Wenjuan Wang

Sara Sulzbach

Susna De

Utilization of HIV-Related Servic

from the Private Health Sector

A Multi-Country Analysis

February 2010

This document was produced for review by the United States Agency for 

International Development. 

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The DHS Working Papers series is an unreviewed and unedited prepublication series of papers reporting 

on research in progress based on Demographic and Health Surveys (DHS) data. This research was carried 

out with support provided by the United States Agency for International Development (USAID) through 

the MEASURE DHS project (#GPO-C-00-03-00002-00). The views expressed are those of the authors 

and do not necessarily reflect the views of USAID, the United States Government, or the organizations to 

which the authors belong. 

MEASURE DHS assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. Additional information about the MEASURE DHS project can 

be obtained by contacting ICF Macro, Demographic and Health Research Division, 11785 Beltsville 

Drive, Suite 300, Calverton, MD 20705 (telephone: 301-572-0200; fax: 301-572-0999; e-mail: 

reports@macrointernational.com; internet: www.measuredhs.com).
Utilization of HIV-Related Services from the Private Health Sector: 

A Multi-Country Analysis 

Wenjuan Wang1

 

Sara Sulzbach2 

Susna De3 

February 2010 

Corresponding authors: Wenjuan Wang, International Health and Development Division, ICF 

Macro, 11785 Beltsville Drive, Calverton, Maryland 20705, USA; Phone: 301-572-0398; Fax: 

301-572-0983; Email: wenjuan.wang@macrointernational.com.

1

International Health and Development Division, ICF Macro 

2

International Health Division, Abt Associates Inc. 

3

Office of Health and HIV/AIDS, USAID/Namibia 
ACKNOWLEDGEMENTS

Funding for this research was provided by the United States Agency for International 

Development (USAID) through the Private Sector Partnership-One project (#GPO-I-00-04-

00007-00) at Abt Associates Inc. Additional support for editing, formatting, and printing this 

working paper was also provided by USAID through the MEASURE DHS project (#GPO-C-00-

08-00008-00) at ICF Macro. Authors thank Kathryn Banke, Vinod Mishra, and Astou Coly for 

useful comments. Authors also thank Obiko Magvanjav for helping with literature review, 

Bryant Robey for editing, and Yuan Gu for formatting the working paper. 

Suggested citation: 

Wang, Wenjuan, Sara Sulzbach, and Susna De. 2009. Utilization of HIV-Related Services from 

the Private Health Sector: A Multi-Country Analysis. DHS Working Papers No. 67. Calverton, 

Maryland, USA: ICF Macro. 
ABSTRACT 

Increasing the participation of private health providers in the AIDS response will help to achieve 

the global goal of “universal access to comprehensive HIV prevention, treatment, care and 

support”. Yet little is known about the extent to which the private health sector is delivering 

HIV-related services. This study uses data from the Demographic and Health Surveys (DHS) and 

AIDS Indicators Surveys (AIS) from 12 countries in Africa, Asia, and Latin America and the 

Caribbean to explore use of HIV testing and STI care from the private for-profit sector, and its 

association with household wealth status. 

The analysis indicates that the private for-profit health sector is active in HIV-related 

service delivery, although the level of participation varies by region and country. From 3 to 45 

percent of women and 6 to 42 percent of men reported the private for-profit sector as their source 

of the most recent HIV testing. While in some countries use of the private for-profit health sector 

for HIV testing and STI care increases with wealth, in others the relationship is not clear, as there 

are no significant differences in using private for-profit HIV-related services between the rich 

and the poor. As the global AIDS response evolves from emergency relief to sustained country 

programs, broader consideration of the role of the private health sector may be warranted. 

Key words: HIV/AIDS, Services utilization, Private health sector, Household wealth 

1 

INTRODUCTION 

The number of people infected by the human immunodeficiency virus (HIV) has grown 

significantly over the past two decades. By the end of 2008, an estimated 33.4 million people 

worldwide were living with HIV, while in 2008 alone 2.7 million people were newly infected 

with HIV and 2.0 million died from acquired immune deficiency syndrome (AIDS) (UNAIDS, 

2009). The HIV/AIDS epidemic has generated tremendous demand for health services, and the 

burden on health care systems will grow as more HIV-positive individuals gain access to 

antiretroviral therapy (ART) and require regular health care to monitor progression of the 

disease. 

In recent years the global AIDS response has expanded in both commitment to 

addressing the epidemic and level of funding. Globally, funding to HIV/AIDS has dramatically 

scaled up the AIDS response, saving an estimated 2.9 million lives through the provision of ART 

(UNAIDS, 2009). Major programmatic initiatives have included the President’s Emergency 

Program for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, TB, and Malaria 

(GFATM), and the World Bank Multi-country AIDS Program (MAP). 

The most significant share of resources for HIV in developing countries has gone to 

governments and non-governmental organizations (NGO). Most investments have focused on 

building the public sector’s capacity to provide HIV-related services. While these efforts have 

greatly increased access to and the quality of essential health services, they have largely 

overlooked the private health sector. A 2004 study of Malawi, Mozambique, South Africa, and 

Swaziland found that a lack of human resources for health, rather than a lack of financial 

resources, was the main bottleneck to expanding access to ART (Kober & Van Damme, 2005). 

In light of public sector capacity constraints and the global goal of “universal access to 
2 

comprehensive HIV prevention, treatment, care and support” (United Nations General Assembly, 

2006), increasing participation of private health providers may help address the current 

bottlenecks and expand access to HIV- related services. 

