Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria.

Background: Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. Methods: This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. Findings: We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. Interpretation: This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. Funding: The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.

Exploring and Monitoring Privacy, Confidentiality, and Provider Bias in Sexual and Reproductive Health Service Provision to Young People: A Narrative Review.

PURPOSE: Poor privacy and confidentiality practices and provider bias are believed to compromise adolescent and young adult sexual and reproductive health service quality. The results of focus group discussions with global youth leaders and sexual and reproductive health implementing organizations indicated that poor privacy and confidentiality practices and provider bias serve as key barriers to care access for the youth. METHODS: A narrative review was conducted to describe how poor privacy and confidentiality practices and provider bias impose barriers on young people seeking sexual and reproductive health services and to examine how point of service evaluations have assessed these factors. RESULTS: 4544 peer-reviewed publications were screened, of which 95 met the inclusion criteria. To these articles, another 16 grey literature documents were included, resulting in a total of 111 documents included in the review. CONCLUSION: Poor privacy and confidentiality practices and provider bias represent significant barriers for young people seeking sexual and reproductive health services across diverse geographic and sociocultural contexts. The authors found that present evaluation methods do not appropriately account for the importance of these factors and that new performance improvement indicators are needed.

The Provision of Private Healthcare Services in European Countries: Recent Data and Lessons for Universal Health Coverage in Other Settings.

Universal Health Coverage (UHC) exists in all of the countries of Europe, despite variation on the ownership structure of health delivery systems. As countries around the world seek to advance UHC and manage the private sector within their health systems, the European experiences can offer useful insights. We found four different models for the provision of healthcare, with the private sector predominant in some countries, and of minimal importance in others. The European experiences indicate that UHC can be effectively provided with, or without, large-scale private sector provision in hospital, specialty, and primary care services, and that moreover it can be provided with high levels of patient satisfaction. These findings offer regulatory models for countries in other regions to review as they advance UHC.

Equity lessons from a large scale private-sector healthcare intervention in Ghana and Kenya: Results for a multi-year qualitative study.

Background: The poor fall sick more frequently than the wealthy, and are less likely to seek care when they do.  Private provision in many Low- and Middle-Income Countries makes up half or more of all outpatient care, including among poor paitents.  Understanding the preferences of poor patients which impel them to choose private providers, and how 3 rd party payment influences these preferences, is important for policy makers considering expansion of national health insurance financing to advance Universal Health Coverage. This paper reports on the results of a qualitative evaluation of the African Health Markets for Equity intiative (AHME), a multi-year initiative in Ghana and Kenya to increase options and improve quality for outpatient services, especially for the poor. Methods: Interviews with patients from private clinics were conducted annually between 2013 and 2018.  Field staff recruited women for exit interviews as they were leaving these clinics. In the final round of data collection (2018), interviewers screened patients for wealth quintile and selected one third of the sample (approximately 10 patients per country) that fell into the two lowest wealth quintiles (Q1 and Q2).  Transcripts were coded using Atlas.ti and coded for analysis using an inductive, thematic approach. Results: We found four primary drivers of patient preferences for private clinics:  convenience; efficiency and predictability, perceived higher quality, and empowerment which was derived from greater choice in where to go.  Conclusions: Our findings indicate that more options will lead to more opportunities for treatment, and decrease the percentage of those, mostly poor, who become ill and go without care of any kind.  This should be considered as a priority  by policy makers seeking to make the best use of existing national infrastructure and expertise to assure equal health for all.  In this way, private providers offer an opportunity to advance national goals.

Measuring Service Quality and Assessing Its Relationship to Contraceptive Discontinuation: A Prospective Cohort Study in Pakistan and Uganda.

