, one con- pharmacies. Counseling about partner notification was cerned banning a drug and its combination products in 40% in intervention pharmacies compared with 21% in Nepal and one assessed a regulatory intervention to control pharmacies, though no recommendation to use a improve quality of pharmacy services in Lao P.D.R. condom was given at intervention pharmacies compared with 13% at control pharmacies [44]. Generally positive The pharmaceutical ban prohibited the export, import, overall results were also observed for training pro- local production, transportation, storage, sale and distri- grammes with non-pharmacy retailers. For example, the bution of Analgin (an analgesic and antipyretic drug) and proportion of Nigerian patent medicine vendors recom- its combination products [42]. As a result, the proportion mending a correct drug dose for malaria increased from of retail outlets with Analgin decreased from 96.5% at 9% in 2003 to 53% in 2004 [45], and in Kenya the pro- baseline to 21.2% five months after the intervention and portion of antimalarial sales with adequate dosage 0% sixteen months after [42]. increased from 32% in 1996 to 83% 3 months after train- ing and to 90% 6 months after training [46]. The regulatory intervention in Lao P.D.R involved inten- sive supervision of the quality of pharmacy services, Of the 26 interventions, data on average SES of the recip- applying sanctions when rules were violated, and provid- ient population was provided for only one. Training of ing up-to-date regulatory documents and information private practitioners in Pakistan clearly benefited a gener- about particular areas needing improvements [43]. The ally poor population, with an estimated median monthly study compared districts with intensified regulation with household income of $48–72 and $48–61 in two com- normal, control districts. Whilst it could not be estab- munities [47]. General information on rural/urban set- lished that the intensive intervention had a greater effect tings was provided for 18 interventions and no than routine regulation, moderate but significant information for 7. No studies provided any evidence on improvements in quality were observed in all districts, the distribution of benefits by relative SES. with mean availability of essential materials increasing by 34% and mean order in the pharmacy (including the pres- Franchising ence of advertisements, and whether drugs were stored in Six interventions were identified, "Green Star" and "Green their original packaging away from sunlight) increasing Key" in Pakistan, "Ray of Hope" in Ethiopia, "Janani" in by 19% [43]. Bihar State, India, "Sewa" in Nepal and "Top Reseau" in Madagascar. Evidence of impact on utilization or quality For these two interventions, no SES information was pro- of health services was mixed. vided about the recipient populations. Effectiveness of the Pakistan, Ethiopia and Bihar interven- Training tions was documented in a single study that used exit Training was by far the most evaluated intervention, with interviews to examine client satisfaction at franchised and 26 interventions covering different types of private pro- non-franchised outlets [48]. Effectiveness of the "Green viders: 4 targeted private doctors, 2 private midwives, 8 Star" and "Green Key" franchises implemented in Paki- private pharmacy workers, 6 drug retailers and 6 a mix of stan was jointly evaluated. Clients attending franchised provider types. Training interventions aimed to improve private services were significantly more likely to report the quality of treatment of a range of different conditions. that they would return than those attending non-fran- Seven interventions focused on treatment of childhood chised services in Pakistan and significantly less likely in illness (use of integrated management of childhood ill- Ethiopia, with no statistically significant difference in ness (IMCI) guidelines, treatment of ARI or diarrhea); 5 Bihar. In all three settings there was no statistically signif- addressed quality of STI treatment; 5 the quality of family icant difference between the franchise status of the clinic planning or reproductive health services; 4 malaria treat- and perceptions of quality (that the service was better than ment; and the remaining studies addressed other commu- others available) or in citing affordability as a preferred nicable diseases (e.g. ARIs), or multiple diseases (e.g. "6 feature of the service [48]. common illnesses"). The Nepali study examined client satisfaction with quality Most interventions produced positive results for at least of care [49]. Clients at intervention clinics 'very satisfied' some outcome indicators. For instance, a study of the with cleanliness increased from 37% to 65%, and with the Ghanaian intervention to improve STI management at availability of essential equipment from 35% to 62% [49]. pharmacies, which evaluated outcomes using simulated Clients were also reported to be more satisfied with the clients, found that when offered treatment, 38% of simu- range of services offered in the intervention clinics (40% lated clients received appropriate oral medication at inter- to 71%) and with privacy (38% to 72%) [49]. Page 6 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 The Top Réseau study reported that coverage of modern Contracting-out contraceptives was higher for women with high exposure Three evaluated interventions were identified, of which to the intervention (have accessed a franchised clinic and one related to contracting-out hospital services in South have been exposed to the IEC activities) than those with Africa and two related to contracting-out primary health low or medium exposure [50]. care services in South Africa and Lesotho. Data on average SES of the recipient population was pro- Contracting-out of district hospitals to private-for-profit vided for one of the six interventions. The Nepali fran- management was implemented in rural South Africa. The chise network clearly benefited a generally poor quality of care provided by three contracted hospitals was population, with an estimated income per capita of $125 compared with that of three, paired public hospitals [52]. [49]. Public hospitals had better structural quality of care but contracted hospitals had better quality of nursing care in Evidence on the socioeconomic distribution of benefits maternity and medical/surgical wards than public hospi- within the recipient community was provided for the fran- tals, similar nursing management quality, and overall, chise networks in Pakistan, Ethiopia and Bihar State. The higher total nursing quality. No statistically