Background
Increasing access to and provision of care without an explicit focus on quality of care limited improvements in maternal, child, and newborn health (MNCH) care during the course of the Millennium Development Goals (2000–2015) [
1]. Research over the last decade has revealed that quality of care is an essential element of health care [
2] and is necessary to achieve progress towards the Sustainable Development Goals [
3]. Evidence from interventions to encourage facility-based births in India [
4,
5], Rwanda [
6], and Malawi [
7] emphasised that quality care, referral systems, supplies, and clinical skills are critical to reducing mortality outcomes. The focus on improving indicators of facility-based MNCH care must be coupled with improvements in the quality of care.
Comprised of six intersecting components, quality of care is care that is safe, effective, patient-centred, timely, efficient, and equitable [
8,
9]. Positive experience of care is intrinsic to improved quality of care, and whilst it can be located within patient-centeredness, it intersects multiple components of quality [
10,
11]. Improved provision of care impacts a person’s experience of care, whereas positive health seeking behaviours and future decision making are impacted by the experience of care [
12]. In maternal health care, evidence links positive pregnancy experiences to higher quality interpersonal exchanges, greater fairness, and greater health worker contact [
13]. Respectful maternal care is also a major component of a person’s experience of care [
14] and a critical component of quality of care [
1].
Experience of care is rarely included as a measure in large-scale facility-assessment tools [
1], in part because it has been historically difficult to define and measure [
12]. The underlying constructs that constitute experience of care are frequently blurred and inconsistent across literature. Moreover, experience of care is linked to but conceptually separate from satisfaction, and the relationship between these concepts is frequently complicated [
15]. Experience of care is a subjective process indicator of quality, while satisfaction is an outcome indicator relative to a person’s expectations of the care they received [
8,
9,
14]. Measures such as communication, timeliness of care, choice, and respect impact both experience of care and satisfaction; however, experience of care and satisfaction are only partially associated with each other [
16]. Evidence illustrates that measuring both experience of care and satisfaction allows for a greater understanding of the quality of services and provides key information for improving service quality [
14].
With regards to MNCH, the World Health Organization (WHO) recognises the complex relationship between experience of care and health outcomes [
17,
18]. Experiences of care can impact health outcomes by encouraging people to seek care at particular facilities or seek follow-up care; experiences of care can also be influenced by health outcomes, whereby negative outcomes lead to negative perceived experiences [
15,
17,
18]. Moreover, experience of care and satisfaction with care are influenced by factors beyond specific health outcomes, such as the provision of seats in the waiting area, facility hygiene, and expectations of care [
19]. Understanding how these various components of experience of care relate to MNCH and can improve respectful, person-centred care is critical for improving quality of care.
As a pillar of quality of care, experience of care appears in the WHO framework for quality of maternal and newborn health care, where it is disaggregated into three critical components: effective communication, respect and dignity, and emotional support [
17]. The framework for improving the quality of paediatric care includes similar domains under experience of care: effective communication and meaningful participation; respect, protection and fulfilment of child rights; and emotional and psychological support [
18]. An additional component – user-centred health systems – has also been used to understand experience of care [
8].
The private sector, which includes individuals and organizations that are neither owned nor directly controlled by governments and are involved in the provision of health services (i.e., for-profit and not-for-profit entities; providers in the formal and informal sectors; and domestic and international actors, charities, faith-based organizations, and non-governmental groups) [
20], plays a growing role in delivering MNCH services as well as sexual and reproductive health services [
21,
22]. An estimated one in five births in low- and middle-income countries is delivered via the private sector [
21]. Yet, the quality of services provided varies [
23,
24]. There is a need to address inconsistent quality of care in the private sector and experiences of care more specifically [
14]. Despite the importance of experience of care on health outcomes and the links between quality of care and experience of care, there has been no synthesis of experiences of quality MNCH services in the private health sector.
The Network for Improving Quality of Care for Maternal, Newborn and Child Health (the Network), a partnership of 11 countries (Bangladesh, Côte d’Ivoire, Ethiopia, Ghana, India, Kenya, Malawi, Nigeria, Sierra Leone, the United Republic of Tanzania, and Uganda) and their technical partners, was launched in 2017 with the aim of halving maternal and newborn deaths and stillbirths in participating health facilities in 5 years’ time [
25]. Network members realize that the private sector has an important role in providing quality MNCH services within mixed (i.e., public and private) health systems. Since 2019, the WHO-based Network Secretariat has been conducting research that aims to fill gaps around how to effectively engage and sustain private sector involvement in delivering quality MNCH care in low- and middle-income countries. As part of this effort, the Network Secretariat conducted a systematic review that addresses four primary research questions:
1.