BACKGROUND: The quality of contraceptive counseling that women receive from their provider can influence their future contraceptive continuation. We examined (1) whether the quality of contraceptive service provision could be measured in a consistent way by using existing tools from 2 large-scale social franchises, and (2) whether facility quality measures based on these tools were consistently associated with contraceptive discontinuation. METHODS: We linked existing, routinely collected facility audit data from social franchise clinics in Pakistan and Uganda with client data. Clients were women aged 15-49 who initiated a modern, reversible contraceptive method from a sampled clinic. Consented participants completed an exit interview and were contacted 3, 6, and 12 months later. We collapsed indicators into quality domains using theory-based categorization, created summative quality domain scores, and used Cox proportional hazards models to estimate the relationship between these quality domains and discontinuation while in need of contraception. RESULTS: The 12-month all-modern method discontinuation rate was 12.5% among the 813 enrolled women in Pakistan and 5.1% among the 1,185 women in Uganda. We did not observe similar associations between facility-level quality measures and discontinuation across these 2 settings. In Pakistan, an increase in the structural privacy domain was associated with a 60% lower risk of discontinuation, adjusting for age and baseline method (P<.001). In Uganda, an increase in the management support domain was associated with a 33% reduction in discontinuation risk, controlling for age and baseline method (P=.005). CONCLUSIONS: We were not able to leverage existing, widely used quality measurement tools to create quality domains that were consistently associated with discontinuation in 2 study settings. Given the importance of contraceptive service quality and recent advances in indicator standardization in other areas, we recommend further effort to harmonize and simplify measurement tools to measure and improve contraceptive quality of care for all.

Definitions, measurement and indicator selection for quality of care in abortion.

Little consensus exists about how to measure quality of care in abortion. Our purpose is to (a) provide common language for healthcare quality definitions, frameworks and measurement; (b) synthesize literature about quality measurement in abortion; and (c) present criteria for quality metric development. Quality includes effectiveness, patient centeredness, timeliness, efficiency and equity of care. Information about structure, process and outcomes of care is used to measure quality. We do not have good evidence about expected population-level health and behavioral outcomes associated with improving abortion service quality. Abortion patients overwhelmingly report high satisfaction with services, but it is not clear if their satisfaction indicates high-quality care. Guidance exists for quality metric selection; measures must focus on priority topics, be scientifically sound and be feasible. Technical quality standards and clinical guidelines exist, but we lack a standard set of quality metrics. Partners in the Abortion Service Quality Initiative (https://asq-initiative.org/) are collaborating to develop the first-ever global standard for measuring abortion service quality in low- and middle-income countries, both in and out of health care facilities. Standardized and validated quality metrics would move our field forward and contribute to quality improvement activities and, ultimately, to improved health outcomes for women and families. IMPLICATIONS: We define quality of health care, synthesize the evidence about quality of care in abortion and advocate for standardized and validated quality metrics to improve health outcomes for women.

Public-private partnerships in practice: collaborating to improve health finance policy in Ghana and Kenya.

Social health insurance (SHI), one mechanism for achieving universal health coverage, has become increasingly important in low- and middle-income countries (LMICs) as they work to achieve this goal. Although small private providers supply a significant proportion of healthcare in LMICs, integrating these providers into SHI systems is often challenging. Public-private partnerships in health are one way to address these challenges, but we know little about how these collaborations work, how effectively, and why. Drawing on semi-structured interviews conducted with National Health Insurance (NHI) officials in Kenya and Ghana, as well as with staff from several international NGOs (INGOs) representing social franchise networks that are partnering to increase private provider accreditation into the NHIs, this article examines one example of public-private collaboration in practice. We found that interviewees initially had incomplete knowledge about the potential for cross-sector synergy, but both sides were motivated to work together around shared goals and the potential for mutual benefit. The public-private relationship then evolved over time through regular face-to-face interactions, reciprocal feedback, and iterative workplan development. This process led to a collegial relationship that also has given small private providers more voice in the health system. In order to sustain this relationship, we recommend that both public and private sector representatives develop formalized protocols for working together, as well as less formal open channels for communication. Models for aggregating small private providers and delivering them to government programmes as a package have potential to facilitate public-private partnerships as well, but there is little evidence on how these models work in LMICs thus far.

Predictors of person-centered maternity care: the role of socioeconomic status, empowerment, and facility type.

BACKGROUND: Low use of maternal health services, as well as poor quality care, contribute to the high maternal mortality in sub-Saharan Africa (SSA). In particular, poor person-centered maternity care (PCMC), which captures user experience, contributes both directly to pregnancy outcomes and indirectly through decreased demand for services. While many studies have examined disparities in use of maternal health services, few have examined disparities in quality of care, and none to our knowledge has empirically examined disparities in PCMC in SSA. The aim of this study is to examine factors associated with PCMC, particularly the role of household wealth, personal empowerment, and type of facility. METHODS: Data are from a survey conducted in western Kenya in 2016, with women aged 15 to 49 years who delivered in the 9 weeks preceding the survey (N = 877). PCMC is operationalized as a summative score based on responses to 30 items in the PCMC scale capturing dignity and respect, communication and autonomy, and supportive care. RESULTS: We find that net of other factors; wealthier, employed, literate, and married women report higher PCMC than poorer, unemployed, illiterate, and unmarried women respectively. Also, women who have experienced domestic violence report lower PCMC than those who have never experienced domestic violence. In addition, women who delivered in health centers and private facilities reported higher PCMC than those who delivered in public hospitals. The effect of employment and facility type is conditional on wealth, and is strongest for the poorest women. Poor women who are unemployed and poor women who deliver in higher-level facilities receive the lowest quality PCMC. CONCLUSIONS: The findings imply the most disadvantaged women receive the lowest quality PCMC, especially when they seek care in higher-level facilities. Interventions to reduce disparities in PCMC are essential to improve maternal outcomes among disadvantaged groups.

