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Abstract
The private health sector is becoming increasingly important in discussions on improving the quality of care for maternal and newborn health (MNH). Yet information rarely addresses what engaging the private sector for MNH means and how to do it. In 2019, the Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network) initiated exploratory research to better understand how to ensure that the private sector delivers quality care and what the public sector must do to facilitate and sustain this process. This article details the approach and lessons learnt from two Network countries, Ghana and Nigeria, where teams explored the mechanisms for engaging the private sector in delivering MNH services with quality. The situational analyses in Ghana and Nigeria revealed challenges in engaging the private sector, including lack of accurate data, mistrust and an unlevel playing field. Challenging market conditions hindered a greater private sector role in delivering quality MNH services. Based on these analyses, participants at multistakeholder workshops recommended actions addressing policy/administration, regulation and service delivery. The findings from this research help strengthen the evidence base on engaging the private sector to deliver quality MNH services and show that this likely requires engagement with broader health systems factors. In recognition of this need for a balanced approach and the new WHO private sector strategy, the WHO has updated the tools and process for countries interested in conducting this research. The Nigerian Ministry of Health is stewarding additional policy dialogues to further engage the private sector.
- private health sector
- maternal health
- newborn health
- Ghana
- Nigeria
- quality of care
Data availability statement
Data are available upon reasonable request. The tools and processes used to conduct this work are publicly available. The policy dialogue guide, study protocols, interview guides, templates and findings are available on the Quality of Care Network web page at https://www.qualityofcarenetwork.org/private-sector/engaging-private-sector-quality-care-maternal-newborn-and-child-health. See 'Country learnings' to navigate through the documents for each country. See 'Policy dialogue process' to view the steps and supporting documents for conducting policy dialogues.
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Summary box
With an increasing proportion of mothers and newborns accessing care in the private sector, achieving universal health coverage with quality requires engaging the private sector and working with everyone involved in delivering maternal and newborn health (MNH) care.
In Ghana and Nigeria, colleagues from the Ministries of Health and WHO country offices conducted situational analyses and policy dialogues on the private sector’s involvement in delivering quality care for MNH, with support from the WHO, the Network Secretariat and country-level working groups.
The findings from Ghana and Nigeria revealed numerous challenges in engaging the private sector, including lack of accurate data on the private health sector, mistrust between the public and private sectors, cumbersome and complicated quality policy frameworks and regulatory systems, and poor market conditions that hindered a greater private sector role in delivering MNH services.
While adding a programmatic lens to engagement of the private sector can help operationalise this work, analyses from Ghana and Nigeria show that successful private sector engagement will likely require addressing other aspects of the health system (eg, financing, regulation, building capacity of the Ministries of Health for improved stewardship and governance of mixed health systems) that are broader than one programme alone.
Introduction
To achieve universal health coverage and the Sustainable Development Goals, health systems must increase the coverage, quality and equity of interventions. Delivering high-quality care across the entire health system (both public and private sectors) could prevent 60% of deaths, including half of all maternal deaths annually.1 Quality of care can also improve respectful care and uptake of skilled birth attendance.2
Private health providers deliver an important and growing share of maternal and newborn health (MNH) care in low-income and middle-income countries.3 More women and children are accessing services in the private health sector and are referred to or from the private sector in their care-seeking journey. The private sector includes individuals and organisations involved in providing health services (ie, for-profit and not-for-profit entities; providers in the formal and informal sectors; and domestic and international actors, charities, faith-based organisations and non-governmental groups) that are neither owned nor directly controlled by governments.4 In low-income and middle-income countries, the private health sector has a mean market share for antenatal care of 44% and a mean market share for delivery care of 40%.5
The Nigerian private health sector provides an estimated 60% of maternal, newborn and child health (MNCH) services (eg, institutional delivery, antenatal care, routine immunisation, contraceptives).6 A higher percentage of women deliver in private health facilities in the southeast (eg, Imo State 71% and Anambra State 53%) than the northwest or northeast.7 Faith-based organisations, like the Christian Health Association of Nigeria, provide a significant proportion of maternal and child health services across all levels of care (ie, primary, secondary and tertiary), serving both rural populations and the urban poor.8 Nurses and midwives tend to run small, for-profit clinics and maternity homes that are patronised by low-income and middle-income populations located in periurban, rural and underserved communities. For-profit tertiary facilities with a full range of MNCH services (including neonatal intensive care facilities) tend to operate in urban settings, where mainly high-income groups can afford their services.9