significant Green Star and Green Key interventions in urban Pakistan differences in perinatal and maternal mortality rates were did not benefit relatively poor groups. Clients with found between contracted and public hospitals [52]. income of $101– $250/month and with income greater than $251 were more likely to use franchised services than General practitioners have for long been contracted on a those earning less than $60/month. Clients with at least part-time basis to provide primary care in rural towns in secondary schooling were also more likely to use fran- South Africa [53]. A quality of care study showed that chised services compared to illiterate clients [48]. patients with hypertension were less likely to have their blood pressure recorded when they sought care at con- Evidence for the Ray of Hope intervention in Ethiopia was tracted practices than at public health facilities. mixed. Clients with income of $101–$250/month were less likely to attend franchised services than those earning Primary care services, drugs, laboratory tests and X-rays less than $60/month. However clients with primary edu- were provided in Lesotho to workers of a construction cation were more likely to attend franchised services com- company and to local communities through a contract pared to clients with the least education [48]. with a commercial medical company [53]. Overall, struc- tural quality was similar between contracted and public The evidence from Bihar was also mixed. There was no sta- providers. However, 37% of STI cases were treated cor- tistically significant association between attending fran- rectly by contracted providers compared with 59% and chised services and monthly household income [48]. 96% of cases treated in "large" and "small" public health Clients with no education were more likely to attend fran- facilities respectively. chised services compared to clients with education [48]. Of the 3 evaluated interventions, data on the average SES Only general SES information was provided for the Top of the recipient community was provided for 2. The indi- Réseau study. vidual GP and the company contract interventions clearly benefited generally poor users given that approximately Accreditation 65% to 78% of them had an estimated household One intervention was identified, a network of accredited monthly income of less than $66 [53]. drug dispensing outlets (ADDO) implemented in rural and peri-urban Tanzania. The accreditation process, man- For the intervention to contract out district hospitals, rural aged by the Tanzania Food Drug Authority (TFDA), aimed location was the only information about SES provided. to improve access to affordable and quality medicines and pharmaceutical services through training and supervision Discussion of outlet dispensing staff, outlet inspections, marketing This paper has reviewed through an "equity lens" [54] the and public education [51]. The proportion of unregistered results of a systematic literature review of the ways of drugs decreased in both intervention and control areas, working with for-profit providers of health services and from 26% to 2% in the former, and from 29% to 10% in public health commodities to improve the utilization and the latter [51]. quality of essential health services, focusing specifically on the extent to which these interventions have been dem- Only general information on the rural and peri-urban sta- onstrated to improve quality and utilization for poor and tus of the recipient populations was available, and no disadvantaged groups. This focus on whether the poor information was provided about ADDO customers' SES. benefit is particularly important as programmes which Page 7 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 work with private for-profit providers might be expected a both of which used the private retail sector for distribu- priori to be pro-rich, since they generally require out-of- tion. In the case of Zambia, full value vouchers were pro- pocket payment (except in the case of a 100% value vided so no out-of-pocket payment was required. In the voucher). Available data indicate that poor people make Tanzanian programme, significantly pro-poor results for significant use of the private sector, and that the quality of ITN coverage were achieved even though users were pay- services they receive is at best variable. While a case can be ing near-market prices for ITNs. Both these interventions made, therefore, for using public funds to work with for- operated at a relatively small scale and more evidence is profit providers, there is a need for much stronger evi- needed of effectiveness at scale. Information about rela- dence that such interventions can lead to health improve- tive equity improvements was provided by the three fran- ments for poor people. chising interventions, for which the socioeconomic distribution of impact was more mixed, with positive The review confirms that international interest in working equity effects shown in some but not all programmes. with the private sector has been translated into a signifi- This is difficult to explain without knowing more about cant number of innovative schemes. A total of 2483 refer- the specific features of the interventions and study con- ences retrieved from our initial search of the published texts. However, we can speculate that by targeting for- and grey literature related to one or more of 8 different mally trained for-profit providers, the potential impact on areas of intervention (social marketing, vouchers, pre- the poorest is lessened and that positive equity effects packaging of drugs, franchising, accreditation, regulation, might require targeting those providers predominantly training and contracting-out). These interventions were used by poor people. Formative research is therefore implemented in a wide range of settings, and addressed a needed to identify which providers are used by poor peo- variety of different health problems. ple and why, focusing on various dimensions of accessi- bility (geographic, social and financial). Where financial Yet despite this large number of studies, relatively few accessibility is a critical constraint, an assessment of alter- qualified for inclusion as impact evaluations. In seeking native subsidy mechanisms should be considered (e.g. to find evidence of impact we took a more liberal position cash transfers, vouchers, provider subsidies). than that of the EPOC group of the Cochrane Collabora- tion [55], and included any studies that had employed The review identified a number of limitations of the liter- either a pre-post, controlled or pre-post with control ature, some