The role of private providers in maternal health.

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 identifi cation 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 eff ectively 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. 1 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). 2 Although these locally based providers are often the fi rst 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. 3 Additionally, for many years the private sector has played a substantial part in provision of services for family planning, one of the most eff ective ways to reduce maternal mortality. 3–6 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 eff ects. 7 However, questions about equity and cost-eff ectiveness need further research. 7 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 eff orts on strengthening of the public health sector, despite the potentially substantial part the private sector could play to address …


The role of private providers in maternal health
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 identifi cation 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 eff ectively 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. 1 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). 2 Although these locally based providers are often the fi rst 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. 3 Additionally, for many years the private sector has played a substantial part in provision of services for family planning, one of the most eff ective ways to reduce maternal mortality. 3-6 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 eff ects. 7 However, questions about equity and cost-eff ectiveness need further research. 7 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 eff orts 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 off ering services for maternal care exist (and where), who the private sector reaches with these services, what services are off ered, 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 fi ll gaps in public services; whether the private sector relieves any burden on the public sector; whether provision of consistent highquality 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 eff ectively 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. 3 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 eff orts 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 For Merck for Mothers see http://www. merckformothers.com