The private sector provides a significant portion of health care (Berman & Laura, 1996; 

Hanson & Berman, 1998; Waters, Hatt & Peters, 2003). A study using DHS data from 19 sub–

Saharan African countries found that an average of 32 percent of family planning users across 

the countries, and up to 51 percent in Gabon, reported a private sector source (Private Sector 

Partnerships-One, 2005). Private practitioners are also important health care providers in Asia. 

As of 2004, for example, the private sector accounted for 80 percent of all outpatient care and 60 

percent of inpatient care in India (Over, 2009). In an urban squatter settlement in Karachi, 

Pakistan, the proportion of women visiting private facilities for antenatal care was much higher 

than the proportion visiting public facilities (Nisar & White, 2003). 

There are various determinants of choosing services from the private health sector versus 

the public sector. Because monetary costs are comparatively higher in the private sector, 

socioeconomic status is usually believed to be associated with using private services, and a 

common concern is that the involvement of the private sector would cause inequity in service 

access. Some studies have found that seeking health care in the private sector is positively 

associated with household wealth status (Chakrabarti, 2007; Obermeyer & Potter, 1991). For 

example, a study in Afghanistan found that, after controlling for other factors, people in the 

richest quintile were 1.6 times more likely to utilize private providers for illness than those in the 

poorest quintile (Steinhardt 2008). Other studies have not found a clear pattern (Bhatia & 

Cleland, 2001; Makinen, Water & Rauch, 2000). Using DHS data, one analysis showed that in 

many African countries the poor also heavily relied on the private sector for curative child care 
3 

(Private Sector Partnerships –One, 2005). Despite the private sector’s expanding role in the 

provision of other health services, there is limited knowledge on the extent to which it delivers 

HIV-related services (Arur, 2009; Ramchandani, 2007). 

Understanding the private sector’s role in serving different wealth segments of the 

population is important to assessing its potential in providing HIV-related services on a broad 

scale. The private sector offers several advantages over other types of facilities. Private health 

facilities not only are largely independent of government and donor financial support but also 

often offer more flexible hours of operation, making them more accessible. Private sector clients 

often perceive service quality and confidentiality to be superior to that of the public sector (Ron, 

Wang & Magvanjav, 2009; Sulzbach, Wang & O’ Hanlon, 2009). 

To further understand the role of the private sector in providing HIV/AIDS services and 

to help inform policy decisions, this study used data from nationally representative surveys to 

document the role of the private health sector in delivering HIV-related services and to assess the 

relationship between wealth status and preference for private providers. 

5 

METHODS 

Data 

The private health sector comprises both private for-profit and private not-for-profit entities. 

Earlier studies exploring the utilization of the private health sector largely combined both types 

of facilities (Brugha 2003). This study, however, focuses on the private for-profit subsector 

because there is very limited information about the extent to which it contributes to the AIDS 

response. Thus, references to the private sector below should be interpreted as the private forprofit sector. 

Our analysis began with an extensive scan of publicly available and internationally 

comparable data with information on utilization of private sector HIV-related services. The scan 

revealed a scarcity of data on private provision of HIV services. Eventually, we identified two 

sources of data on utilization of private HIV and related services: the Demographic and Health 

Surveys (DHS) and AIDS Indicator Surveys (AIS). Other data sources do not capture the source 

of HIV services or do not distinguish between private for-profit and private not-for-profit 

facilities. Even the DHS and AIS contain only a limited number of variables related to HIV 

services. Given sensitivities about HIV status, neither DHS nor AIS ask respondents about HIV 

treatment. Two indicators of HIV-related services—HIV testing and STI care—contain detailed 

information on sources of care. Both surveys only recently began asking source of care; for 

example, DHS and AIS began asking source of HIV testing in 2004 and 2005, respectively. 

We examined recent DHS and AIS data from all countries for which data are available to 

identify relevant variables that permit analysis of the utilization of HIV-related services provided 

by the private for-profit sector. Some recent DHS and AIS asked about source of HIV testing and 

STI care but did not distinguish between private for-profit and not-for-profit providers. 
6 

Eventually, we included in the analysis 12 countries: 9 from sub–Saharan Africa, 2 from Latin 

America and the Caribbean, and 1 from Asia. All countries selected for the study provided 

detailed data on sources of HIV testing for men and women. Four countries—Chad, Ethiopia, 

Guinea, and Rwanda—did not include sufficient information on source of STI care and thus 

were excluded from the relevant analysis. 

Table 1 lists the DHS and AIS in the 12 countries studied. All surveys were conducted in 

2004 or later. Eight countries had data from DHS and four countries had data from AIS. 

 

Table 1. Summary of DHSs and AISs Included in the Analysis 

Country Year Survey Respondents 

Africa Region 

Benin 2006 DHS All women, age 15–49; all men, age 15–64 

Chad 2004 DHS All women, age 15–59; all men, age 15–59 

Cote d’Ivoire 2005 AIS All women, age 15–49; all men, age 15–49 

Ethiopia 2005 DHS All women, age 15–49; all men, age 15–59 

Guinea 2005 DHS All women, age 15–49; all men, age 15–59 

Rwanda 2005 DHS All women, age 15–49; all men, age 15–59 

Tanzania 2007 AIS All women, age 15–49; all men, age 15–49 

Uganda 2006 DHS All women, age 15–49; all men, age 15–54 

Zimbabwe 2005 DHS All women, age 15–49; all men, age 15–54 

LAC Region 

Guyana 2005 AIS All women, age 15–49; all men, age 15–49 

Haiti 2005 DHS All women, age 15–49; all men, age 15–59 

Asian Region 

Vietnam 2005 AIS All women, age 15–49; all men, age 15–59 

 