of which have been alluded to already. First, design, with or without randomisation. We do not feel, there are few evaluations of impact that allow robust con- therefore, that we have been overly rigid in our standards clusions to be drawn. This is not surprising as many inter- of "rigour" in evaluation design. However, even using ventions were not set up as research exercises, and these relatively loose criteria, it is clear that the ability of evaluation therefore had to fit around other implementa- these interventions to produce a significant impact on tion priorities. We do not wish to imply that other types quality and utilization of care is far from fully demon- of study are not of value, especially those which focus on strated. description and analysis of implementation process. However, better evidence of impact is needed [56]. Other Even fewer studies (5 interventions in total) reported data weaknesses of study design included limited justification on the average SES of populations served, and therefore, for selection of control groups and few attempts to iden- of the beneficiaries of any improvements in quality or uti- tify and control for potential confounders. Second, very lisation of care. However, although detailed data were few studies presented information about the SES of the lacking in the majority of studies, it is evident that many target population or of programme beneficiaries. Among interventions have worked successfully in poor communi- those studies included in the review, varied SES measures ties. For example, even where specific information about were used, hampering comparison of results across con- SES is not provided, rural districts in low-income coun- texts. Finally, many studies assess relatively short-term tries are very likely to contain populations defined as effects under controlled conditions, leaving the long term absolutely poor by any standards and successful interven- impact and sustainability of the interventions open to tions in these contexts are likely to produce equity question. improvements. Finally our review had limitations. First, we searched only We deliberately sought information about the socioeco- English and French language literature, and used search nomic distribution of benefits across socioeconomic engines and databases that primarily index English lan- groups and found information available for only 5 inter- guage sources; for grey literature we restricted our search ventions. Strong evidence of benefits favouring the poor- to sources that were web-accessible. Secondly, we encoun- est was provided by the two ITN interventions (social tered some difficulties in classifying interventions since marketing of ITNs in Tanzania and vouchers in Zambia), many employ a mix of approaches, for instance social Page 8 of 11 (page number not for citation purposes) International Journal for Equity in Health 2007, 6:17 http://www.equityhealthj.com/content/6/1/17 marketing and pre-packaging of drugs, or vouchers and such interventions have operated successfully in relatively training providers. We sought to classify studies by pri- poor regions or poor countries indicates that it is possible mary or main intervention. However, it should be noted the poor do benefit significantly – the challenge for the that interventions included under the same sub-heading future is to design evaluations and report results in ways are in reality highly heterogeneous. Moreover, with com- that can assess this clearly, and indicate how equity can be plex interventions such as these, the context is likely to enhanced. have a strong influence on both the manner of implemen- tation and the intervention's success, meaning that any Competing interests generalisation should be undertaken cautiously [11]. The author(s) declare that they have no competing inter- Finally, our conception of poverty is limited. We focused ests. primarily on SES, but there are other dimensions of disad- vantage that might be important, such as gender, ethnic- Authors' contributions ity, and epidemiological vulnerability. CG, KH and AM defined the scope of the research subject These limitations notwithstanding, practical suggestions EP developed the search strategy, undertook the search, for future work can be identified: reviewed the literature and summarised the search find- ings (cid:127) The general SES and other features of the recipient com- munity must be reported in order to assess whether results KH, CG and EP drafted the manuscript can be generalized across contexts. AM, CG, and KH critically revised the manuscript (cid:127) The socioeconomic distribution of programme benefits should be examined whenever possible. Measuring SES is All authors approved the final manuscript challenging: income or expenditure are difficult to meas- ure accurately, and may not capture the main dimensions Additional material of vulnerability; proxies such as asset indices are easier to collect but may raise other methodological and empirical Additional file 1 difficulties [57]. Moreover, the benefits of assessing SES Summary of evaluated interventions. The file contains information about must be weighed against the feasibility and costs of col- the type, location and date of each intervention, the design of their evalu- lecting this information, especially where this involves ation study and the outcomes and socioeconomic measures used. large household surveys. Where household survey data on Click here for file asset ownership are available from other sources, data on [http://www.biomedcentral.com/content/supplementary/1475- the same assets can be collected at exit interviews with spe- 9276-6-17-S1.doc] cific private providers, and clients located in the overall SES distribution by applying asset weights from the household survey [14,58]. Acknowledgements All authors are members of the LSHTM Health Economics and Financing (cid:127) Information on relative SES must be interpreted with Programme. CG and KH are members of the Consortium for Research on care, and in light of the characteristics of the overall study Equitable Health Systems, which is funded by the UK Department for Inter- population: in a relatively homogeneous, poor setting, national Development. beneficiaries who appear relatively better off may still be poor in absolute terms compared with the national distri- References bution of income. 1. Smith E, Brugha R, Zwi A: Working with private sector provid- ers for better health care: an introductory guide. London , Options and LSHTM; 2001. (cid:127) An outcome that favours the poor does not on its own 2. 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