Private practitioners in the slums of Karachi: what quality of care do they offer?
Introduction
In many developing countries, private health services have expanded since the 1980s (Golladay and Liese, 1980; Alailima and Mohideen, 1984; Viveros-Long, 1986; Naylor, 1988; Griffin, 1989; Liu and Wang, 1991; Mulou et al., 1992; Bennett et al., 1997). Low income groups in cities often consult private practitioners (PPs), as reported in studies from Pakistan (Qureshi and Shepard, 1988), the Philippines (Akin et al., 1986), Mexico (Ward, 1987), India (Yesudian, 1991; Uplekar, 1989), and Singapore (Fong and Phua, 1985). Thus the urban poor are paying “fees for services” to private practitioners, from their own income. Slum dwellers' health care costs are often “out-of-pocket” (Qureshi and Shepard, 1988; Akin et al., 1986; Roth, 1987; DeFerranti, 1985; Kachiryan et al., 1987; Garner and Thaver, 1993).
Some authors have described private practitioners as “detrimental” to the primary health care approach towards achieving health for all (Roemer, 1984; Heendeiya, 1987). Private practitioners are criticised for being expensive and motivated by profit rather than the welfare of their clients (Barros et al., 1986; Berman et al., 1987). Other experts comment that private providers are concentrated in urban areas, whereas the greatest health care need is in rural locations (Bhat, 1991; Bloom, 1988); and that they provide only curative services, and ignore prevention in primary care (Naylor, 1988; McCord, 1988).
In 1978, the Second European Conference on Teaching of General Practice defined the role of private practitioners as: “a licensed medical graduate who gives personal primary and continuing care to individuals, families and to a practice population irrespective of age, sex and illness... S/he will include and integrate physical, psychological and social factors in his consideration about health and illness... S/he will know how and when to intervene, through treatment, prevention and education, to promote the health of his patients and their families” (Ko Ing, 1988). However, little is documented about practitioners in developing countries and how they manage the potential conflict between making a profit on the one hand and the expectations of their profession on the other. Furthermore, little has been documented about the impact of managing this tension on the quality and appropriateness of the care they provide.
Private practitioners work in different settings which will affect the services they are providing. A closer look at these characteristics helps to identify policy implications. We have divided these components in the setting as follows.
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Financing and provision of health care. Both public and private sectors can be involved in finance alone, in service provision alone or in both (as suggested by Frenk (1991)and Bennett (1991)). For example, services can be provided privately and financed privately, as in the case of a private hospital which finances through fees for services or private insurance schemes. However, sometimes the services are provided privately but financed by the state (for example government contracting out of services); and sometimes the public owned system is financed privately, through user charges or payment for various services, or compulsory government insurance schemes for private organizations. In Pakistan, like many other developing countries, private practitioners are providing services privately to clients who pay privately. These providers set up the practice from their own resources and provide services by charging fees. A few, however, are contracted by public organizations to provide services to their employees.
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The geographical distribution. Private practitioners work mainly in urban areas. They practice in areas where the population is more concentrated and clients more numerous. In Pakistan, this is often true in slums (katchi abadis), (Garner and Thaver, 1993).
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The existing health services. Private practitioners are either engaged entirely in private practice (Bhat, 1991) or also work in the public sector (Smith, 1982). It has been noted that higher socio-economic status households shift their demands from the public to the private sector (Heller, 1982; Aljunid and Norhassim, 1992; Berman et al., 1987). However, the urban poor, especially from slums, also seek private health care (Garner and Thaver, 1993). In addition, ethnicity (Kroeger, 1983), age (Heller, 1982) gender (Feldman, 1983) and characteristics of disorders (Yesudian, 1994) influence the use of private care.
There is, however, little written about how the public and private sector interact (Aljunid, 1995). Some studies have examined regulation, for example, in India (Yesudian, 1994), Malaysia (Aljunid, 1995) and Tanzania (Mujinja et al., 1993). The private health sector either competes with public services to attract trained workers (Roemer, 1984) or it responds to the human resource problem by contributing to the public sector “after office hours” (Ngalande-Banda and Walt, 1995; Yesudian, 1994). The interaction of the private sector with the public sector has also been studied in terms of referrals for investigation and specialized care (Lachman and Stander, 1991) and in relation to in-patient services.