Who Serves the Poor? An Equity Analysis of Public and Private Providers of Family Planning and Child Health Services in Kenya.

Understanding differences in the wealth status of patients can inform planning decisions aimed at providing affordable access to high quality care to all. This study assesses differences in the wealth status of clients of family planning and child health services by health sector. It also describes reason for facility choice, cost of services, and the proportion of additional clients of these services, and assesses if there are any differences by health sector. A cross-sectional survey of 2,173 clients from 96 health facilities in urban areas of 6 counties in Kenya was conducted, stratified by health facility type. The 4 strata were public, faith-based, private for profit, and social franchise. Client wealth was benchmarked to the national and urban population of the 2014 Kenya Demographic and Health Survey (DHS), and assessed using the EquityTool. There were significant differences in the client wealth distribution between facility types, and public sector facilities served a significantly higher proportion of poor clients than other types of facilities. In all three non-public facility types, more than 25% of clients were from the poorest two wealth quintiles, without significant differences between facility types. No facility type stands out as expanding access to health services more than another. Results show that social franchises do better at reaching the poor than earlier studies have indicated, though not as well as faith-based and public facilities. Findings suggest that private providers remain important within the larger health system, more so for family planning than childhood illness management. In urban areas with significant facility choice, this study quantifies differences in client wealth across four health sectors. Incorporating these findings into policy and programmatic interventions can improve equity in access to and use of quality health services.

Putting women at the center: a review of Indian policy to address person-centered care in maternal and newborn health, family planning and abortion.

BACKGROUND: Person-centered care is a critical component of quality care, essential to enable treatment adherence, and maximize health outcomes. Improving the quality of health services is a key strategy to achieve the new global target of zero preventable maternal deaths by 2030. Recognizing this, the Government of India has in the last decade initiated a number of strategies to address quality of care in health and family welfare services. METHODS: We conducted a policy review of quality improvement strategies in India from 2005 to 15, covering three critical areas- maternal and newborn health, family planning, and abortion (MNHFP + A). Based on Walt and Gilson's policy triangle framework, we analyzed the extent to which policies incorporated person-centered care, while identifying unaddressed issues. Data was sourced from Government of India websites, scientific and grey literature databases. RESULTS: Twenty-two national policy documents, comprising two policy statements and 20 implementation guidelines of specific schemes were included in the review. Quality improvement strategies span infrastructure, commodities, human resources, competencies, and accountability that are driving quality assurance in MNHFP + A services. However, several implementation challenges have affected compliance with person-centered care, thereby affecting utilization and outcomes. CONCLUSION: Focus on person-centered care in Indian MNHFP + A policy has increased in recent years. Nevertheless, some aspects must still be strengthened, such as positive interpersonal behavior, information sharing and promptness of care. Implementation can be improved through better provider training, patient feedback and monitoring mechanisms. Moreover, unless persisting structural challenges are addressed implementation of person-centered care in facilities will not be effective.

Where women go to deliver: understanding the changing landscape of childbirth in Africa and Asia.

Growing evidence from a number of countries in Asia and Africa documents a large shift towards facility deliveries in the past decade. These increases have not led to the improvements in health outcomes that were predicted by health policy researchers in the past. In light of this unexpected evidence, we have assessed data from multiple sources, including nationally representative data from 43 countries in Asia and Africa, to understand the size and range of changing delivery location in Asia and Africa. We have reviewed the policies, programs and financing experiences in multiple countries to understand the drivers of changing practices, and the consequences for maternal and neonatal health and the health systems serving women and newborns. And finally, we have considered what implications changes in delivery location will have for maternal and neonatal care strategies as we move forward into the next stage of global action. As a result of our analysis we make four major policy recommendations. (1) An expansion of investment in mid-level facilities for delivery services and a shift away from low-volume rural delivery facilities. (2) Assured access for rural women through funding for transport infrastructure, travel vouchers, targeted subsidies for services and residence support before and after delivery. (3) Increased specialization of maternity facilities and dedicated maternity wards within larger institutions. And (4) a renewed focus on quality improvements at all levels of delivery facilities, in both private and public settings.

