14b IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION THE CHALLENGE Urbanizing countries can struggle to ensure uniform minimum standards of care quality—particularly when the private sector grows quickly but unevenly, with limited government capacity for robust oversight and regulation and limited consumer ability to differentiate between high-and low-quality care. Accreditation and reaccreditation standards in the public sector sometimes do not extend to the private sector, while private sector accreditation bodies can be of mixed quality and subject to abuse. The lack of evidence-based care protocols can also lead to overtreatment, particularly in the context of rising incomes and parallel increases in health-seeking behavior. New approaches are needed to create and apply more universal quality standards while enabling patients to make educated choices about where to seek care. PRIVATE SPENDING, PROVIDERS, FACILITIES, AND MEDICAL SCHOOLS ARE PROLIFERATING… Between 2000 and 2016, private health expenditure in middle-income countries more than doubled—and the market is growing quickly to meet consumer demand.i In India, the number of private hospitals and medical providers grew at rates of 12% to 13% per year between 2000 and 2010; in urban areas, the private sector now provides 79% of ambulatory treatment and 68% of inpatient care.ii Private sector growth also extends to medical education; in many large middle-income countries (MICs), including Bangladesh, India, Indonesia, and Brazil, more than half of all medical schools are now private.iii.”iv …But Governments Are Struggling to Ensure Quality Amidst Rapid Expansion Countries can struggle to ensure equitable care when the private-sector grows very quickly but does not conform with uniform quality standards. At times, public accreditation and reaccreditation standards when they exist) may not extend to the private sector, creating gaps in quality oversight.v In India, where private spending accounts for almost three-quarters Japan Trust Fund for OCTOBER 2018 Scaling Up Nutrition IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION of overall health expenditure,vi the private sector has less qualified health providers; Urbanizing nonetheless, these private providers typically exert more effort and thus offer better care countries can than their more knowledgeable public sector counterparts.vii However, the lack of consistent struggle to ensure private sector standards and qualifications can prove problematic for care of more complex uniform conditions, particularly when it leads to poor treatment. In Mumbai, for example, most private general practitioners in a slum neighborhood are unable to write an appropriate minimum care prescription for drug-sensitive tuberculosis.viii The challenge can also extend to medical standards when education. In Indonesia, one-third of private medical schools lacked any accreditation, while the private sector three-quarters fell short of the highest accreditation standards.ix Patients often lack tools to and demand distinguish high-quality care from inappropriate treatment. grow quickly but government THE PATH FORWARD: TOWARD UNIVERSAL oversight capacity and consumer AND APPROPRIATE QUALITY STANDARDS understanding Expand Public Sector Accreditation and Regulatory Systems to are limited. Private Institutions Countries can expand existing accreditation and reaccreditation standards to private-sector institutions through legal channels or private-sector partnerships (PPPs). Thailand, for example, legally mandated that all medical school graduates pass a common national licensing exam, with re-licensing every five years.x Similarly, Tanzania’s accredited drug dispensing outlet (ADDO) program is a PPP to improve access to quality medicines in retail drug outlets.xi Evidence on the effectiveness of such approaches is promising but limited. A Cochrane review on public-sector stewardship for private sector providers found a handful of studies from MICs; overall, regulatory approaches (sometimes combined with training interventions) appear helpful in improving private-sector quality, but the certainty of the evidence is low.xii Offer Accessible Public Reporting on Quality or Accreditation Social franchising Status can help providers Publicly available reporting on how different providers perform can help patients become highlight quality more discerning consumers of health care; it may also induce positive changes in health worker performance to protect their reputations or to attract patients. Rigorous studies of assurances and public reporting systems are mostly limited to high-income settings, but systematic review access support. evidence suggests that they are associated with consistent and significant reductions in Pakistan’s overall mortality.xiii With increasing mobile phone and internet access, web-based quality Greenstar Network databases may be more applicable in middle-income countries; for a low-tech solution, visits in-network performance data can also be posted on bulletin boards or in other public