In Ghana, private health providers deliver over half of all consumer health services, 11% of antenatal care services and 11% of institutional deliveries.10 11 These figures vary by geography and socioeconomic status. In rural areas, 6% of women accessed private antenatal care services, while in urban areas 16% of women accessed private antenatal care services.10 Among the lowest wealth quintile, less than 3% of women accessed private antenatal care services, while among the highest wealth quintile 24% of women accessed private antenatal care services.10 The Ministry of Health has memorandums of understanding with the Christian Health Association of Ghana (CHAG), the Ahmadiyya Muslim Mission and the Ghana Association of Quasi Health Institutions to deliver health services to select populations like the underserved. While faith-based organisations like the CHAG tend to offer a full range of MNH services, some self-financing facilities (also referred to as for-profit or commercial) tend to focus on providing antenatal care due to market barriers that prevent them from expanding into tertiary neonatal intensive care.12
Despite the perception that the private health sector provides higher quality services than the public health sector, knowledge gaps persist around the benefits of private sector care.13 Engaging the private sector in the quality of care agenda for MNH is further complicated by limited capacity of governments to steward mixed health systems and missed opportunities for cross-sector knowledge transfer and learning. For example, guidance developed by the Ministries of Health is often not transferred to the private sector with the same speed at which it is transferred to the public sector. Data on care provided in the private sector may not be reflected in the health management information system and overall MNH accountability system. Quality of care experiences, best practices and innovations are being developed in either the public sector or the private sector, yet cross-sector learning and cross-sector transfer of this knowledge rarely occur. With an increasing proportion of mothers and newborns accessing care in the private sector, these gaps and missed opportunities must be addressed. Achieving universal health coverage with quality requires the meaningful inclusion of private providers for service delivery in mixed health systems (also known as ‘private sector engagement’)14 15 and working with everyone involved in delivering MNH care.
In 2019, at the request of its members, the Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network) initiated exploratory research to better understand how to ensure that the private sector delivers quality care and what the public sector must do to facilitate and sustain this process. This article details the approach and lessons learnt from two Network countries, Ghana and Nigeria, where country teams explored the mechanisms for engaging the private sector in delivering MNH services with quality.
Our approach
The private sector is becoming increasingly important in discussions on improving the quality of care for MNH. Yet, apart from sporadic reports, information rarely addressed what engaging the private sector for MNH means and how to do it. As an entry point, the WHO and the Network Secretariat approached this project from a quality of care for MNH lens. We established a global advisory working group to help identify the project scope—MNH service delivery in the formal private sector—and to provide input on the project methods and tools. This focus included preventive, promotive and curative services within the private sector, as well as the policies and regulations affecting the delivery of quality MNH services. Traditional and informal private sector providers (eg, traditional birth attendants, peddlers) were beyond the scope of this project as were private service aspects in relation to service delivery (eg, supply chain, education/training, insurance providers). The WHO collaborated with the Ministries of Health in Ghana and Nigeria to engage teams to examine the mechanisms for engaging the formal private sector in the delivery of quality care for MNH.
Following our review of the literature as well as inputs from colleagues and our global advisory working group,16 we adapted Bryce et al’s17 evaluation framework for the scale-up for maternal and child survival to guide this work. The project logic model (figure 1) depicts the key components of the private sector’s engagement in delivering quality MNH services within health systems. These components (eg, leadership, market competitiveness, behaviour change) are organised by the five domains under which they operate: inputs, processes, outputs, outcomes and impact. Equity and contextual factors (eg, political, technological, administrative) may affect progress of these pathways.
Project logic model for mapping the private sector’s engagement in delivering quality for MNH as part of the national health system. MNH, maternal and newborn health. QoC, quality of care.
The Ministries of Health in Ghana and Nigeria, supported by the WHO country offices, conducted situational analyses on the private sector’s involvement in delivering quality of care for MNH, with assistance from the Network Secretariat and country-level working groups. Three components comprised this analysis: a literature review focusing on grey literature and country context; a stakeholder assessment; and key informant interviews. The situational analyses were then shared with attendees at multistakeholder dialogues in each country, where participants reviewed and validated the findings. With the challenges identified, participants prioritised key issues hindering the effective engagement of the private sector in delivering quality of care for MNH. These issues addressed the thematic areas of policy/administration, regulation and service delivery. Based on the key challenges and solutions identified via the situational analysis and multistakeholder workshop, stakeholders proposed recommended actions for engaging the private sector.