Table 2 presents country-specific demographic data relevant to the analysis, providing a 

picture of the broader context for the 12 countries. All countries except Guyana are classified as 

low-income countries by the World Bank and have low levels of health expenditures. With the 

exception of Vietnam, all others are experiencing a generalized HIV epidemic. 
7 

Table 2. Selected Health and Demographic Data by Country 

Country 

Population 

(thousands)1

GDP per 

Capita 

(constant 

2000 US$)1

HIV 

Prevalence 

Rate 

(percent)2

Physicians per 

10,000 

Population1

Private Expenditure 

as Percentage of 

Total Health 

Expenditure3

Africa Region 

Benin 9,025 328 1.2 0.4 46.7 

Chad 10,764 260 3.5 0.4 64.4 

Cote d’Ivoire 19,268 554 3.9 -- 77.0 

Ethiopia 79,087 174 2.1 0.3 39.6 

Guinea 9,380 404 1.6 1.1 87.7 

Rwanda 9,736 271 2.8 0.5 36.3 

Tanzania 40,432 354 6.2 0.2 40.8 

Uganda 30,916 324 5.4 0.8 73.1 

Zimbabwe 13,403 428 15.3 1.6 47.4 

LAC Region 

Guyana 739 1,062 2.5 4.8 15.5 

Haiti 9,612 411 2.2 2.5 32.4 

Asian Region 

Vietnam 85,155 617 0.5 5.6 67.6 

 

 

1 World Development Indicators, 2009. 

2

 UNAIDS, 2008. 

3 World Health Organization, Statistical Information System, 2008. 

Analysis 

For HIV testing, the analysis centered on women and men who reported ever having an HIV test. 

The survey provided a list of options from which respondents selected the source of their most 

recent HIV test. According to the country context, we categorized the sources as public, private 

for-profit, NGO, and “other”. In general, public providers included government hospitals, 

government health centers, public voluntary counseling and testing (VCT) centers, health posts, 

family planning clinics, and other government providers; private for-profit providers included 

private hospitals, private clinics, private health centers, and private stand-alone VCT centers; and 
8 

the NGO category included NGO health centers, clinics, and stand-alone VCT centers. When 

necessary, we consulted experts familiar with specific country health systems to ensure accurate 

classification. 

The sample for the analysis of STI care included respondents seeking STI care among 

those reporting an STI or STI symptoms in the last 12 months. In DHS and AIS, respondents 

who had ever had sex were asked whether they had an STI in the past 12 months or whether they 

experienced STI symptoms, such as a genital sore or ulcer or genital discharges. Women and 

men who answered in the affirmative were asked if they sought advice and/or treatment. Care 

seekers were then asked the source of care, with reporting multiple sources allowed. The 

classification criteria for the four categories of sources aligned with those for source of HIV 

testing within the same country. 

Typically, respondents reported a greater variety of sources for STI care than for HIV 

testing. For example, respondents commonly pointed to private pharmacies as a source for STI 

care but not for HIV testing. Respondents also reported traditional healers, relatives, and friends 

as sources of STI care. For consistency, we classified traditional healers as “private” and 

families, friends, and relatives as "other". 

We conducted descriptive analysis to show the overall coverage of HIV testing and STI 

care, as well as the extent to which people utilized HIV testing services and STI care from the 

private sector. Then we used bivariate analysis to assess the unadjusted association, and 

multivariate logistic regression to assess the adjusted association, between household wealth 

status and use of the private sector for each service. In multivariate analysis, the dependent 

variable was using a private source for services; the primary independent variable of interest was 
9 

household wealth status. Other background variables such as age, educational attainment, marital 

status, urban/rural residence and religion were controlled in the analysis. 

DHS and AIS collect data on a range of household assets and utility services and then 

develop a wealth index based on these variables by using principal components analysis (Filmer 

& Pritchett, 2001; Rustein & Johnson, 2004). The wealth index has been shown to be a more 

reliable socioeconomic proxy than income variables and other quantitative socioeconomic 

measures in developing countries (Khan, Hutchinson & Hotchkiss, 2007). This wealth index 

variable was used in the current analysis on the association between household wealth and 

private sector use. 

Due to a very limited sample, some countries were excluded from the bivariate and 

multivariate analysis. For HIV testing, 10 countries—Benin, Cote d’Ivoire, Ethiopia, Rwanda, 

Tanzania, Uganda, Zimbabwe, Guyana, Haiti, and Vietnam—were included in the analysis. For 

STI care, we performed analysis for women in seven countries—Benin, Cote d’Ivoire, Tanzania, 

Uganda, Zimbabwe, Haiti, and Vietnam—and for men in five countries—Cote d’Ivoire, 

Tanzania, Uganda, Zimbabwe, and Haiti—where survey samples on private service use for STI 

care were of sufficient size. 

We analyzed the data using STATA 10.0 Statistical Software and performed separate 

analyses for women and men. We accounted for complex DHS survey design to estimate 

efficient regression coefficients and applied sampling weights in all the analyses to enable us to 

generalize the results to the population. The sample weight variable was the pre-existing 

individual sampling weight in the DHS or AIS datasets. 

11 

RESULTS 

This section first summarizes women and men’s overall HIV testing, STI care, and reliance on 

the private sector for each health service. Second, we present the results of bivariate and 

multivariate analysis on the relationship between household wealth status and private sector 

utilization for each service. 

Use of HIV testing and STI care from the private sector 

Prevalence of prior HIV testing and private sector utilization 

Knowledge of one’s HIV status is critical to both prevention and treatment. Although global 

efforts have made HIV counseling and testing increasingly available, uptake of these services 

remains low. 