How does the provision of quality health care by the private sector affect morbidity and mortality among mothers, newborns, and children?
2.
How does provision of quality health care by the private sector affect utilization of services by mothers, newborns, and children?
3.
How effective and efficient is the private sector at delivering quality of care?
4.
Among mothers, newborns, and children utilizing health care provided by the private sector, what are their experiences of care? [
26]
This study is part of that larger systematic review. Given the extensive amount of data and studies in the entire systematic review, our aim in this article is to answer the fourth research question by systematically assessing the evidence from studies reporting outcome data on experiences of private sector quality MNCH care. Results from complementary analyses on the first three research questions will be presented in separate companion articles.
Methods
We conducted a systematic review following guidance in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses [
27,
28]. As noted in the PICOTS in Table
1, studies reporting on qualitative, quantitative, and/or mixed-methods data from low- and middle-income countries were considered. For inclusion in the systematic review, studies must have examined at least one of the following outcomes: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, components of quality of care (i.e. safety, effectiveness, timeliness, efficiency, equity, people-centred care), and/or experience of care, including respectful care. In recognition of the rapid increase in public-private collaborations for health during the late 1990s [
29], studies must have been published between 1 January 1995 and 30 June 2019 in English, French, German, or Italian. Ethical approval was not required.
Table 1
PICOTS criteria used in the systematic review
Populations | Pregnant people, mothers, newborns, and children (aged 9 years and under) |
Interventions | Delivery of quality maternal, newborn, and/or child health services by the private sector |
Control | Not necessary |
Outcomes | Quantitative, qualitative, or mixed-methods data on: • maternal morbidity • maternal mortality • newborn morbidity • newborn mortality • child morbidity • child mortality • components of quality care (i.e. safety, effectiveness, timeliness, efficiency, equity, people-centred care) • experience of care, including respectful care • service utilization |
Timeframe | 1 January 1995 to 30 June 2019 |
Setting | Low- and middle-income countries |
We searched journals from eight electronic databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, and Web of Science) and two websites (Health Care Provider Performance Review and the Maternal healthcare markets Evaluation Team at the London School of Hygiene & Tropical Medicine). We supplemented these searches with hand searching of reference lists and expert-recommended articles. The searches, application of inclusion/exclusion criteria, screening, and data extraction were conducted using a published protocol and data extraction tools [
26]. The search was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42019143383). Search terms appear in Table
2, and the full electronic search strategy for each database appears in the protocol [
26]. Searches were completed on 23 June 2020.
Table 2
Search terms and their combinations
private sector | quality | matern* |
for-profit | | pregnan* |
for profit | | mother* |
public-private | | newborn* |
private enterprise* | | infant* |
NGO | | child* |
non-government* | | pediatric* |
| | paediatric* |
| | neonat* |
Quantitative and qualitative data were extracted on the following categories:
-
Background information (e.g., author, date, setting, study objective)
-
Intervention background information (e.g., implementing agency, geographic level, study population)
-
Intervention details (e.g., intervention recipients, nature of intervention, dimensions of quality care)
-
Critical outcomes (both quantitative and qualitative):
-
◦ Maternal morbidity
-
◦ Maternal mortality
-
◦ Newborn morbidity
-
◦ Newborn mortality
-
◦ Child morbidity
-
◦ Child mortality
-
◦ Service utilization
-
◦ Experience of care, including respectful care
-
◦ Components of quality care (i.e. safety, effectiveness, timeliness, efficiency, equity, people-centred care)
-
Evaluation/study details (e.g., study type, data type, intervention claims, strategy effectiveness, cost data)
-
Study quality (qualitative and quantitative)
JS and SRL extracted and quality assessed studies in duplicate. Quantitative studies were assessed using the Effective Public Health Practice Project quality assessment tool [
30], and qualitative studies were assessed using Miltenburg et al.’s quality assessment tool based on criteria developed by Walsh and Downe [
31,
32]. The analysis synthesizes data from studies related to experience of care, including respectful care.
