Academic journal article Bulletin of the World Health Organization

Hard Gains through Soft Contracts: Productive Engagement of Private Providers in Tuberculosis control/Engagement Productif Des Prestateurs Prives Dans la Lutte Antituberculeuse: Des Benefices Bien Reels Sans Contrat leonin/Ventajas De Los Contratos Relacionales: Contratacion Productiva De Proveedores Privados En la Lucha Contra la Tuberculosis

Academic journal article Bulletin of the World Health Organization

Hard Gains through Soft Contracts: Productive Engagement of Private Providers in Tuberculosis control/Engagement Productif Des Prestateurs Prives Dans la Lutte Antituberculeuse: Des Benefices Bien Reels Sans Contrat leonin/Ventajas De Los Contratos Relacionales: Contratacion Productiva De Proveedores Privados En la Lucha Contra la Tuberculosis

Article excerpt

Introduction

Private health care providers play a prominent role in delivering curative services in the majority of low-income countries. (l-5) They are often the first point of contact for a large number of rich and poor patients and manage a significant number of patients with diseases of public health importance. (1-4) However, many private providers are known to diagnose and treat inappropriately a range of diseases, such as tuberculosis (TB), (6) malaria, (7-9) human immunodeficiency virus infection/acquired immune deficiency syndrome (HIV/AIDS) (10) and sexually transmitted infections. (11,12) They also tend to prescribe antibiotics irrationally. (1-4,13) Several studies have reported that private providers rarely monitor the effects of treatment, maintain clinical records, or notify diseases of public health importance. (1-13)

Contracting with private providers for health services delivery is often perceived as a possible mechanism for governments to "withdraw" or be selective in their commitment to health-care provision and a way to improve efficiency of health-care provision by introducing market mechanisms. (14-16)

In reality however, in many countries, private providers already manage most patients and operate on a largely free health-care market, while providing low quality care. (1-4) In such instances, contracting can instead be used as a mechanism for governments to reach out and establish a working collaboration with existing private providers and to ensure that they provide high quality services at low cost to patients.

Contracting is defined as "a voluntary alliance between independent partners who accept reciprocal duties and obligations and who expect to benefit from their relationship." (14) A standard contract defines in detail the mutual responsibilities between the contractual partners, the financial conditions of the contract and the legal implications of a breach. A "softer" version of contracting, called "relational contracting," involves mutual agreement between the collaborative partners about the general terms of collaboration. Financial transactions play a less important role. Relational contracts are not legally enforceable, but end when either of the partners withdraw. Such contracts may have lower transaction costs and be less complicated to handle for both health authorities and providers with limited capacity to write, manage and monitor standard contracts. (15)

In most countries, National TB Programme (NTP) implementation of quality assured and subsidized TB diagnosis and treatment has been limited largely to public sector services. In reality, however, many patients with symptoms of TB, including the very poor, do seek and receive care from a wide variety of health-care providers outside the network of NTP services, who often provide care of questionable quality at a high cost to patients. (5,6) Over the past ten years an increasing number of initiatives involving such private providers in TB control have been undertaken to help align their practices with national and international standards of TB care. (17) Today, over 40 "public-private mix" projects for improved TB control including some scaled-up programmes are in place in 15 countries. (18) These include diverse projects linking NTPs to various care providers, such as private general practitioners, specialist chest physicians, private hospitals, non-qualified village doctors, informal and formal private practitioners, and not-for-profit nongovernmental organizations (NGOs). Experiences from these initiatives may be useful in understanding how to establish suitable forms of agreement when attempting to engage the private sector in quality assured management of diseases of public health importance.

We reviewed initiatives that involved for-profit providers in TB control and describe the collaborative arrangements of such initiatives, and assess their public health effects in terms of quality of diagnosis and treatment as well as contribution to TB case detection. …

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