Quality in the field of medicine is equivalent to the term in industry or business: the process to achieve the optimum possible care at lowest possible cost (Donabedian, 1966). Its assessment can be defined as a judgement about the process of care, based on the extent to which the care contributes to the valued outcome. Donabedian (1966)suggests the components of quality of care are: structure (physical features of health care); process (interaction and activities between doctors and patients); and outcome (changes in a patient's current and future health status). This framework has been refined by Williamson (1971)and Doll (1974). There are, however, problems with this approach. Even if structure and outcome can be measured, the relationship between them is variably and poorly defined, and structure is an indirect measure. An alternative approach using structure for assessing quality of care is to measure the capability of the health unit to perform specific activities and compare it with a standard (Garner et al., 1990). Although the relationship between changes in health status and the process of care are not easy to establish (Irvine, 1990), process variables are relatively easy to identify and have been studied more frequently (McAuliffe, 1979).
Quality assurance (Cleary and McNeil, 1988) and medical audit (Marinker, 1990a, Marinker, 1990b; Hughes and Humphery, 1990) are used to assess quality in health care. These processes involve assessing and identifying reasons for low quality as well as taking action to improve it. Quality has been assessed using the dimensions of effectiveness, equity, efficiency and humanity (Black, 1990). Medical audit has been labelled as the “third clinical science” (Russel and Wilson, 1992) as it has been perceived to pursue scientific principles and methodological rigour. A comprehensive conceptual framework for assessing quality of medical care needs to incorporate technical care (Donabedian, 1980) as well as consumers' satisfaction (Calnan, 1988; Pascoe, 1983). The technical care of the provider is in turn influenced by his/her knowledge and skill and attitudes to and organization of services. In contrast, lay images of health, specific goals of consumers and levels of experience of health care, besides the technical care of providers, affect consumers' satisfaction and hence quality of care of providers. Assessing quality of care and identifying areas in need of improvement provides baseline data to plan efficiency improvements in the delivery of medical care, although exactly how these will be brought about in the private sector has yet to be delineated. The necessity of starting this process by first assessing quality of care of private practitioners in developed countries was commented upon in the 1970s (Irvine, 1970; Buck et al., 1974). The current study aimed to examine the knowledge and practices of private practitioners working with low income groups in a defined geographical area of Karachi, and to record the quality of care provided.
Section snippets
Study site
The formal health system in Pakistan is based on public assistance, though the private health sector plays an important role. A study conducted in various areas of Pakistan between 1984 and 1988 showed that of all the respondents interviewed at their homes, 20–26% reported ill during the last two weeks and of these nearly two-thirds sought care from a private clinic or hospital (The Aga Khan University, 1988).
Karachi, in the Southwest, is Pakistan's largest and most populous city. Unofficial
Characteristics
All 201 private practitioners were qualified doctors working in Karachi slums, and were predominantly men (90%). Detailed interviews of 15 of them revealed that the most commonly cited reason for undertaking private practice as their career was the need to support their families (8 out of 15) and hence they did not proceed to post-graduate training or specialization. Almost half of them (7 out of 15) opted to locate their practice in a slum because it was near to their house, or because there
Knowledge and practice
This assessment of care quality provided by private practitioners considered technical competence in terms of knowledge of what to do and then actually measured their performance, in terms of clinical management and interpersonal communication. This was done by assessing their knowledge (vignettes) and practice (observation of the doctor–patient encounter).
The vignettes, or case studies, are a simple approach for assessing potential quality of care by health personnel. However, as they do not
Acknowledgements
Dr Thaver acknowledges the support extended to him by private practitioners working in slums of Karachi. Dr Garner and Professor Harpham were supported by the Overseas Development Administration (U.K.) through its programme grant to the Urban Health Programme and Dr McPake was supported through the programme grant to the Health Economics and Financing Programme, both based at the London School of Hygiene and Tropical Medicine, 1989–1994. However, the U.K. Department for International
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