WHO South-East Asia Journal of Public Health
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COMMENTARY
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 59-60

Pandemic preparedness requires better regulation and stewardship of private providers that dominate provision of primary health care


1 Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Department of Pathology and Laboratory Medicine, Aga Khan University, Sindh, Pakistan
2 Centre for Universal Health, London, UK
3 Public Health England, London, UK
4 Department of Pathology and Laboratory Medicine, Aga Khan University, Sindh, Pakistan

Date of Web Publication26-Feb-2021

Correspondence Address:
Dr Mishal S Khan
Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Department of Pathology and Laboratory Medicine, Aga Khan University, Sindh, Pakistan

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DOI: 10.4103/2224-3151.309874

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How to cite this article:
Khan MS, Rahman-Shepherd A, van der Mark N, Dar O, Hasan R. Pandemic preparedness requires better regulation and stewardship of private providers that dominate provision of primary health care. WHO South-East Asia J Public Health 2021;10, Suppl S1:59-60

How to cite this URL:
Khan MS, Rahman-Shepherd A, van der Mark N, Dar O, Hasan R. Pandemic preparedness requires better regulation and stewardship of private providers that dominate provision of primary health care. WHO South-East Asia J Public Health [serial online] 2021 [cited 2021 Apr 21];10, Suppl S1:59-60. Available from: http://www.who-seajph.org/text.asp?2021/10/3/59/309874

Many Asian low- and middle-income countries’ health systems are characterized by a failure of the public sector to adequately provide, regulate and monitor primary health care services, resulting in the dominance of poorly regulated health care providers in the private sector. The long-standing neglect by many Asian governments to invest in public sector primary health care services – with the notable exceptions of Bhutan, Maldives, Sri Lanka and Thailand – has created a vacuum that has been filled by private providers, from which the majority of people seek care.[1],[2] As we summarize here, coronavirus disease 2019 (COVID-19) has highlighted the consequences of poorly regulated privately dominated primary health care provision on patient impoverishment, the quality of care delivered and the levels of infectious disease transmission.

Although COVID-19 can develop into a severe illness, the early stages of infection are usually characterized by mild respiratory symptoms. Numerous studies show that patients with mild symptoms often approach private drug shops or clinics as the first point of care.[2] In the absence of well- disseminated and binding standard treatment guidelines, such providers often rely on (social) media, rather than public health agency guidelines or peer-reviewed medical literature, to obtain information on clinical management options.[3] In addition, these private providers typically make a profit from the provision of consultations, tests and medications, including non-pharmaceutical interventions. The absence of clear treatment guidelines, and the potential financial benefits to forprofit private providers from overprovision of care, can result in the use of inappropriate and expensive treatments, often with little regard to side-effects or the risk–benefit ratio for the patient.[4] Furthermore, pre-existing gaps in effective health coverage, coupled with the predominance of the public relying on private providers to routinely access health care, can lead to price gouging and result in catastrophic out-of-pocket health expenditures. For example, during the COVID-19 pandemic, price increases for personal protective equipment (PPE) were observed in pharmacies across four Asian low- and middle- income countries.[5]

Poor infection prevention and control practices are already well documented among private providers.[6] Many private providers practise in health care facilities that are overcrowded and do not have appropriate ventilation, specimen collection areas, biosafety standards or PPE. Furthermore, lack of awareness regarding COVID-19 transmission, compounded by shortages of PPE for health care providers, can lead to a serious risk of transmission at some private health care facilities. Although several countries have encouraged symptomatic individuals to call helplines, rather than visiting health care facilities, there are many vulnerable groups – including women, elderly people, refugees and people with low literacy – who may not easily be able to use phones to seek health care advice.[7]

The role of private diagnostic laboratories as part of the network delivering primary health care and potentially impeding infectious disease control is also important. The costs and quality of the services provided by private laboratories can vary greatly. For example, anecdotal reports exist of incorrect diagnostic tests being used for COVID-19 in private laboratories, and private laboratories have been shown to give incorrect results of diagnostic tests for other infectious diseases.[8] Furthermore, in the case of COVID-19, additional complexity is created by the speed with which new tests are being developed and marketed. In the absence of regulations and guidance, many private laboratories market tests with little appreciation of their role in patient care or their position in the diagnostic algorithm.

Although COVID-19 has highlighted the need to prioritize locally appropriate actions to manage the role of private providers in the delivery of primary health care, it has done so at a time when government budgets and human resources are highly overstretched. It may not be possible to fix the deep- rooted challenges associated with strengthening public primary health care while we are struggling to control a pandemic of unprecedented scale; nonetheless, it is critical to recognize the long-term challenges we will face if we allow primary health care delivery to be dominated by poorly regulated private providers. The lack of contextualized knowledge about how to achieve improved regulation and stewardship in mixed health systems is a major barrier to progress, and there is an urgent need for investment in research to produce that knowledge locally.[9] We must also look for specific opportunities emerging in the light of COVID-19. For example, since the pandemic has shown the susceptibility of health care providers to infectious diseases, private providers may be more willing to voluntarily engage with government agencies and be part of informationsharing networks. This could facilitate sharing of guidelines and alerts by government agencies and reduce reliance on sources that might propagate misinformation. Equally, there is an opportunity for governments to include better regulation of private providers in their pandemic preparedness plans. Moving forward, there is an urgent need for more effective stewardship of mixed health systems to minimize the elements of poorly regulated private health care provision that can undermine the basic principles of equity, affordability and quality of health care.

Disclaimer: The views expressed in the submitted article are our own and not an official position of an institution or funder.

Source of support: None.

Conflict of interest: None declared.

Authorship: MSK wrote a first draft of the paper. All other authors added to the first draft and approved the final version.

 
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