Table 3 describes the overall utilization of HIV testing in the 12 study countries. Despite 

the higher prevalence of HIV in Africa compared with other regions, the rate of HIV testing in 

Africa is low to moderate. Ethiopia is noteworthy for having the lowest rate of HIV testing and 

relatively low HIV prevalence. Gender differences are evident but not consistent across the 

region. Compared with Africa, the two countries studied in Latin America and the Caribbean 

reported generally higher levels of HIV testing, despite relatively lower HIV prevalence, with 

levels of testing higher among women than men. Although Vietnam is the only country in the 

study classified as experiencing a concentrated epidemic (i.e., HIV prevalence is concentrated in 

high-risk populations), HIV infection appears to be expanding rapidly into the general 

population. Nevertheless, overall coverage of HIV testing remains low in Vietnam; only 5 

percent of women and 6 percent of men reported ever receiving an HIV test. 
12 

Table 3. Percentage of Women and Men Who Ever Received an HIV Test 

Country Women (percent) Men (percent) 

Africa Region 

Benin 17.7 13.1 

Chad 2.1 3.9 

Cote D’Ivoire 12.6 9.6 

Ethiopia 4.1 5.1 

Guinea 2.5 6.6 

Rwanda 24.0 20.9 

Tanzania 40.9 29.2 

Uganda 29.4 23.1 

Zimbabwe 25.8 18.6 

LAC Region 

Guyana 28.7 21.1 

Haiti 18.3 10.5 

Asia Region 

Vietnam 5.0 5.8 

 

Table 4 presents the percentage of respondents, among those who have had HIV testing, 

receiving their most recent HIV test from a public, private, or NGO source. Table 4 omits the 

“other” category, which is applicable in only two countries in which more than 5 percent of 

people reported an HIV test provided by sources other than public, private, or NGO sources. 

In all countries except Haiti, the majority of people received HIV testing at a public 

facility, while use of private services was generally low. In Africa the highest use of the private 

sector was among Ethiopian women and Chadian men, with 24 percent receiving an HIV test in 

a private facility, although overall utilization of HIV testing services was low in both countries. 

In Haiti 45 percent of women and 42 percent of men turned to private providers for HIV 

testing, which was the highest level among all countries studied. Guyana also reported a high 

level of private sector use, at 18 percent of women and 30 percent of men, among those tested for 
13 

HIV. In Vietnam the public sector was the predominant source of HIV testing. Only 6 percent of 

women and 7 percent of men received HIV testing in the private sector. 

Table 4. Percentage of Women and Men Undergoing Most Recent HIV Test, by Source 

Women Men 

Country 

Public 

Sector 

Private 

Sector

NGO 

Sector

Total 

number of 

women ever 

received an 

HIV test 

Public 

Sector

Private 

Sector

NGO 

Sector

Total 

number of 

men ever 

received an 

HIV test

Africa Region 

Benin 82.0 14.9 0.5 3,050 87.3 11.0 0.0 676 

Chad1 44.7 10.0 0.0 200 64.2 23.7 0.0 127 

Cote d’Ivoire 88.0 8.5 0.4 397 79.9 13.6 0.7 294 

Ethiopia 67.8 23.6 5.1 469 71.8 18.6 6.0 435 

Guinea2 53.0 14.6 0.0 152 71.1 20.2 0.0 186 

Rwanda3 55.2 7.9 1.7 2,898 82.4 14.3 3.3 1,060 

Tanzania4

 34.3 2.6 20.0 3,443 54.1 5.6 40.0 1,960 

Uganda 71.5 17.2 7.0 2,486 63.6 17.9 16.2 593 

Zimbabwe 69.6 11.2 16.7 2,276 39.3 12.7 38.8 1,259 

LAC Region 

Guyana5

 39.4 18.2 12.2 774 50.8 29.9 13.7 441 

Haiti 40.0 44.5 13.2 1,918 33.2 42.0 18.5 508 

Asia Region 

Vietnam 94.0 6.0 0.0 585 92.9 6.7 0.0 603 

 

1

 In Chad, 39 percent of women ever testing did not report the source of the last test. 2 In Guinea, 27 percent of women ever testing did not report the source of the last test. 3 In Rwanda, 35 percent of women ever testing did not report the source of the last test. 4

In Tanzania, 42 percent of women ever testing did not report the source of the last test. 5

 In Guyana, 18 percent of women ever testing did not report the source of the last test.

Respondent’s choice of provider varied by gender. Figure 1 shows that, except in Benin, 

Ethiopia, and Haiti, a higher proportion of men than women patronized the private sector instead 

of the public sector for HIV testing. Men also were more likely than women to receive HIV 

testing from NGO providers—for example, in Zimbabwe at 39 percent of men compared with 17 
14 

percent of women. Across most countries however, use of NGO services was low compared with 

private and public services (Table 4), 

 

Figure 1. Percentage of Men and Women Who Had the Most Recent HIV Test in the Private Sector

6.0%

44.5%

18.2%

11.2%

17.2%

2.6%

7.9%

14.6%

23.6%

8.5%

10.0%

15.4%

6.7%

42.0%

29.9%

12.9%

17.9%

5.6%

14.3%

20.2%

18.6%

13.6%

23.7%

11.0%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

Vietnam

Haiti

Guyana

Zimbabwe

Uganda

Tanzania

Rwanda

Guinea

Ethiopia

Cote d'Ivoire

Chad

Benin

Men

Women

STI care-seeking and private-sector utilization

Among the very low proportion of all respondents, especially men, who reported an STI or STI 

symptoms in last 12 months (usually less than 10%), a significant percentage sought advice or 

treatment from a provider (Table 5). In African countries with the exception of Ethiopia, at least 

half of men sought STI care, and nearly as high a proportion of women. Generally, in all studied 

countries except Guyana and Vietnam, higher percentages of men than women reported seeking 