Qualitative data were thematically analysed using a three-stage approach, appropriate for systematic reviews [
33]. All data were coded with descriptive codes that were in turn collated into broader descriptive themes. Analytic themes were deduced from the returned literature, using measures of experience of care taken from literature as guidance. Measures related to experience of care addressed patient-provider relationships (e.g., patient involvement in decisions about their care and information about their care, feeling isolated, receiving information, provider attention, friendliness of care, confidence and trust in the services received, treatment by doctors, abuse, confidentiality, privacy, communication), client assessments (e.g., client satisfaction, overall satisfaction, rating of consultations, reliability of services, client complaint scores), quality (e.g., interpersonal aspects of quality, perceptions of quality, client quality scores), time (e.g., waiting times, time spent with health care providers, timeliness of care, delays in receiving services), patient experiences (e.g., general experience, care experience, women’s experience of human and physical resources, client preference, seeking alternative care), costs (e.g., costs of care, financial burdens), and facility experiences (e.g., facility cleanliness, seats available in the waiting area, privacy, availability of services, reasons for choosing the facility, returning clients). Within the included studies on experience of care, data on satisfaction with care are included in the results to acknowledge the relational nature of satisfaction as an outcome measure of experience [
9].
Given the heterogeneity between the studies in terms of study designs and interventions, it was not possible to conduct a meta-analysis for the outcome experience of care. Quantitative findings are presented using a narrative synthesis with tables of descriptive statistics. More detailed summary tables, including quality scores, appear in Additional File
1. The following findings present descriptive statistics followed by analytic themes.
Discussion
By systematically reviewing the evidence of mothers’, newborns’, and children’s experiences of care in the private sector, this article provides insights into best practices for delivering high quality experiences of care. The findings illustrate the importance of interpersonal relationships with health care workers, in particular staff friendliness, positive attitudes including non-judgement, time spent listening to women, and responsive counselling. The relationship between mothers, newborns, and children and health care workers is essential and cannot be underestimated, as it impacts person-centred care, timeliness, and equity. Timeliness of care, privacy, and affordability were also important aspects of women’s experiences of care in the private sector and by extension, women’s health outcomes. These components of positive experiences of care emerged as noteworthy in both quantitative and qualitative studies. Researchers frequently mixed experience of care and satisfaction with care in their studies, emphasising the complexity of these measures and their variation across contexts as well as their subjective nature amongst people seeking care.
Beyond “affordability” as a socioeconomic measure of inequality, there is a paucity of evidence on inequalities and experiences of private health care among women, children, and newborns. Parents and caregivers may or may not judge care provided to themselves and that provided to their children differently (e.g., a caregiver may be prepared to wait longer for care for themselves than their child, a caregiver may be willing to pay more for care for their children than themselves). Experiences in private facilities raise important questions on the affordability and by extension, the choice of care that women, children, and newborns may obtain. Compared to public health systems, private health systems may both directly and indirectly exacerbate socio-demographic inequalities. People seeking private health care may experience prohibitive costs at point of care; Indigenous and lower-income women may experience lower quality services. These inequalities and the continued marginalisation of certain populations have been identified as challenges across mixed health systems, regardless of the sector (public or private) in which people seek and receive care.
The context of private sector delivery of quality MNCH care is essential to consider. Studies highlight the varied and complex roles that the private sector has in different settings, for example, facilitating MNCH care delivery in areas where public sector infrastructure and capacity is weaker [
60] or providing alternative options for care where public health facilities exist [
21]. Whilst some of the included studies linked fewer people seeking care in certain types of private facilities with components of experience of care (e.g., lower waiting times, more time spent with health care providers, higher expectations of quality due to higher costs of care) [
61], this linkage was not universal. To better understand the factors influencing higher scores of experience of care in certain private health facilities, it is necessary to examine the context of the private health sector, including evidence on the accessibility and coverage of private facilities as well as disaggregation by the type of private provider.
This systematic review contributes to previous reviews on the public and private health sectors in low- and middle-income countries [
62,
63]. It complements findings from Basu et al. that timeliness and staff interactions were important components of experience of care [
62] and findings from Berendes et al. that the private sector is possibly more client oriented than the public sector [
63]. As this systematic review focused on private sector delivery of quality MNCH care, it corroborates that timeliness and staff interactions were major factors in mothers’, newborns’, and children’s experiences of quality care in private medical facilities. Included comparative studies of public and private health providers offer useful suggestions for policymakers, including the possible need to regulate the provision of care and to improve specific elements of experiences that are important, in order to ensure positive service provision of quality experiences of care across mixed health systems.
Due to language restrictions, relevant studies may have been excluded from this systematic review, particularly studies from Latin American and the Caribbean. We were also unable to locate 108 texts, despite our best efforts to locate authors and library assistance. The majority of these missing texts appear to be grey literature, particularly abstracts from the Popline database that closed in September 2019. Moreover, publication bias, particular in intervention research, may have resulted in an increased proportion of negative or neutral findings being rejected for publication [
64]. This potential source of bias has important implications on generalizability of claims in this article. Furthermore, this systematic review focused on experience of receiving care in the private sector, but we must also acknowledge the importance of private providers’ experiences implementing interventions to improve quality of care in the private sector [
65].