Advancing a conceptual model to improve maternal health quality: The Person-Centered Care Framework for Reproductive Health Equity.

Background: Globally, substantial health inequities exist with regard to maternal, newborn and reproductive health. Lack of access to good quality care-across its many dimensions-is a key factor driving these inequities. Significant global efforts have been made towards improving the quality of care within facilities for maternal and reproductive health. However, one critically overlooked aspect of quality improvement activities is person-centered care. Main body: The objective of this paper is to review existing literature and theories related to person-centered reproductive health care to develop a framework for improving the quality of reproductive health, particularly in low and middle-income countries. This paper proposes the Person-Centered Care Framework for Reproductive Health Equity, which describes three levels of interdependent contexts for women's reproductive health: societal and community determinants of health equity, women's health-seeking behaviors, and the quality of care within the walls of the facility. It lays out eight domains of person-centered care for maternal and reproductive health. Conclusions: Person-centered care has been shown to improve outcomes; yet, there is no consensus on definitions and measures in the area of women's reproductive health care. The proposed Framework reviews essential aspects of person-centered reproductive health care.

Clinical and perceived quality of care for maternal, neonatal and antenatal care in Kenya and Namibia: the service provision assessment.

BACKGROUND: The majority of women in sub-Saharan Africa now deliver in a facility, however, little is known about the quality of services for maternal and newborn basic and emergency care, nor how this is associated with patient's perception of their experiences. METHODS: Using data from the Service Provision Assessment (SPA) survey from Kenya 2010 and Namibia 2009, we explore whether facilities have the necessary signal functions for providing emergency and basic maternal (EmOC) and newborn care (EmNC), and antenatal care (ANC) using descriptives and multivariate regression. We explore differences by type of facility (hospital, center or other) and by private and public facilities. Finally, we see if patient satisfaction (taken from exit surveys at antenatal care) is associated with the quality of services (specific services provided). RESULTS: We find that most facilities do not have all of the signal functions, with 46 and 27 % in Kenya and 18 and 5 % in Namibia of facilities have high/basic scores in routine and emergency obstetric care, respectively. We found that hospitals preform better than centers in general and few differences emerged between public and private facilities. Patient perceptions were not consistently associated with services provided; however, patients had fewer complaints in private compared to public facilities in Kenya (-0.46 fewer complaints in private) and smaller facilities compared to larger in Namibia (-0.26 fewer complaints in smaller facilities). Service quality itself (measured in scores), however, was only significantly better in Kenya for EmOC and EmNC. CONCLUSIONS: This analysis sheds light on the inadequate levels of care for saving maternal and newborn lives in most facilities in two countries of Africa. It also highlights the disconnect between patients' perceptions and clinical quality of services. More effort is needed to ensure that high quality supply of services is present to meet growing demand as an increasing number of women deliver in facilities.

Prohibit, constrain, encourage, or purchase: how should we engage with the private health-care sector?

The private for-profit sector's prominence in health-care delivery, and concern about its failures to deliver social benefit, has driven a search for interventions to improve the sector's functioning. We review evidence for the effectiveness and limitations of such private sector interventions in low-income and middle-income countries. Few robust assessments are available, but some conclusions are possible. Prohibiting the private sector is very unlikely to succeed, and regulatory approaches face persistent challenges in many low-income and middle-income countries. Attention is therefore turning to interventions that encourage private providers to improve quality and coverage (while advancing their financial interests) such as social marketing, social franchising, vouchers, and contracting. However, evidence about the effect on clinical quality, coverage, equity, and cost-effectiveness is inadequate. Other challenges concern scalability and scope, indicating the limitations of such interventions as a basis for universal health coverage, though interventions can address focused problems on a restricted scale.

Recent trends in working with the private sector to improve basic healthcare: a review of evidence and interventions.

