Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Engaging Private Health Care Providers to Identify Individuals with TB in Nepal

In Nepal, 47% of individuals who fell ill with TB were not reported to the National TB Program in 2018. Approximately 60% of persons with TB initially seek care in the private sector. From November 2018 to January 2020, we implemented an active case finding intervention in the Parsa and Dhanusha districts targeting private provider facilities. To evaluate the impact of the intervention, we reported on crude intervention results. We further compared case notification during the implementation to baseline and control population (Bara and Siraha) notifications. We screened 203,332 individuals; 11,266 (5.5%) were identified as presumptive for TB and 8077 (71.7%) were tested for TB. Approximately 8% had a TB diagnosis, of whom 383 (56.2%) were bacteriologically confirmed (Bac+). In total, 653 (95.7%) individuals were initiated on treatment at DOTS facilities. For the intervention districts, there was a 17%increase for bacteriologically positive TB and 10% for all forms TB compared to baseline. In comparison, the change in notifications in the control population were 4% for bacteriologically positive, and −2% all forms. Through engagement of private sector facilities, our intervention was able to increase the number of individuals identified with TB by over 10% in the Parsa and Dhanusha districts.

Costs incurred by patients with oral potentially malignant disorders: is there a public health need for financial protection in India?

Objectives Financial protection mechanisms are in place to overcome the costs of a few diseases in India. Our objective was to estimate the costs incurred due to Oral Potentially Malignant Disorders (OPMD) and to determine predictors of such costs. Results We found that the median (Interquartile range IQR) total costs of OPMD was Indian Rupees (INR) 500 (350–750), direct medical costs was INR 0 (0–50), direct non-medical costs was INR 150 (40–200) and indirect costs was INR 350 (250–500). The travel cost to attend the health facilities [INR 100 (40–150)] and the patient’s loss of wages [INR 200 (150–400)] mainly accounted for the direct non-medical and indirect costs respectively. The median expenditure on smokeless and smoking forms of tobacco was INR 6000 (5400–7200) and INR 2400 (1800–3600) respectively. On multiple linear regression analysis, rural residence, belonging to below poverty line family, being a sole earner in the family, number of months since diagnosis and first visit at a private provider were found to be the significant predictors of total costs of OPMD. Financial protection mechanisms are needed for covering the direct non-medical and indirect costs. Early management of OPMD might mitigate the costs of OPMD.

Recognizing and mediating bureaucratic barriers: increasing access to care through small and medium-sized private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers. Expanding purchasing arrangements has helped many countries integrate private providers into government-supported payment schemes, reducing financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in these schemes. The difficulties of this process are exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and “street-level” SHI bureaucrats. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a governance environment where regulations are weak and impermanent, street-level bureaucrats often created an accreditation process that was inconsistent and opaque. Support from the implementing organizations increased communication between SHI officials and providers, which clarified rules and increased providers’ confidence in the system. The intermediaries also reduced bureaucrats’ ability to apply regulations at will and helped to standardize the accreditation process for both providers and bureaucrats. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses and facilitate process efficiency. However, intermediaries only have a temporary role to play where there is potential to: 1) directly increase private providers’ power in a complex regulatory system; 2) reform the system itself to be more responsive to the limitations of on-the-ground implementation.

Quality of antenatal care and its sociodemographic determinants: results of the 2015 Pelotas birth cohort, Brazil

Background Inadequate antenatal care (ANC) has been associated with adverse pregnancy outcomes. ANC quality is considered a key component of the right to health and a route to equity and dignity for women and their children. Although ANC coverage is relatively high in Brazil, there are revealed some health disparities when coverage is examined by socio-demographic determinants. In this study we evaluated ANC quality and its socio-demographic determinants using data from the 2015 Pelotas birth cohort, Rio Grande do Sul, Brazil. Methods This study is part of the 2015 Pelotas population-based birth cohort (n = 3923 pregnant women) conducted in southern Brazil. ANC quality was assessed through 19 content and service utilization indicators recommended by the Brazilian Ministry of Health. Descriptive analyses and associations of each of the ANC indicators and independent variables were performed using the chi-square and linear trend test. ANC indicators were analyzed individually and aggregated as a score. Associations between ANC score quality and socio-demographic variables were assessed with ordinal regressions. Mediation analysis with G-computation was performed to estimate direct and indirect effect of mother’s level of education on ANC quality mediated by the number of consultations and timing of ANC initiation. Base and post confounders were included. Results The results showed that except for breast examination, height measurement, tetanus toxoid vaccination and ANC starting at the first trimester, all ANC indicators showed more than 80% coverage during ANC visits. In the adjusted analysis, inadequate quality ANC was associated with lower maternal education level, not having a partner, being multiparous, being attended by a private provider and by the same professional in all consultations. In the mediation analyses, 6.8% of the association between ANC quality and mother’s education was mediated by the trimester in which ANC started, while 12.8% was mediated by the number of ANC visits. Conclusions ANC quality is associated with pregnant women’s socio-demographic characteristics. Significant efforts are needed to improve the quality of facility-based maternity care.

