The role of private providers in maternal health
Authors: Priya Agrawal, Oona M R Campbell, Ndola Prata
Journal: The Lancet Global Health (2014)

Every day, nearly 800 women die from complications of pregnancy and childbirth. A great many of these deaths are preventable; however, there is no single, straightforward solution. Because identification of every woman who will have a life-threatening complication during pregnancy or childbirth is impossible, saving of women's lives during pregnancy and childbirth needs a systems approach with on-call structures in place that can respond immediately and effectively to these complications, around the clock. This challenge is daunting for most of the countries where the burden of maternal mortality is highest, but should not paralyse action. To accelerate progress to reach Millennium Development Goal 5, health systems should bring solutions to the women who need them most, and make these solutions sustainable at adequate scale. Private health care is one of the fastest growing segments of the health-care system, and private providers (ie, all non-public-sector providers) and businesses (ie, pharmacies) are an important source of health care for families in the lower wealth quintiles in low-income and middle-income countries.1Patouillard E Goodman CA Hanson KG Mills AJ Can working with the private for-profit sector improve utilization of quality health services by the poor? A systematic review of the literature.Int J Equity Health. 2007; 6: 17Crossref PubMed Scopus (123) Google Scholar In countries such as Nigeria and Uganda, more than 50% of the population in the lowest income bracket seek health services from private health workers (eg, licensed and unlicensed providers, midwives, pharmacists, and traditional healers).2International Finance CorporationThe business of health in Africa: partnering with the private sector to improve people's lives. World Bank.http://www.unido.org/fileadmin/user_media/Services/PSD/BEP/IFC_HealthinAfrica_Final.pdfGoogle Scholar Although these locally based providers are often the first line of response for families in need of health care, little is known about the services they provide, the quality of their care, or the fees they charge. Private providers attend deliveries both at homes and in medical facilities, constituting a substantial proportion of delivery services in some low-income and middle-income countries.3Madhavan S Bishai D Stanton C Harding A Engaging the private sector in maternal and neonatal health in low and middle income countries. FHS Working Paper 12.http://www.dfid.gov.uk/r4d/Output/183583/Default.aspxGoogle Scholar Additionally, for many years the private sector has played a substantial part in provision of services for family planning, one of the most effective ways to reduce maternal mortality.3Madhavan S Bishai D Stanton C Harding A Engaging the private sector in maternal and neonatal health in low and middle income countries. FHS Working Paper 12.http://www.dfid.gov.uk/r4d/Output/183583/Default.aspxGoogle Scholar, 4Cleland J Shah IH The contraceptive revolution: focused efforts are still needed.Lancet. 2013; 381: 1604-1606Summary Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 5Cleland J Conde-Agudelo A Peterson H Ross J Tsui A Contraception and health.Lancet. 2012; 380: 149-156Summary Full Text Full Text PDF PubMed Scopus (390) Google Scholar, 6Khurram Azmat S Tasneem Shaikh B Hameed W et al.Impact of social franchising on contraceptive use when complemented by vouchers: a quasi-experimental study in rural Pakistan.PLoS One. 2013; 8: e74260Crossref PubMed Scopus (36) Google Scholar Recent evidence from social franchising suggests that this model of clinical service delivery by private providers is positively associated with client volume, client satisfaction, and in some instances increased use of services and positive health effects.7Beyeler N York De La Cruz A Montagu D The impact of clinical social franchising on health services in low- and middle-income countries: a systematic review.PLoS One. 2013; 8: e60669Crossref PubMed Scopus (44) Google Scholar However, questions about equity and cost-effectiveness need further research.7Beyeler N York De La Cruz A Montagu D The impact of clinical social franchising on health services in low- and middle-income countries: a systematic review.PLoS One. 2013; 8: e60669Crossref PubMed Scopus (44) Google Scholar Whether the private sector can have a key role in prevention of maternal mortality is an essential question. So far, the development and donor community has largely focused its efforts on strengthening of the public health sector, despite the potentially substantial part the private sector could play to address maternal health. The potential role of the private sector as a contributor to achieve Millennium Development Goal 5 should be explored, not ignored. To do so, more data and analyses are needed to understand the private sector's size and importance in maternal health, including how many private providers and facilities offering services for maternal care exist (and where), who the private sector reaches with these services, what services are offered, and what is the content and quality of care. Other key questions include why some services are sought in the private setting rather than public settings; to what extent private providers fill gaps in public services; whether the private sector relieves any burden on the public sector; whether provision of consistent high-quality care by private providers can be sustainably ensured; whether private providers subsidise or exploit the poor; to what degree private-sector models promote or diminish equity; and how the public and private sectors can be linked effectively for referral, transport, and management of human resources for health. Robust studies of private-care models are needed to answer these key questions. Very few well designed studies about the successes or failures of private-sector models in maternal health (eg, franchising, especially for labour and delivery services) have been reported.3Madhavan S Bishai D Stanton C Harding A Engaging the private sector in maternal and neonatal health in low and middle income countries. FHS Working Paper 12.http://www.dfid.gov.uk/r4d/Output/183583/Default.aspxGoogle Scholar To that end, Merck for Mothers will test various approaches for private care in countries with a high burden of maternal mortality (eg, Uganda, Senegal, and India). The overall goals of Merck for Mothers is to address the two leading causes of maternal mortality: postpartum haemorrhage (bleeding after childbirth) and pre-eclampsia and eclampsia (hypertensive disorders of pregnancy), as well as family planning. Merck for Mothers is a 10-year US$500 million initiative that will assess its programmes in partnership with the London School of Hygiene and Tropical Medicine to address some of these key questions. However, many more such efforts are needed. The private sector's potential contribution to address maternal mortality cannot be ignored. Growth of the private sector in health could be an important opportunity to tackle maternal mortality. To do so, the specialty needs to invest in expanding of the knowledge base for the role and effectiveness of private care to increase access to affordable high-quality maternal care. Global progress towards achievement of Millennium Development Goal 5 could depend on this effort. PA is the executive director of Merck for Mothers, and owns Merck stock or stock options. OMRC is funded partly by Merck as the team lead of the Merck for Mothers' external assessment done by the London School of Hygiene and Tropical Medicine. NP is a member of the Merck for Mothers advisory board. We thank Heather L Sings (Merck & Co) for assistance in the preparation of this Comment.