In conducting this systematic review, we observed that studies and reports largely do not consider the delivery of MNCH care in the mixed health system. Thus, the design, analysis, and reporting of studies are often not organized in a way that captures mixed health system data or presents disaggregated findings. As a result, this oversight leads to cherry picking of findings or conclusions, poor comprehension of the actual situation, and at times, the politicization of private sector service delivery.
Conclusions
Insights from this systematic review confirm that experience of care is fundamental for people seeking quality MNCH care in the private sector. The private sector is varied, complex, and context specific. While inaccessibility amongst some private services allows for privileged experiences of care, this is not inevitable. Meaningful engagement with, and regulation of, private sector service delivery can support efforts to achieve universal health coverage with quality. Of course, providing quality MNCH care and ensuring positive experiences of care in mixed health systems require the existence of basic prerequisites like the availability of clean water, sanitation, and hygiene; essential equipment; medications; and enabling environments for health care workers.
Policymakers, programme implementers, and private sector stakeholders must recognise that experience of care can be a stronger determining factor in health-related decision making than the quality of care available in public and private facilities. In addition to influencing care outcomes, experiences of care amongst mothers, newborns, and children influence their future decision-making and choice of both health providers and health facilities. Poor experiences of care lead people and their caregivers to seek care elsewhere, thus encouraging private providers to prioritise experience of care to ensure market competitiveness and future revenue.
Findings from this systematic review support recommendations aimed at strengthening the evidence base on experiences of private sector MNCH care and recommendations for improving experiences of private sector MNCH care. In order to better understand experiences of quality MNCH care within the private health sector, the following recommendations are made for researchers:
-
Experience of care is frequently only a small component of studies on quality of care. Additional research should centre experience of care as a key focus, explore the relationship between experience of private sector quality care and socioeconomic inequalities, and fill in gaps around mothers’ experiences of private health care for childbirth.
-
Experience of care should not be an outcome limited to adults. The experiences of children, newborns, and parents or carers seeking care for their children can also add value to studies investigating quality of care.
-
Establishing criteria for understanding experience of care would help reduce variations within qualitative and quantitative data. Satisfaction and experience of care are important but separate constructs. Criteria more clearly presenting the differences between experience of care and satisfaction with care are required, as is the centring of inequalities in experiences of care.
-
This systematic review excluded 64 studies that presented aggregated findings on the public and private sectors and 45 studies that did not specify whether the health facilities were public and/or private. To better understand experiences of care in the private sector, we encourage researchers to specify what types of health facilities are included in the study and to disaggregate their data on the public and private sectors when conducting analyses. Had we been able to draw upon this work and knowledge, we might have been able to generate more conclusive evidence on experiences of quality MNCH care provided by the private and public sectors.
-
The private sector is heterogenous, so having additional details about the types of private facilities included in a study (e.g., self-financing, faith-based, NGO) could show valuable differences.
In order to improve experiences of MNCH care within the private health sector, the following recommendations are made for policymakers and programme implementers:
-
Patients seeking MNCH care may switch between the public and private sectors, obtaining private antenatal care but choosing to deliver in a public facility, for example. Improving experience of care requires approaching the entire mixed health system and also strengthening case referrals between the public and private sectors.
-
In certain settings, a lack of economic incentives to establish and operate private health facilities delivering MNCH care in rural areas means that private health facilities are likelier to deliver MNCH care in urban areas and to people from higher socioeconomic groups. Expanding access to low-interest loans and providing economic incentives to private health facilities can help facilitate the entry of private MNCH providers in hard-to-reach and rural areas as well as amongst lower socioeconomic groups, thus expanding access to affordable quality care and helping deliver universal health coverage.
-
Even if mothers, newborns, and children report positive experiences of care, poor dissemination of updated guidelines and standards to private health providers means that the quality of MNCH care delivered may not always align with national standards. Greater dissemination and outreach to private facilities and providers is warranted as is the inclusion of stakeholders from the private sector in developing national policies, standards, and strategies. Additional resources and easier access to financing can also help facilitate greater compliance with national quality standards.
-
Comparative studies of experiences of quality MNCH care in public and private health facilities provide opportunities for shared learning between facilities; however, this cross-learning is rarely instutionalised. We encourage Ministries of Health to strengthen and operationalise a mechanism for public-private dialogue in order to foster relationships, create open and transparent communication, and co-develop and co-implement an agenda to strengthen quality of MNCH care.
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