Long Live Marketization for Local Public Spaces: A Study of Scandinavian Managers’ Satisfaction with Private Provider Performance

Continued critiques, evidence and newer reform trends have increasingly contested the use of market-centered models–the competition prescription–for urban public space maintenance as well as other local services. This article adopts a contextualized contingency perspective on the competition prescription and questions the contested status of market-centered models in a survey-based study of the current use of and satisfaction with private providers for maintenance of parks/greenspaces and road/streets in Scandinavian local governments. The study finds widespread use of and satisfaction with private providers. However, satisfaction depends on national context and multiple contingencies. The study challenges the contested status of market-centered models, highlights that different models serve different strategic objectives, and directs attention to discussions of context and key contingencies that define how well market-centered models perform.

TB case fatality and recurrence in a private sector cohort in Mumbai, India

BACKGROUND: Half of India´s three million TB patients are treated in the largely unregulated private sector, where quality of care is often poor. Private provider interface agencies (PPIAs) seek to improve private sector quality of care, which can be measured in terms of case fatality and recurrence rates.METHODS: We conducted a retrospective cohort survey of 4,000 private sector patients managed by the PATH PPIA between 2014 and 2017. We estimated treatment and post-treatment case-fatality ratios (CFRs) and recurrence rates. We used Cox proportional hazards models to identify predictors of fatality and recurrence. Patient loss to follow-up was adjusted for using selection weighting.RESULTS: The treatment CFR was 7.1% (95% CI 6.0–8.2). At 24 months post-treatment, the CFR was 2.4% (95% CI 1.7–3.0) and the recurrence rate was 1.9% (95% CI 1.3–2.5). Treatment fatality was associated with age (HR 1.02, 95% CI 1.02–1.03), clinical diagnosis (HR 0.61, 95% CI 0.45–0.84), treatment duration (HR 0.09, 95% CI 0.06–0.10) and adherence. Post-treatment fatality was associated with treatment duration (HR 0.87, 95% CI 0.79–0.91) and adherence.CONCLUSIONS: We found a moderate treatment phase CFR among PPIA-managed private sector patient with low rates of post-treatment fatality and recurrence. Routine monitoring of patient outcomes after treatment would strengthen PPIAs and inform future post TB interventions.

Recognizing and mediating bureaucratic barriers: increasing access to care through small private providers in Kenya

Background: Equitable access to health services can be constrained in countries where private practitioners make up a large portion of primary care providers, making affordability a challenge. Expanding purchasing arrangements in many countries has helped integrate private providers into government-supported payment schemes and reduced financial barriers to care. However, private providers often must go through an onerous accreditation process to enroll in government-supported financing arrangements. The difficulties of this process can be exacerbated where health policy is changed often and low-level bureaucrats must navigate these shifts at their own discretion, effectively re-interpreting or re-making policy in practice. This paper analyzes one initiative to increase private provider accreditation with social health insurance (SHI) in Kenya by creating an intermediary between providers and SHI officials. Methods: This paper draws on 126 semi-structured interviews about SHI accreditation experience with private providers who were members of a franchise network in Kenya. It also draws on four focus group discussions conducted with franchise representatives who provided accreditation support to the providers and served as liaisons between the franchised providers and local SHI offices. There was a total of 20 participants across all four focus groups. Results: In a regulatory environment where regulations are weak and impermanent, officials created an accreditation process that was inconsistent and opaque: applying rules unevenly, requesting bribes, and minimizing communication with providers. The support provided by the implementing organizations clarified rules, reduced the power of local bureaucrats to apply regulations at their own discretion, gave providers greater confidence in the system, and helped to standardize the accreditation process. Conclusions: We conclude that intermediary organizations can mitigate institutional weaknesses, reduce barriers to effective care expansion caused by street-level bureaucrats, and facilitate the adoption of systems which reduce rent-seeking practices that might otherwise delay or derail initiatives to reach universal health coverage.

Estimating the pre- and post-diagnosis costs of tuberculosis care for adults in Karachi, Pakistan: Household economic impact and strategies for meeting the costs

Background Despite of free TB care in Pakistan, patients still have to bear high costs which push them more into poverty. This study estimated the types of costs households bear for TB care, and coping mechanisms used for bearing TB expenditures among adults ≥ 18 years in Karachi, Pakistan. Methods A total of 516 TB patients with completion of at least one month intensive treatment were recruited from four public sector hospitals in Karachi, Pakistan. A standardized questionnaire to estimate patient's costs was administered. Direct medical and non-medical costs incurred as out-of-pocket and indirect costs (loss of income) during pre-diagnostic, diagnostic, treatment and hospitalization phase were estimated. Results Out of 516 participants, 52.1% were female with a mean age of 32.4 (± 13.7) years. The median costs per patient borne during the pre-diagnostic, diagnostic, treatment and hospitalization was estimated at USD63.8/ PKR7377, USD24/ PKR2755, USD10.5/ PKR1217 and USD349.0/ PKR40300, respectively. The total household median costs was estimated at USD129.2/ PKR14919 per patient. The median indirect costs were estimated at USD52.0/ PKR5950 per patient. First point of care was a private provider by 54.1% of patients, 36% attended public service, 5% and 4.1% went to dispensary and pharmacy, respectively. Conclusion TB patients bear substantial out-of-pocket costs before they are enrolled in publically funded TB program. There should be provision of transport and food vouchers, also health insurance for in-patient treatment. This advocates a critical investigation into an existing financial support network for TB patients in Pakistan with an eye towards easing the burden.