STI care. 
15 

Table 5. Percentage of Population Seeking Care for STIs in Last 12 Months 

Country Women Men 

Africa Region 

 

Benin 48.5 83.1 

Chad 63.7 87.9 

Cote D’Ivoire 48.9 69.3 

Ethiopia 36.6 42.6 

Guinea 69.2 81.0 

Rwanda 49.1 52.2 

Tanzania 68.3 77.2 

Uganda 67.1 80.5 

Zimbabwe 63.8 72.5 

LAC Region 

Guyana 53.8 29.1 

Haiti 49.0 54.3 

Asia Region 

Vietnam* 82.7 21.1 

 

*In Vietnam, only 35 men reported an STI or STI symptoms in the last 12 

months, and 7 reported that they sought care. 

Table 6 shows the percentage of respondents seeking STI care from each type of provider 

in 8 of the 12 countries in our study. In the other four, Chad, Ethiopia, Rwanda, and Guinea, 

there was insufficient data for disaggregating private sources. (Data for responses such as family, 

friends, or relatives, which were classified as “other”, are not presented in Table 6). Because 

respondents were allowed to report more than one source, the sum of the percentages in each 

country may exceed 100 percent. 

Compared with HIV testing, respondents evidenced greater reliance on the private sector 

for STI care in all countries analyzed. In some countries, including Tanzania, Zimbabwe, and 

Vietnam, the public sector provided the largest share of STI care. In Benin, Uganda, Haiti, and 

Guyana, however, private care utilization was high, from 41 percent in Benin to 53 percent in 

Haiti, among women seeking care. 
16 

In all countries except Haiti, more men than women reported seeking STI care from the 

private sector. For example, in Uganda, 58 percent of men reported reliance on the private sector 

compared with 49 percent of women. 

Table 6. Percentage of Population Seeking Care for STIs, by Source 

Women Men 

Country 

Public 

Sector 

Private 

Sector

NGO 

Sector

Total 

number of 

women 

seeking STI 

care 

Public 

Sector

Private 

Sector

NGO 

Sector

Total 

number of 

men 

seeking STI 

care

Africa Region 

Benin 54.0 40.8 5.0 524 41.9 44.2 2.3 91 

Cote D’Ivoire 54.9 15.8 5.2 451 51.0 19.1 6.1 236 

Tanzania 60.0 19.7 13.7 257 51.2 30.9 12.6 211 

Uganda 53.8 48.8 7.4 1,012 44.8 57.6 1.1 182 

Zimbabwe 83.5 15.5 0.0 424 68.8 29.2 0.0 285 

LAC Region 

Guyana 44.1 51.0 0.0 37 46.1 52.3 0.0 19 

Haiti 33.3 52.6 2.7 866 27.1 29.6 17.2 150 

Asia Region 

Vietnam 75.0 39.3 0.0 850 54.4 45.6 0.0 35 

 

Given that STI symptoms can also indicate risk for HIV, in that both HIV and STIs can 

be transmitted through unprotected sex, use of STI care may be viewed as an entry point for HIV 

prevention, such as HIV testing and counseling on risk reduction. Thus examining the patterns 

for both types of HIV-related services within the same country can help to identify any 

consistent patterns of reliance on the private sector. 

In the two countries studied in Latin America and the Caribbean, we found high 

utilization of the private sector for both HIV testing and STI care. In Africa we observed 

substantial variation. Uganda reported a high level of private sector STI care and also a 
17 

comparatively high level of private sector HIV testing. In Benin, however, the private sector 

provided a large percentage of STI care, but the public sector was the predominant provider of 

HIV testing. 

The role of household wealth in utilization of private sector services 

As mentioned, because the cost of services is generally higher in the private sector than the 

public and NGO sectors, it is believed that reliance on private sector providers for health care 

increases with income. Our study examined the relationship between household wealth status 

and use of the private sector for HIV-related services. 

Unadjusted relationship between the wealth status and use of the private sector for HIV 

testing and STI care

Figure 2 shows the percentage of women in studied countries who received their most recent 

HIV test in the private sector, by household wealth status. In all countries except Vietnam, use of 

the private sector for HIV testing is highest among individuals in the richest households. 
18 

Figure 2. Utilization of Private Sector HIV Testing, by Household Wealth Status (Women) 

0%

10%

20%

30%

40%

50%

60%

lowest

Second

Middle

Fourth

Highest

In Africa, however, a substantial proportion of the poorest women in some countries 

turned to the private sector for HIV testing. In Cote d’Ivoire and Uganda women in the poorest 

households reported the second-highest use of the private sector for HIV testing. In Uganda, 

where use of the private health sector is generally high, about 15 percent of women from the 

poorest households received their most recent HIV test in a private hospital or clinic. In the two 

Latin America and the Caribbean countries studied, while use of the private sector for HIV 

testing increased with household wealth, use of the private sector was high among women across 

wealth groups. 

