Malaria in the Private Sector: The role of the Private Sector (Independent Private Health Subsector) in ensuring equity and access to services in Uganda

Malaria in the Private Sector: The role of the Private Sector (Independent Private Health Subsector) in ensuring equity and access to services in Uganda

The term ‘private sector’ is used to include a diverse range of health care providers: from formal groups of health professionals and commercial companies of various sizes; large healthcare and workplace programs run by major corporations; to civil society groups, associations and informal providers such as unqualified medicine sellers and shopkeepers.

In Uganda, the private sector health market is large and vibrant. Despite having to pay, many people choose to access malaria services through the private sector. This is due to, for example, a greater variety of providers, better availability of products, and a perception that goods and services are of higher quality compared to the public sector.

Yet, while the private sector can improve access to services, particularly where the public sector is weak, it is no magic bullet. Paying for health care can impoverish households. Key populations at-risk of malaria may remain neglected. Also, the quality of services, medicines and other technologies provided in the private sector can be poor. To address these issues, governments need to engage more strategically with the Independent Private Health Subsector.

The capacity and reach of the private sector is not uniform across the country. It plays a particularly large role in providing services to the general population in Uganda, but has a mixed or more limited role in other countries. However, since private sector data is rarely included in official statistics, there is limited evidence of the exact scale of its contribution.

A range of strategies for engaging the private sector have been implemented in other countries, and successes have been documented. For example, market-based incentives, such as subsidizing the costs of long lasting insecticide treated nets, have been applied to keep the cost of essential malaria commodities affordable, thereby stimulating demand. Formal provider associations have been successfully encouraged to self-regulate. Public-private partnerships have helped to bring innovations in malaria medicines and other technologies to the market. Consumer empowerment initiatives and behavior change communication campaigns have been implemented.

Key messages

1.      Strong and sustained engagement with the private sector is essential to reach the target of the millennium development goals. The private sector already makes a significant contribution to malaria prevention, diagnosis and treatment in Uganda, and will continue to be an important partner in malaria control efforts in the future.

2.       In Uganda, between 40 - 60 per cent of health care for poor people is provided by the private sector. Partnerships between the public and private sectors can help reduce the cost of essential malaria medicines. Companies engaged in forestry and mining often have direct access to mobile and migrant populations at high-risk of contracting malaria, who are often beyond the reach of the public sector.

3.    Engaging the private sector is not without its challenges. The cost of private care may deter the poor from seeking treatment, or impoverish them if they do. In circumstances where the capacity to regulate medicines supply is poor, many private providers sell low-quality medicines, or treatments which are sometimes banned on the markets. Prescribing practices may also be poor. This contributes to emerging resistance to malaria medicines in the country.

4.    More strategic engagement with the private sector is therefore needed. This should aim to tap new resources and optimise private sector strengths such are reaching remote ‘markets’. Increasing the affordability and quality of services provided in the private sector is also important.

To achieve this, government and development partners need to:

i)     Support better regulation of the private sector, more efficiently and consistently, to improve access to quality malaria products and services.

ii)   Build the evidence base on where the private sector has been effective and delivered results in malaria control. This will allow malaria programs to select the most appropriate strategies for engaging the private sector in their context.

iii) Devise means for private sector financing for malaria. It is crucial, however, that governments have the capacity to regulate and manage these resources.

iv) Capitalise on opportunities to establish public-private partnerships, to implement malaria control programs. Such partnerships should engage and support local health associations, and be carefully planned in order to remain sustainable.

v)   Bring the private sector into national and regional fora. This is key to increasing engagement between public and private sectors and building trust. It should also help to better define the role of the private sector in key areas, such as reaching remote and mobile populations and combating the sale of sub-standard medicines.

Challenges

To harness the full potential of the private sector, a number of crucial challenges must be addressed. A key issue is that governments have had limited capacity (or will) to regulate private sector markets. This is urgently needed to address, for example, the patchy availability of quality medicines for malaria, the proliferation of substandard or fake medicines, poor prescribing practices and high prices in the private sector.

National malaria control programs need to better understand the nature, role and scale of the private sector’s (potential) contribution. There are knowledge gaps on how private markets work, which make decision-making difficult. For example, the cost-effectiveness of interventions delivered by the private sector is under-researched, and malaria treatment practices by informal providers are not fully understood. Little is known about how supplier behavior affects prices for the consumer, despite the evidence that retailers have an important influence on the availability, quality and price of malaria products.

This will require collecting data nationally, analyzing distribution chains in all sectors, as well as taking into account consumer demand.

Sustainable financing is another important issue. There are a wide range of non-state funding sources that can be better tapped for malaria control in the country, including global funding mechanisms. But making these work in a sustainable manner relies on sustained political engagement, as well as the capacity of associations and institutions (nationally) to regulate and manage financing partnerships effectively.

Opportunities

While these challenges are not unique to the country, opportunities related to the potential contribution of the private sector are.;

Uganda, in particular, has a burgeoning private sector whose resources remain largely untapped. The presence of natural and energy resources in the region also presents an opportunity. Companies in these industries often operate in remote locations, which are beyond the reach of public services. They are therefore well placed – operationally, logistically and financially – to extend the health care they provide to employees and their families, who represent some of the most vulnerable groups at risk of malaria. This is already happening in some countries with established natural resource industries. Experience suggests that developing positive relationships with communities and governments is key to success and sustainability.

Existing national malaria efforts and fora provide further opportunities to pool resources for the procurement of medicines and technologies, and share knowledge. New national efforts could focus specifically on best practices for engaging the private sector in malaria control.

In a climate of limited funding, strategic engagement with the private sector provides malaria control programs with both an opportunity and an obligation. There is an opportunity to widen access, improve quality and reduce costs of malaria interventions, through a variety of approaches. However, the private sector cannot be considered a panacea. There is also an obligation to actively engage with the private sector at sub-national and national level to plan and design programs which ensure equity for poor and marginalized communities across the country.