Lessons learnt on private sector engagement in Ghana
The situational analysis in Ghana, conducted in 2020, revealed a number of challenges in engaging the private sector, including lack of accurate data on the private health sector and mistrust between the public and private sectors.12 The absence of a convening platform and regular dialogue between the public and private health sectors may contribute to mistrust and misunderstandings. Numerous stakeholders spoke of cumbersome and complicated quality policy frameworks and regulatory systems. Challenging market conditions hindered a greater private sector role in delivering MNH services. Private sector respondents reported a number of factors that deterred them from filling market gaps and delivering quality MNH services beyond antenatal care, such as lack of viable credit options, delayed reimbursements from the National Health Insurance Scheme, and uneven government support depending on whether the organisation was faith-based or self-financing.
One particular challenge was fragmentation of the self-financing private sector as it was poorly organised and lacked representative organisations to advocate on behalf of its members. Without concerted collaboration across the self-financing private sector and the private health sector as a whole, it was difficult for the private sector to effectively dialogue and engage with the public health sector on national priorities including MNH. This fragmentation also contributed to an unlevel playing field between all private sector actors. As a result, the situational analysis found that it was easier for selected private actors, like the CHAG which has a special relationship with the Ministry of Health, to engage with the public health sector and to deliver quality MNH services.12
In January 2021, the Ministry of Health convened a multistakeholder dialogue in Accra to develop recommended actions for engaging the private sector in Ghana (table 1). Over 50 representatives participated from the public and private health sectors, including the Ministry of Health, the Ministry of Gender and Social Protection, the self-financing private sector and development partners.18 Within policy and administration, the recommended actions emphasised developing legislative instruments and updating the private sector policy from 2013. Within regulation, the broad message was to improve regulation not just for the sake of regulation but to improve collaboration, engagement, accountability and transparency between the public and private sectors. Finally, the recommended actions under service delivery addressed resources/support for the private sector and strengthening linkages and referrals between both sectors.
Summary of recommended actions from Ghana by thematic area
In reflecting on the findings in the situational analysis and the outcomes of the multistakeholder dialogue in Ghana, it is clear that achieving success in MNH requires that the public sector engage the private sector in every step of the process. This process starts with building trust and communication between parties. Stakeholder engagement needs to be institutionalised in the Ministry of Health, with regular exchanges between the public and private sectors. When establishing this mechanism for public–private dialogue, an independent facilitator who can bring information together and support the process may add value.
Immediate opportunities exist to facilitate the delivery of quality MNH care, including harmonising quality structures, strengthening case referrals, and improving data sharing, reporting and analytics. The outdated referral policy needs to be reviewed and updated to include opportunities for public service providers to refer patients to private providers in instances when appropriate facilities exist to receive the patient. Revising the referral policy also needs to address the cost of care in the private sector, as the National Health Insurance Authority takes care of MNH in public facilities.
Greater attention is needed in the development of an enabling environment for the private sector to deliver quality MNH services. Financial mechanisms (eg, viable credit options, vouchers) and health insurance tariffs for the private sector must be revisited to ensure they are adequate, as delivering quality care requires the availability of resources. Human resources are another challenge, as most private facilities struggle to recruit full-time staff and rely on locum staff. This shortage also contributes to private facilities requesting the secondment of public sector staff. Lastly, harmonising and streamlining regulatory requirements and assessment standards would benefit both the public and private health sectors.
The Ministry of Health leadership and ownership of the process and its outcomes were crucial. Following the multistakeholder dialogue meeting in Ghana, the Ministry of Health has constituted a task team to facilitate the implementation of the recommended actions and has disseminated the findings of the situational analysis report to its stakeholders. The Ministry of Health will use the reports from the situational analysis and multistakeholder dialogue as a guide in developing any future policies and strengthening engagement of the private health sector in Ghana.
Lessons learnt on private sector engagement in Nigeria
Despite the significant role that the non-profit and for-profit private sector plays in Nigeria, the situational analysis conducted in late 2020 and early 2021 revealed challenges that hinder private sector engagement in delivering quality MNH services.9 19 Private sector actors reported a reluctancy to report and share data with the government. This reluctancy stemmed from lack of support and incentives, as well as concern over how the information would be used, such as raising taxes on their services/businesses. The presence of numerous regulatory structures contributed to confusion, and unfavourable market conditions hindered the delivery of quality MNH care.