Similarly, in the majority of countries men from the richest households reported the 

highest use of the private sector for HIV testing (Figure 3). Ethiopia was an exception, probably 

because the sample size was so small—fewer than 10 men in these household wealth groups 

received an HIV test. 
19 

Figure 3. Utilization of Private Sector HIV Testing by Household Wealth Status (Men)

0%

10%

20%

30%

40%

50%

60%

lowest

Second

Middle

Fourth

Highest

Figures 4 and 5 show private health sector utilization of STI care among women and men 

by household wealth status. Due to small sample sizes resulting from disaggregating by wealth 

status, only a few countries (seven for women and five for men) were included in the analysis. In 

all countries with data for women (Figure 4), women in the top wealth quintile reported the 

highest use of private services. In most of these countries, utilization of the private sector 

increased with wealth, although a substantial proportion of women from the poorest households 

sought STI care from the private sector. In the countries with data for men (Figure 5), we did not 

find a consistent association between wealth status and men seeking care for STIs in the private 

sector, probably due to the small sample sizes. 
20 

Figure 4. Utilization of Private Sector STI Care by Household Wealth Status (Women) 

0%

10%

20%

30%

40%

50%

60%

70%

Benin Cote D’Ivoire Tanzania Uganda Zimbabwe Haiti Vietnam

Lowest

Second

Middle

Fourth

Highest

Figure 5. Utilization of Private Sector STI Care by Household Wealth Status (Men) 

0%

10%

20%

30%

40%

50%

60%

70%

Cote D’Ivoire Tanzania Uganda Zimbabwe Haiti

Lowest

Second

Middle

Fourth

Highest
21 

Adjusted relationship between wealth status and use of the private sector for HIV testing and 

STI care 

Table 7 presents the results of multivariate analysis on the effect of household wealth on the 

likelihood of using a private sector source for HIV testing, among women and men. We dropped 

Ethiopia from the multivariate analysis, since the bivariate analysis showed that 99% of 

Ethiopian women and 93% of Ethiopian men using the private sectors were from the richest 

group. In four of the eight countries with complete data—Benin, Tanzania, Zimbabwe, and 

Guyana—women in richer households were significantly more likely to use the private sector for 

HIV testing, after controlling for other background characteristics. In contrast, in Cote d’Ivoire, 

Rwanda, Uganda, and Haiti, the multivariate analysis did not detect significantly higher private 

sector use among the wealthy compared with other groups, although bivariate analysis showed 

highest use of the private sector for HIV testing among the richest group. 

Among men, in three countries—Benin, Tanzania, and Zimbabwe—higher wealth status 

was shown to be significantly associated with more use of the private sector. In Haiti and 

Guyana, however, the strong positive unadjusted association between wealth and use of private 

sector disappeared after controlling for other variables. 
22 

Table 7. Results of Multivariate Analysis on the Association between Household Wealth Status and Use of 

the Private Sector for the Most Recent HIV Testing among Women and Men 

Women Men 

HIV testing HIV testing 

Country and wealth status OR ( 95% CI, p-value) OR ( 95% CI, p-value) 

African Region 

Benin 

Lowest 1.00 1.00 

Second 0.83(0.45, 1.54; 0.555) 2.48(0.29, 21.03; 0.403) 

Middle 0.78(0.45, 1.35; 0.373) 2.40(0.31, 18.54; 0.403) 

Fourth 1.12(0.66, 1.89; 0.670) 1.85(0.23, 14.61; 0.560) 

Highest 2.09(1.25, 3.48; 0.005) 8.85(1.17, 66.79; 0.034) 

Cote d’Ivoire 

Lowest 1.00 1.00 

Second 0.44(0.04, 4.48; 0.484) 7.83(0.66, 93.29; 0.101) 

Middle 0.17(0.03, 1.07; 0.059) 4.55(0.34, 61.79; 0.248) 

Fourth 0.33(0.03, 3.21; 0.332) 2.89(0.19, 43.40; 0.435) 

Highest 0.67(0.07, 6.50; 0.727) 8.57(0.58, 127.06; 0.116) 

Rwanda 

Lowest 1.00 1.00 

Second 1.28(0.66, 2.50; 0.466) 0.45(0.15, 1.38; 0.161) 

Middle 0.81(0.40, 1.67; 0.574) 0.80(0.36, 1.79; 0.587) 

Fourth 1.51(0.80, 2.85; 0.204) 0.81(0.34, 1.93; 0.635) 

Highest 1.57(0.85, 2.89; 0.146) 1.30(0.63, 2.70; 0.481) 

Tanzania 

Lowest 1.00 1.00 

Second 0.80(0.21, 3.01; 0.743) 2.00(0.44, 8.96; 0.369) 

Middle 3.11(0.87, 11.11; 0.080) 1.66(0.35, 7.85; 0.523) 

Fourth 2.29(0.63, 8.29; 0.206) 4.32(1.02, 18.25; 0.046) 

Highest 5.08(1.48, 17.42; 0.010) 8.78(2.02, 38.27; 0.004) 

Uganda 

Lowest 1.00 1.00 

Second 0.51(0.34, 0.77; 0.002) 0.76(0.29, 1.98; 0.571) 

Middle 0.37(0.23, 0.61; 0.000) 1.85(0.75, 4.56; 0.179) 

Fourth 0.41(0.25, 0.67; 0.000) 1.68(0.73, 3.86; 0.218) 

Highest 0.78(0.50, 1.24; 0.298) 1.87(0.79, 4.42; 0.150) 

Zimbabwe 

Lowest 1.00 1.00 

Second 3.05(0.79, 11.77; 0.106) 1.69(0.66, 4.31; 0.269) 

Middle 2.90(1.05, 7.96; 0.039) 0.88(0.29, 2.65; 0.821) 

Fourth 4.57(1.41, 14.80; 0.012) 2.50(0.88, 7.13; 0.086) 

Highest 8.18(2.38, 28.11; 0.001) 4.39(1.34, 14.40; 0.015) 