The private sector provides the majority of health care in Africa and Asia. A number of interventions have, for many years, applied different models of subsidy, support and engagement to address social and efficiency failures in private health care markets. We have conducted a review of these models, and the evidence in support of them, to better understand what interventions are currently common, and to what extent practice is based on evidence. Using established typologies, we examined five models of intervention with private markets for care: commodity social marketing, social franchising, contracting, accreditation and vouchers. We conducted a systematic review of both published and grey literature, identifying programmes large enough to be cited in publications, and studies of the listed intervention types. 343 studies were included in the review, including both published and grey literature. Three hundred and eighty programmes were identified, the earliest having begun operation in 1955. Commodity social marketing programmes were the most common intervention type, with 110 documented programmes operating for condoms alone at the highest period. Existing evidence shows that these models can improve access and utilization, and possibly quality, but for all programme types, the overall evidence base remains weak, with practice in private sector engagement consistently moving in advance of evidence. Future research should address key questions concerning the impact of interventions on the market as a whole, the distribution of benefits by socio-economic status, the potential for scale up and sustainability, cost-effectiveness compared to relevant alternatives and the risk of unintended consequences. Alongside better data, a stronger conceptual basis linking programme design and outcomes to context is also required.

Availability and quality of anti-malarials among private sector outlets in Myanmar in 2012: results from a large, community-based, cross-sectional survey before a large-scale intervention.

BACKGROUND: Global malaria control efforts are threatened by the spread and emergence of artemisinin-resistant Plasmodium falciparum parasites. In 2012, the widespread sale of partial courses of artemisinin-based monotherapy was suspected to take place in the highly accessed, weakly regulated private sector in Myanmar, posing potentially major threats to drug resistance. This study investigated the presence of artemisinin-based monotherapies in the Myanmar private sector, particularly as partial courses of therapy, to inform the targeting of future interventions to stop artemisinin resistance. METHODS: A large cross-sectional survey comprised of a screening questionnaire was conducted across 26 townships in Myanmar between March and May, 2012. For outlets that stocked anti-malarials at the time of survey, a stock audit was conducted, and for outlets that stocked anti-malarials within 3 months of the survey, a provider survey was conducted. RESULTS: A total of 3,658 outlets were screened, 83% were retailers (pharmacies, itinerant drug vendors and general retailers) and 17% were healthcare providers (private facilities and health workers). Of the 3,658 outlets screened, 1,359 outlets (32%) stocked at least one anti-malarial at the time of study. Oral artemisinin-based monotherapy comprised of 33% of self-reported anti-malarials dispensing volumes found. The vast majority of artemisinin-based monotherapy was sold by retailers, where 63% confirmed that they sold partial courses of therapy by cutting blister packets. Very few retailers (5%) had malaria rapid diagnostic tests available, and quality-assured artemisinin-based combination therapy was virtually nonexistent among retailers. CONCLUSION: Informal private pharmacies, itinerant drug vendors and general retailers should be targeted for interventions to improve malaria treatment practices in Myanmar, particularly those that threaten the emergence and spread of artemisinin resistance.

Improving uptake and use of malaria rapid diagnostic tests in the context of artemisinin drug resistance containment in eastern Myanmar: an evaluation of incentive schemes among informal private healthcare providers.

BACKGROUND: As efforts to contain artemisinin resistance and eliminate Plasmodium falciparum intensify, the accurate diagnosis and prompt effective treatment of malaria are increasingly needed in Myanmar and the Greater Mekong Sub-region (GMS). Rapid diagnostic tests (RDTs) have been shown to be safe, feasible, and effective at promoting appropriate treatment for suspected malaria, which are of particular importance to drug resistance containment. The informal private sector is often the first point of care for fever cases in malaria endemic areas across Myanmar and the GMS, but there is little published information about informal private provider practices, quality of service provision, or potential to contribute to malaria control and elimination efforts. This study tested different incentives to increase RDT use and improve the quality of care among informal private healthcare providers in Myanmar. METHODS: The study randomized six townships in the Mon and Shan states of rural Myanmar into three intervention arms: 1) RDT price subsidies, 2) price subsidies with product-related financial incentives, and 3) price subsidies with intensified information, education and counselling (IEC). The study assessed the uptake of RDT use in the communities by cross-sectional surveys of 3,150 households at baseline and six months post-intervention (6,400 households total, 832 fever cases). The study also used mystery clients among 171 providers to assess quality of service provision across intervention arms. RESULTS: The pilot intervention trained over 600 informal private healthcare providers. The study found a price subsidy with intensified IEC, resulted in the highest uptake of RDTs in the community, as compared to subsidies alone or merchandise-related financial incentives. Moreover, intensified IEC led to improvements in the quality of care, with mystery client surveys showing almost double the number of correct treatment following diagnostic test results as compared to a simple subsidy. CONCLUSIONS: Results show that training and quality supervision of informal private healthcare providers can result in improved demand for, and appropriate use of RDTs in drug resistance containment areas in eastern Myanmar. Future studies should assess the sustainability of such interventions and the scale and level of intensity required over time as public sector service provision expands.