In June 2021, the Federal Ministry of Health convened a multistakeholder dialogue in Abuja to develop recommended actions for engaging the private sector in Nigeria (table 2). Forty-five representatives participated from the public sector, the private health sector, civil society organisations, professional associations, academia and development partners.19 Within policy and administration, the recommended actions emphasised the need for an enabling environment, greater engagement of the for-profit private sector and involvement of the private sector in developing health policies. Within regulation, the recommended actions addressed ensuring adequate resources for regulation, active involvement of the private sector in regulation and strengthening data sharing and tools. The recommended actions under service delivery focused on costs of delivering quality services, better participation of the private sector in technical working groups, and improved dissemination of quality standards and guidelines to private providers. Finally, the workshop developed recommended actions for creating an enabling environment for the private sector that included access to financial services.
Summary of recommended actions from Nigeria by thematic area
In reflecting on the findings in the situational analysis and the outcomes of the multistakeholder dialogue in Nigeria, the national stakeholders concluded that the government needs to provide the necessary stewardship for the private sector to ensure quality MNH services. This stewardship involves regularly engaging with private sector associations to understand their challenges, as well as involving both for-profit and not-for-profit private sector stakeholders in the development of national health policies and implementation strategies. These policies, strategies, plans, guidelines and quality standards must then be thoroughly disseminated to relevant private sector actors as must data tools (eg, health management information system registers, tally sheets).
Supporting the private sector also includes establishing a public–private platform for dialogue and engagement, strengthening the technical capacity of the Federal Ministry of Health staff to effectively engage the private sector, expanding public–private partnerships, engaging the private sector in formulating and implementing health policy, and using an independent technical facilitator to broker information for private sector engagement. Engaging the private sector in delivering quality MNH services will take time and will require face-to-face interactions to establish trust and regular communication. Finally, strong regulatory and accountability frameworks for monitoring, evaluation and certification of private health facilities are required to gauge the progress of engaging the private health sector.
The Federal Ministry of Health is taking forward key messages to all stakeholders that engaging the private sector is crucial to achieving universal health coverage goals in Nigeria. Creating an enabling environment for the private sector to deliver quality MNH care benefits both the public and private health sectors. This research has provided a baseline for improving the structure and coordination to adequately engage private healthcare associations in health regulation.
Moving the agenda forward
To effectively engage with the private sector, it is important to understand the sector’s challenges as well as the factors that would incentivise its adoption of quality of care standards. Data are key. Enhancing the private sector’s ability to collect and use its own data is a particular challenge. Private providers in Ghana and Nigeria shared that the reporting requirements are often unclear. Some providers expressed a reluctance to share data with the government since they did not know how their data would be used. Providing clarity to members of the private sector on how their data contribute to national goals could improve reporting at private facilities. Establishing strong mechanisms and incentives to report data can also lead to improved willingness among private providers.20 21
Additionally, it is important to review the effectiveness of existing referral systems and opportunities for improvements. These systems include case referral processes between private and public sector facilities for MNH cases, such as the private sector referring to tertiary public facilities or crowded public sector facilities referring to qualified private sector facilities. These systems also include referral processes within the private sector (eg, revisiting private sector ambulance services). Building more effective, timely and streamlined pathways for care would help improve the quality of the entire health system as well as MNH outcomes.
Based on the findings from Ghana and Nigeria, stakeholder engagement should be institutionalised and should happen regularly to build trust through public–private dialogue. There is also a clear need for an enabling environment. A lack of access to affordable financing options prevented many private providers, particularly clinics and maternity homes, from investing in quality improvement programmes and from expanding to meet increased demand for quality MNH services. The recommended actions developed at the stakeholder dialogues point to a recognition of the role of the government (which could include multiple government entities such the Ministry of Health, regulators and insurers) to create an enabling environment that includes regulatory and financing systems. Financial mechanisms, including payment and reimbursement under national and state health insurance, as well as access to credit facilities for the private sector, must be revisited to ensure they facilitate quality MNH service delivery.