 (cont’d) 
23 

Table 7 – cont’d 

Women Men 

HIV testing HIV testing 

Country and wealth status OR ( 95% CI, p-value) OR ( 95% CI, p-value) 

LAC Region 

Guyana 

Lowest 1.00 1.00 

Second 0.77(0.42, 1.45; 0.415) 1.44(0.53, 3.89; 0.467) 

Middle 2.04(1.08, 3.83; 0.028) 1.36(0.52, 3.59; 0.524) 

Fourth 2.14(1.10, 4.16; 0.026) 1.51(0.68, 3.37; 0.307) 

Highest 2.76(1.47, 5.16; 0.002) 2.05(0.83, 5.05; 0.116) 

Haiti 

Lowest 1.00 1.00 

Second 1.11(0.68, 1.84; 0.669) 1.21(0.40, 3.69; 0.733) 

Middle 0.85(0.48, 1.53; 0.586) 1.74(0.64, 4.72; 0.270) 

Fourth 0.82(0.43, 1.54; 0.534) 2.08(0.63, 6.89; 0.229) 

Highest 1.22(0.65, 2.31; 0.537) 2.89(0.84, 9.91; 0.090) 

Asian Region 

Vietnam* 

Lowest -- 1.00 

Second -- 0.48(0.03, 8.14; 0.605) 

Middle 1.00 -- 

Fourth 5.77(0.43, 78.31; 0.184) 1.48(0.11, 19.98; 0.765) 

Highest 4.60(0.36, 58.75; 0.236) 1.74(0.16, 19.02; 0.646) 

 

 

*As no Vietnamese women in two lowest quintile wealth groups had HIV testing in the private sector; the 

middle wealth group was treated at the reference group. Among men, the middle wealth group was dropped 

due to nobody in this group used the private sector for HIV testing. 

In analyzing the effect of wealth on use of the private sector for STI care, most countries 

analyzed did not show a significant association (Table 8). In Uganda, however, women from 

richer households were more likely than poorer women to use private sector services. In Haiti, 

women in the highest household wealth quintile were over three times more likely than those in 

the lowest quintile to use the private sector for STI care. Among five countries included for 

men’s analysis, only Tanzania showed a positive effect of household wealth status on the 

likelihood of using the private sector for STI care, after controlling for other factors. 
24 

Table 8. Results of Multivariate Analysis on the Association between Household Wealth Status and Use of 

the Private Sector for STI Care among Women and Men 

Women Men 

STI care STI care 

Country and wealth status OR ( 95% CI, p-value) OR ( 95% CI, p-value) 

African Region 

Benin 

Lowest 1.00 -- 

Second 1.14(0.54, 2.42; 0.725) -- 

Middle 1.03(0.51, 2.10; 0.925) -- 

Fourth 0.89(0.45, 1.75; 0.730) -- 

Highest 1.60(0.79, 3.25; 0.189) -- 

Cote d’Ivoire 

Lowest 1.00 1.00 

Second 0.98(0.18, 5.23; 0.979) 0.29(0.07, 1.25; 0.095) 

Middle 1.88(0.41, 8.66; 0.409) 1.03(0.27, 3.86; 0.967) 

Fourth 3.36(0.74, 15.26; 0.114) 0.97(0.30, 3.16; 0.956) 

Highest 3.88(0.93, 16.25; 0.063) 0.17(0.03, 0.88; 0.056) 

Tanzania 

Lowest 1.00 1.00 

Second 0.40(0.11, 1.50; 0.171) 1.20(0.38, 3.81; 0.752) 

Middle 0.32(0.09, 1.16; 0.082) 3.94(1.28, 12.16; 0.019) 

Fourth 0.73(0.24, 2.26; 0.577) 2.69(0.94, 7.72; 0.064) 

Highest 1.53(0.43, 5.45; 0.501) 6.68(1.42, 31.43; 0.019) 

Uganda 

Lowest 1.00 1.00 

Second 1.71(1.03, 2.85; 0.038) 4.99(1.22, 20.38; 0.026) 

Middle 2.19(1.30, 3.68; 0.003) 1.09(0.27, 4.31; 0.903) 

Fourth 2.47(1.50, 4.04; 0.000) 1.10(0.26, 4.75; 0.891) 

Highest 2.41(1.37, 4.21; 0.002) 3.05(0.60, 15.61; 0.174) 

Zimbabwe 

Lowest 1.00 1.00 

Second 0.20(0.03, 1.11; 0.064) 0.84(0.32, 2.19; 0.712) 

Middle 0.88(0.29, 2.64; 0.811) 0.91(0.35, 2.35; 0.836) 

Fourth 0.81(0.22, 2.93; 0.735) 0.55(0.17, 1.81; 0.319) 

Highest 1.61(0.37, 6.97; 0.521) 0.52(0.10, 2.63; 0.418) 

 (cont’d) 
25 

Table 8 – cont’d 

Women Men 

STI care STI care 

Country and wealth status OR ( 95% CI, p-value) OR ( 95% CI, p-value) 

LAC Region 

Haiti 

Lowest 1.00 1.00 

Second 1.63(0.75, 3.53; 0.214) 0.90(0.17, 4.73; 0.897) 

Middle 1.49(0.70, 3.17; 0.303) 1.36(0.29, 6.32; 0.684) 

Fourth 1.99(0.82, 4.86; 0.130) 0.91(0.15, 5.33; 0.913) 

Highest 3.24(1.19, 8.78; 0.021) 1.26(0.18, 8.99; 0.810) 

Asian Region 

Vietnam*

Lowest 1.00 -- 

Second 1.75(0.93, 3.13; 0.061) -- 

Middle 1.05(0.52, 2.14; 0.887) -- 

Fourth 1.89(1.01, 3.52; 0.046) -- 

Highest 3.38(1.59, 7.17; 0.002) -- 

 

*Only 7 Vietnamese men reported seeking STI care, so men were dropped from this multivariate analysis. 