A total market approach for condoms in Myanmar: the need for the private, public and socially marketed sectors to work together for a sustainable condom market for HIV prevention.

BACKGROUND: Concerns about appropriate pricing strategies and the high market share of subsidized condoms prompted Population Services International (PSI)/Myanmar to adopt a total market approach (TMA). This article presents data on the size and composition of the Myanmar condom market, identifies inefficiencies and recommends methods for better targeting public subsidy. METHODOLOGY: Data on condom need and condom use came from PSI/Myanmar's (PSI/M's) behavioural surveys; data for key populations' socioeconomic status profiles came from the same surveys and the National Tuberculosis Prevalence Survey. Data on market share, volumes, value and number of condoms were from PSI/M's quarterly retail audits and Joint United Nations Programme on HIV/AIDS (UNAIDS). RESULTS: Between 2008 and 2010, the universal need for condoms decreased from 112.9 to 98.2 million while condom use increased from 32 to 46%. Free and socially marketed condoms dominated the market (94%) in 2009-11 with an increase in the proportion of free condoms over time. The retail price of socially marketed condoms was artificially low at 44 kyats ($0.05 USD) in 2011 while the price for commercial condoms was 119-399 kyats ($0.15-$0.49 USD). Equity analyses demonstrated an equal distribution of female sex workers across national wealth quintiles, but 54% of men who have sex with men and 55% of male clients were in the highest two quintiles. Donor subsidies for condoms increased over time; from $434,000 USD in 2009 to $577,000 USD in 2011. CONCLUSION: The market for male condoms was stagnant in Myanmar due to: limited demand for condoms among key populations, the dominance of free and socially marketed condoms on the market and a neglected commercial sector. Subsidies for socially marketed and free condoms have prevented the growth of the private sector, an unintended consequence. A TMA is needed to grow and sustain the condom market in Myanmar, which requires close co-ordination between the public, socially marketed and commercial sectors.

Cost-effectiveness of using a social franchise network to increase uptake of oral rehydration salts and zinc for childhood diarrhea in rural Myanmar.

INTRODUCTION: This paper examines the cost-effectiveness of achieving increases in the use of oral rehydration solution and zinc supplementation in the management of acute diarrhea in children under 5 years through social franchising. The study uses cost and outcome data from an initiative by Population Services International (PSI) in 3 townships of Myanmar in 2010 to promote an ORS-Zinc product called ORASEL. BACKGROUND: The objective of this study was to determine the incremental cost-effectiveness of a strategy to promote ORS-Z use through private sector franchising compared to standard government and private sector practices. METHODS: Costing from a societal perspective included program, provider, and household costs for the 2010 calendar year. Program costs including ORASEL program launch, distribution, and administration costs were obtained through a retrospective review of financial records and key informant interviews with staff in the central Yangon office. Household out of pocket payments for diarrheal episodes were obtained from a household survey conducted in the study area and additional estimates of household income lost due to parental care-giving time for a sick child were estimated. Incremental cost-effectiveness relative to status quo conditions was calculated per child death and DALY averted in 2010. Health effects included deaths and DALYs averted; the former modeled based on coverage estimates from a household survey that were entered into the Lives Saved Tool (LiST). Uncertainty was modeled with Monte Carlo methods. FINDINGS: Based on the model, the promotional strategy would translate to 2.85 (SD 0.29) deaths averted in a community population of 1 million where there would be 81,000 children under 5 expecting 48,373 cases of diarrhea. The incremental cost effectiveness of the franchised approach to improving ORASEL coverage is estimated at a median $5,955 (IQR: $3437-$7589) per death averted and $214 (IQR: $127-$287) per discounted DALY averted. INTERPRETATION: Investing in developing a network of private sector providers and keeping them stocked with ORS-Z as is done in a social franchise can be a highly cost-effective in terms of dollars per DALY averted.