'Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary.' This is one of the findings of a new study in Health Policy and Planning. 'Clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas.'
CITATION: How much healthcare is wasted? A cross-sectional study of outpatient overprovision in private-for-profit and faith-based health facilities in Tanzania
Jessica J C King, Timothy Powell-Jackson, Christina Makungu, James Hargreaves, Catherine Goodman
Health Policy and Planning, https://doi.org/10.1093/heapol/czab039
Published: 14 April 2021 [restricted access]
Overprovision — healthcare whose harm exceeds its benefit — is of increasing concern in low- and middle-income countries, where the growth of the private-for-profit sector may amplify incentives for providing unnecessary care, and achieving universal health coverage will require efficient resource use. Measurement of overprovision has conceptual and practical challenges. We present a framework to conceptualize and measure overprovision, comparing for-profit and not-for-profit private outpatient facilities across 18 of mainland Tanzania’s 22 regions. We developed a novel conceptualization of three harms of overprovision: economic (waste of resources), public health (unnecessary use of antimicrobial agents risking development of resistant organisms) and clinical (high risk of harm to individual patients). Standardized patients (SPs) visited 227 health facilities (99 for-profit and 128 not-for-profit) between May 3 and June 12, 2018, completing 909 visits and presenting 4 cases: asthma, non-malarial febrile illness, tuberculosis and upper respiratory tract infection. Tests and treatments prescribed were categorized as necessary or unnecessary, and unnecessary care was classified by type of harm(s). Fifty-three percent of 1995 drugs prescribed and 43% of 891 tests ordered were unnecessary. At the patient-visit level, 81% of SPs received unnecessary care, 67% received care harmful to public health (prescription of unnecessary antibiotics or antimalarials) and 6% received clinically harmful care. Thirteen percent of SPs were prescribed an antibiotic defined by WHO as ‘Watch’ (high priority for antimicrobial stewardship). Although overprovision was common in all sectors and geographical regions, clinically harmful care was more likely in for-profit than faith-based facilities and less common in urban than rural areas. Overprovision was widespread in both for-profit and not-for-profit facilities, suggesting considerable waste in the private sector, not solely driven by profit. Unnecessary antibiotic or antimalarial prescriptions are of concern for the development of antimicrobial resistance. Option for policymakers to address overprovision includes the use of strategic purchasing arrangements, provider training and patient education.
- Limited resources available for universal health coverage must be used efficiently in low- and middle-income countries, and overprovision is not only wasteful but can cause clinical harm to individual patients and wider public health harms.
- By sending standardized patients (SPs) to 227 private-for-profit and faith-based health facilities in Tanzania, we found 81.4% of patients received some unnecessary care, 67.2% received care that could threaten public health (prescription of an unnecessary antibiotic or antimalarial) and 6.2% received care that could be clinically harmful to the individual patient.
- Private-for-profit facilities were more likely to provide potentially clinically harmful care than not-for-profit facilities but no more likely to provide unnecessary care or care harmful to public health.
- Policymakers need to understand factors that lead to overprovision when considering interventions such as changing provider payment mechanism, training and consumer education.
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Coordinator, WHO-HIFA Collaboration: HIFA project on Learning for Quality Health Services
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