spaces. In China, providers monthly such reporting has been shown to help reduce antibiotic prescriptionsxiv and improve rational use of medicines.xv so they can receive training, learn Leverage Social Franchising as an Additional Layer of Oversight about new Social franchising allows in-network providers to adopt branding that identifies them as practices, and offering quality-assured services or commodities. The Janani franchise in Bihar, India, for discuss difficult example, repaints signs and wall advertisements for in-network providers on a yearly basis. cases. Franchisees who are expelled or choose not to re-enroll do not get their signage repainted.xvi Social franchising’s emphasis on uniform care can also help introduce a common set of OCTOBER 2018 2 IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION standards across multiple providers. The Greenstar Network in Pakistan provides monthly visits to in-network providers during which they can discuss difficult cases, receive one-on- one training, and learn about new clinical practices.xvii Similarly, the Planned Parenthood Federation of America independently evaluates and re-certifies its local affiliates every four years.xviii A systematic review of clinical social franchising in low- and middle- income countries found that social franchising was positively associated increased client satisfaction, but that its effects on health care utilization and outcomes relative to other models of care were mixed.xix SPOTLIGHT Accredited Drug Dispensing Outlet Program ► Tanzania’s Accredited Drug Dispensing Outlet (ADDO) program used supply- and demand-side interventions to improve the quality of medicines sold at retail drug shops in urban and peri-urban areas. On the supply-side, ADDO focused on helping elevate retail drug shops to accreditation standards via provider training on appropriate medicine use and referral, as well as best practices for improving drug storage and management. The ADDO program ran as a pilot program in one region and eventually rolled out nationwide. In the pilot region, the proportion of unregistered medicines fell from 26 percent to 2 percent,xx and after national rollout 93 percent of samples passed quality tests.xxi Nonetheless, some research suggests that dispensers may still be overprescribing some antibiotics.xxii The success in the initial pilot prompted a nationwide scale-up; by 2013, the program was active in all regions. It also inspired Tanzania’s Ministry of Health and Social Welfare to make an official policy decision (as of 2009) to phase out unaccredited drug stores. Similar initiatives have also been rolled out in Uganda and Liberia; initial results there show a decrease in illegal distribution of injections in Uganda and a reduction in expired, damaged, or counterfeit drugs in Liberia .xxiii The Greenstar Network ► The Greenstar Network in Pakistan is a large network of private providers that receive subsidized supplies, signage, and socially branded contraceptives, as well as training and monthly check-ins to discuss difficult cases. Providers are invited to join the network via the Pakistan Medical Association.xxiv By mid-2017, the network included 7,000 franchised clinics and 70,000 retail outlets. Greenstar Social Marketing (the network’s coordinating body) reports that it has provided 25.5 million couple-years of protection through its network of providers, accounting for 53% of all private-sector contraceptive distribution.xxv A review of the program found that it was associated with an increased number of family planning clients and greater access to family planning among the poor. xxvi However, the review also documented variations in quality-of-care and the pricing of some family planning methods across in-network providers. OCTOBER 2018 3 IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION ENDNOTES i World Bank, “Domestic Private Health Expenditure per Capita (Current US$),” World Bank, accessed September 30, 2018, https://data.worldbank.org/indicator/SH.XPD.PVTD.PC.CD?locations=XP-XN- XT-XM. ii Shailender Kumar, “Private Sector in Healthcare Delivery Market in India: Structure, Growth and Implications,” Working Paper (New Delhi, India: Institute for Studies in Industrial Development, December 2015), http://isid.org.in/pdf/WP185.pdf. iii Tim Evans et al., “Addressing the Challenges of Health Professional Education: Opportunities to Accelerate Progress Towards Universal Health Coverage” (Doha, Qatar: World Innovation Summit for Health, 2016), http://www.wish.org.qa/wp- content/uploads/2018/01/IMPJ4495_WISH_Workforce_REPORT_WEB.pdf. iv Abimbola Olaniran et al., “Who Is a Community Health Worker? - A Systematic Review of Definitions,” Global Health Action 10, no. 1 (2017): 1272223, https://doi.org/10.1080/16549716.2017.1272223. v World Health Organization, “Quality and Accreditation in Health Care Services: A Global Review” (Geneva: World Health Organization, 2003), http://apps.who.int/iris/handle/10665/68410. vi World Bank, “DataBank,” World Bank, 2018, http://databank.worldbank.org/data/home.aspx. vii