Without an enabling environment and trust among the public and private sectors, the private sector may not be able to fully participate in all technical, programmatic and financial efforts offered by the government (eg, trainings, policy dialogues, result-based financing). In Ghana and Nigeria, for instance, it is difficult for the private sector to know the current policy and technical guidelines that would enable them to effectively operate and deliver quality MNH services in every context. Greater attention is needed to engage the private sector, particularly for-profit actors, and to ensure key technical information is disseminated throughout the private sector.
Ghana and Nigeria are only two countries, but these examples help strengthen the evidence base. They also provided valuable inputs in operationalising the WHO strategy for engaging the private sector in health. Forthcoming findings from Bangladesh will provide additional insights into how the private sector is functioning in an Asian context to deliver quality MNH services. Countries in the Network and beyond are actively searching for more information about how to effectively engage the private sector in delivering quality of care. Whether teams are starting at the beginning with familiarisation of private sector concepts or are establishing processes for transferring knowledge between the public and private sectors, it is clear that greater involvement of private sector requires enriching the existing evidence base.
The project’s global advisory working group noted a tension in the country-level recommended actions, as these focused on health system reform and were not specific to MNH. Additional research and disaggregation of country-level data by provider type may generate firmer conclusions and help clarify whether it is worth approaching engagement of the private sector from an MNH lens. While adding a programmatic lens to engagement of the private sector can help operationalise this work, including the private sector governance behaviours,15 the analyses from Ghana and Nigeria show that factors to engage the private sector in delivering quality MNH care most likely lie within other aspects of the health system (eg, financing, regulation) which are broader than one programme alone.
End users of MNH services—women, communities and representative civil society organisations—are an important stakeholder voice that was not involved directly in the multistakeholder process. As countries navigate engaging the private sector to deliver quality MNH services, the voice of the community is especially important to include when deliberating and making decisions about issues of regulation and policies developed for private sector participation and engagement in service delivery. Issues of inclusion and equitable access will need to be part of the deliberations during these private sector engagement processes.
Conclusion
In recognition of this need for a balanced approach, the WHO and the Network Secretariat have updated the tools and process (see Data availability statement section) for teams wishing to conduct this research. These updated tools and processes also reflect the new WHO private sector strategy and governance behaviours,15 as well as best practices from the newly launched Country Connector on Private Sector in Health, such as the OpenWHO training on engaging the private sector. We encourage interested countries to draw on the process and resources to identify opportunities for improved engagement of the private sector when planning and implementing their national quality of care plans and processes for MNH. We encourage partners to support countries in implementing the recommended actions that result from this work.
Data availability statement
Data are available upon reasonable request. The tools and processes used to conduct this work are publicly available. The policy dialogue guide, study protocols, interview guides, templates and findings are available on the Quality of Care Network web page at https://www.qualityofcarenetwork.org/private-sector/engaging-private-sector-quality-care-maternal-newborn-and-child-health. See 'Country learnings' to navigate through the documents for each country. See 'Policy dialogue process' to view the steps and supporting documents for conducting policy dialogues.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the WHO, the Ghana Health Service Ethics Review Committee and the Nigerian National Health Research Ethics Committee. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We wish to thank David Clarke, Anna Cocozza and Aurelié Paviza (WHO) for their contributions to the wider discussions around this research. We thank Roseline Doe and Paul Dsane-Aidoo (WHO Country Office Ghana) for engaging with the Ministry of Health to facilitate and implement the process. We thank Maraki Fikre, Elom Otchi and Suleiman Yakubu (independent consultants) for their involvement in data collection and analysis, as well as Mikael Ostergren (independent consultant) for supporting the policy dialogue process. Lastly, we thank the members of our Advisory Working Group on Private Sector Delivery of Quality Maternal and Newborn Health Care for their advice and inputs. The content of this abstract/manuscript/presentation/website represents the views and opinions of the authors/organisations and does not necessarily reflect the views and opinions of the US Agency for International Development (USAID) or the US Government.
Footnotes
Handling editor Seye Abimbola
Twitter @slattof, @ojomuyiwa, @TedbabeDegefie
Contributors BM, NY and SRL conceived the idea for the manuscript. SRL wrote the first draft of the manuscript with input from BM and NY. All authors contributed to subsequent revisions and approved the manuscript prior to its submission. SRL is the guarantor.
Funding This work was supported by the MSD for Mothers and the Maternal, Newborn, Child and Adolescent Health and Ageing Department of the WHO. MSD for Mothers had no role in the design and development of the study protocol or the decision to publish.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.