IMPROVING THE QUALITY OF PRIVATE-SECTOR DELIVERY OF PUBLIC-HEALTH SERVICES - CHALLENGES AND STRATEGIES

Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges rema in, one being that a large proportion of patients with conditions of p ublic health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit ' private sector. Private providers (PPs) often offer services which a re perceived by users to be more attractive. However, the available ev idence suggests that serious deficiencies in technical quality are oft en present. Evaluations of interventions to promote evidence-based car e in high income countries have shown that multi-faceted strategies wh ich increase provider knowledge have had some success in improving ser vice quality. A wider range of factors needs to be considered in low a nd middle income countries (LMICs), especially factors which contribut e to discrepancies between provider knowledge and practice. Studies ha ve shown that PPs, especially, perceive or experience patient and comm unity pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specifi c multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and trea tment-taking behaviour, and feasible mechanisms for ensuring and monit oring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, impleme nting and evaluating strategies to improve the quality of service prov ision will depend on the involvement of the key stakeholders, includin g policy makers and PPs, Focusing on studies from Asia, Africa and Lat in America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are sugge sted. Interventions need to be inexpensive, practical, efficient, effe ctive and sustainable over the medium to long term. Achieving this is a significant challenge.