27 

DISCUSSION 

Using DHS and AIS data from 12 developing countries, we examined the use of the private forprofit health sector for HIV testing and STI care and explored its association with household 

wealth status. Both services are considered critical for preventing HIV transmission and ensuring 

the availability of care and support. In light of growing demand for HIV/AIDS services, further 

exploration of the private health sector’s current and potential contributions to HIV/AIDS 

prevention and treatment is warranted. This analysis is a first step in examining the extent to 

which private providers deliver HIV-related services in multiple countries, based on data from 

representative national surveys. 

Review of available data and literature reveals that the private health sector has not 

generated sufficient attention to its role in the overall global response to AIDS. Most national, 

population-based surveys do not ask about sources of HIV-related services, nor do they 

distinguish between private for-profit and private not-for-profit sources of care. Given the 

differences between these two components of the private health sector, particularly their 

objectives (social mission versus profitability) and revenue goals (donor-supported versus selfsustaining), the inability to distinguish types of private sector providers limits measurement of 

the unique contributions of each. Moreover, in light of the shift toward sustainable country 

programs in the AIDS response, there is considerable interest in the role of the private for-profit 

sector. Although recent DHS and AIS in some countries have included detailed source options 

for questions on health care–seeking behavior, it is not yet possible to examine changes in 

utilization patterns over time. Advocacy efforts should encourage continued inclusion of such 

questions in population-based surveys. 
28 

The analysis is subject to the limited data availability. Due to small sample sizes and 

insufficient data in some countries, the multivariate analysis was limited to a small number of 

countries, especially for men. The small sample sizes also influence the power of the study, 

reflected by the wide 95% confidence intervals in some countries. In addition, relatively small 

samples may limit the ability to detect the significance in the regression analysis. The study did 

not account for some potentially important variables, such as perceptions of quality and 

availability of private sector services. While DHS and AIS provide relatively high-quality and 

comparable information, the data are self-reported, thereby introducing potential bias. Moreover, 

the scarcity of available data restricts the ability to generalize the results. In particular, the 

availability of data from only one Asian country makes it impossible to generalize the results of 

the analysis to the entire region, while data from only two countries of Latin America and the 

Caribbean cannot permit generalization to the region as a whole. 

Despite the limited availability of data, the results of this analysis add to the small but 

growing body of evidence on the role of the private sector in health service delivery. Several 

studies have suggested that the private sector plays a very active role in some Asian countries 

(Alkunid, 1995; Berman, 1998; Jilani, Azhar, Jilani, & Siddiqui, 2009). Our analysis indicates 

that the private health sector is active in HIV service delivery, although the level of participation 

varies by country. 

Our study found large variations in private utilization of HIV-related services in Africa, 

which may be linked to country-specific socioeconomic conditions, different levels of privatesector development, and levels of external funding for HIV and AIDS. Donor funding directed to 

NGOs or government facilities may discourage seeking care from private for-profit providers. 

For example, Tanzania demonstrated relatively low utilization of private providers for HIV 
29 

testing but high reliance on NGO services. This pattern is supported by Tanzania’s 10-fold 

increase in donor funding—largely directed to NGOs—for HIV services between 2002 and 2005 

(Sulzbach, Wang & De, 2009). 

The study generally found larger use of private sector services for STI care than HIV 

testing. The explanation may lie in the curative nature of STI care, for which the private sector 

typically plays a greater role. In addition, fewer regulatory restrictions govern the provision of 

STI services compared with HIV services. 

A variety of factors can affect health care–seeking behaviors, including types of illness, 

availability of health services, demographic characteristics, attitudes, beliefs, and proximity to 

providers (Anderson, 1995; Nuwaha, 2006). Poor populations also face financial obstacles to 

accessing health services. Previous studies have shown that socioeconomic status is one of the 

most important predictors of whether and where people seek care for illness (Ahmed, 2005; 

Larson, 2006). Our study found use of the private health sector for HIV testing and STI care 

increases with wealth in some countries, a finding that is consistent with some previous studies 

(Ramchandani, Mehta & Saple, et al. 2007). In other countries we did not find significant 

differences by wealth level among respondents in use of the private sector. 

Notably, our results revealed that the poor are using private sector HIV-related services. 

Some previous studies also have demonstrated that the private sector serves both low-income 

and high-income groups (Nguyen, Berman & Larsen, 2002; Sohail & Do, 2008). National and 

international HIV stakeholders may be wise to reassess the role of the private sector in 

expanding access to critical health services, and to reexamine the notion that the private health 

sector primarily serves the wealthy. Further analysis of the association between wealth and the 
30 

demand for private sector HIV services is needed and will be possible as future DHS and AIS 

data become available. 

This analysis provides a basis for assessing the utilization of private sector–provided 

HIV-related services. As the global approach to the AIDS epidemic continues to evolve from an 

emergency response to a sustained effort, and as levels of donor funding become less certain due 

to the current global economic crisis, it is critical to explore options for efficiently engaging all 

sectors of the health system to maximize the AIDS response. The private health sector is a 

relatively untapped resource that should not go overlooked. Private providers may play a role in 

increasing access to essential HIV prevention, care, and treatment services through partnerships 

with governments and donors. Such partnerships may relieve current bottlenecks resulting from 

infrastructure and human resource constraints in the public sector and may help countries reach 

the ambitious goal of universal access to HIV services. 
31 

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