Jishnu Das, “Money for Nothing: The Dire Straits of Medical Practice in Delhi, India,” Working Paper, World Bank Policy Research Working Paper (Washington, DC: World Bank, July 2005), http://documents.worldbank.org/curated/en/763851468033364319/pdf/wps3669.pdf. viii Zarir F. Udwadia, Lancelot M. Pinto, and Mukund W. Uplekar, “Tuberculosis Management by Private Practitioners in Mumbai, India: Has Anything Changed in Two Decades?,” PLOS ONE 5, no. 8 (August 9, 2010): e12023, https://doi.org/10.1371/journal.pone.0012023. ix Evans et al., “Addressing the Challenges of Health Professional Education: Opportunities to Accelerate Progress Towards Universal Health Coverage.” x Jaratdao Reynolds et al., “A Literature Review: The Role of the Private Sector in the Production of Nurses in India, Kenya, South Africa and Thailand,” Human Resources for Health 11 (April 12, 2013): 14, https://doi.org/10.1186/1478-4491-11-14. xi Edith Patouillard et al., “Can Working with the Private For-Profit Sector Improve Utilization of Quality Health Services by the Poor? A Systematic Review of the Literature,” International Journal for Equity in Health 6, no. 1 (November 7, 2007): 17, https://doi.org/10.1186/1475-9276-6-17. xii Charles S. Wiysonge et al., “Public Stewardship of Private For-Profit Healthcare Providers in Low- and Middle-Income Countries,” The Cochrane Database of Systematic Reviews, no. 8 (August 11, 2016): CD009855, https://doi.org/10.1002/14651858.CD009855.pub2. xiii Paolo Campanella et al., “The Impact of Public Reporting on Clinical Outcomes: A Systematic Review and Meta-Analysis,” BMC Health Services Research 16 (July 22, 2016), https://doi.org/10.1186/s12913-016-1543-y. xiv Lianping Yang et al., “Public Reporting Improves Antibiotic Prescribing for Upper Respiratory Tract Infections in Primary Care: A Matched-Pair Cluster-Randomized Trial in China,” Health Research Policy and Systems 12 (October 10, 2014): 61, https://doi.org/10.1186/1478-4505-12-61. xv Xuan Wang et al., “Effect of Publicly Reporting Performance Data of Medicine Use on Injection Use: A Quasi-Experimental Study,” ed. Kenneth Bond, PLoS ONE 9, no. 10 (October 14, 2014): e109594, https://doi.org/10.1371/journal.pone.0109594. xvi Dominic Montagu, “Franchising of Health Services in Low-Income Countries,” Health Policy and Planning 17, no. 2 (June 2002): 121–30. xvii Montagu. xviii Montagu. xix Naomi Beyeler, Anna York De La Cruz, and Dominic Montagu, “The Impact of Clinical Social Franchising on Health Services in Low- and Middle-Income Countries: A Systematic Review,” ed. Chris Bullen, PLoS ONE 8, no. 4 (April 23, 2013): e60669, https://doi.org/10.1371/journal.pone.0060669. xx Edmund Rutta et al., “Accrediting Retail Drug Shops to Strengthen Tanzania’s Public Health System: An ADDO Case Study,” Journal of Pharmaceutical Policy and Practice 8 (2015): 23, https://doi.org/10.1186/s40545-015-0044-4. xxi Rutta et al. OCTOBER 2018 4 IMPROVE ACCREDITATION, REGULATION, AND QUALITY STANDARDS… FOR EQUITABLE CARE AMIDST RAPID GROWTH AND URBANIZATION xxii Martha Embrey et al., “Understanding the Role of Accredited Drug Dispensing Outlets in Tanzania’s Health System,” ed. Vicki Marsh, PLOS ONE 11, no. 11 (November 8, 2016): e0164332, https://doi.org/10.1371/journal.pone.0164332. xxiii Rutta et al., “Accrediting Retail Drug Shops to Strengthen Tanzania’s Public Health System.” xxiv Asma M. Qureshi, “Case Study: Does Training of Private Networks of Family Planning Clinicians in Urban Pakistan Affect Service Utilization?,” BMC International Health and Human Rights 10, no. 1 (November 9, 2010): 26, https://doi.org/10.1186/1472-698X-10-26. xxv Greenstar, “Greenstar Social Marketing (GSM),” Greenstar, 2016, https://www.greenstar.org.pk/family_planning. xxvi J. McBride and R. Ahmed, “Social Franchising as a Strategy for Expanding Access to Reproductive Health Services: A Case Study of the Green Star Service Delivery Network in Pakistan,” Commercial Market Strategies Technical Paper Series (Washington, DC: USAID, September 2001), https://www.popline.org/node/251253. REFERENCES Beyeler, Naomi, Anna York De La Cruz, and Dominic Montagu. “The Impact of Clinical Social Franchising on Health Services in Low- and Middle-Income Countries: A Systematic Review.” Edited by Chris Bullen. PLoS ONE 8, no. 4 (April 23, 2013): e60669. https://doi.org/10.1371/journal.pone.0060669. Campanella, Paolo, Vladimir Vukovic, Paolo Parente, Adela Sulejmani, Walter Ricciardi, and Maria Lucia Specchia. “The Impact of Public Reporting on Clinical Outcomes: A Systematic Review and Meta- Analysis.” BMC Health Services Research 16 (July 22, 2016). https://doi.org/10.1186/s12913-016- 1543-y. 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Yang, Lianping, Chaojie Liu, Lijun Wang, Xi Yin, and Xinping Zhang. “Public Reporting Improves Antibiotic Prescribing for Upper Respiratory Tract Infections in Primary Care: A Matched-Pair Cluster- Randomized Trial in China.” Health Research Policy and Systems 12 (October 10, 2014): 61. https://doi.org/10.1186/1478-4505-12-61. OCTOBER 2018 6