To measure progress towards Sustainable Development Goal 3, the global community has agreed upon a number of targets. Notably, we will dramatically reduce maternal mortality, end preventable deaths of children under five, and ensure universal access to reproductive health services, while attaining universal health coverage . Given the already high reliance on the private sector for provision of health services in many countries, it is important to determine if support or promotion of the private sector will increase inequity in access to health services . This concern exists because private services are not free, whereas public sector services in many countries are free or subsidized.
The source of care for FP varied significantly across countries when looking at our 12 country sample, with the private sector providing the majority of FP in Bangladesh, Cambodia, DRC, Haiti and Nigeria, and was the source of just under 50% of contraceptives in the Dominican Republic. The DRC, Nigeria, Mali and Senegal all exhibit a similar pattern of contraceptive use with low overall mCPR, and contraceptive use highly skewed towards the wealthiest women. However, our analyses provide further insight, demonstrating that even the wealthy women in Senegal, Mali and Zambia have limited reliance upon the private sector. In these three countries in particular, the private sector is not highly utilized for any health need examined in this article, indicating a generally small private sector footprint.
Limited use of the private sector for FP means that interventions that want to leverage these private providers successfully are non-traditional. One example from Mali is the creation of a public sector social franchise network, where selected primary health facilities receive branding, training and oversight from a social franchisor . By contrast, in Nigeria Shelton and Finkle  advocate for expansion of traditional social franchising and social marketing channels, as well as task-sharing so that private patent medical vendors can deliver injectable contraceptives.
The introduction of a new contraceptive method is a good example of the utility of looking at FP use by wealth and source of supply across countries. In the DRC, the Dominican Republic, and Nigeria, private sector pharmacies are the largest provider of short-term methods. Although pharmacies are primarily providing oral contraceptives in these countries, it is likely that the role of pharmacies will expand with the introduction of Sayana® Press in DRC and Nigeria, as well as social marketing of Sayana Press in Nigeria, and significant purchases in Senegal. Of the 12 countries in this study, nine have received some doses of this new contraceptive between 2014 and 2017. Among the largest procurers are Senegal, DRC and Nigeria receiving 761,200 doses, 818,000 doses, and 2,508,000 doses respectivelyFootnote 1 . The private sector will likely play a very large role in providing access to this product, and our data show that women across the socio-economic spectrum use the private sector to obtain their FP method.
When examining the treatment of childhood illnesses, it is important first to understand patterns of prevalence. Our data show that in the Dominican Republic, Ghana, Haiti, Kenya, Liberia and Nigeria, household wealth quintile and diarrhea prevalence have a high inverse correlation. However, only Ghana, Kenya and Liberia have a greater than two percentage point difference in prevalence between urban and rural areas. Combining these two findings, it is indicative of the fact that the poorest are primarily located in rural areas in these countries. Prevalence of fever/ARI is only consistently associated with household wealth in Kenya and Zambia, and in both of these countries, prevalence of fever/ARI is lower in the poorest quintile than in quintile 2. There is a greater than two percentage point difference in prevalence between urban and rural areas in Bangladesh, Ghana, Haiti, Kenya, Liberia, Zambia, Dominican Republic and Senegal, with the latter two countries having a higher prevalence in urban areas.
In our 12 country sample, the Asian countries and Nigeria had substantially greater use of the private sector for treatment of both diarrhea and fever/ARI, consistent with trends seen across all LMICs . Among those who seek treatment for diarrhea or fever/ARI, use of the private sector is positively correlated with household wealth quintile, even in countries with an overall low reliance upon the private sector. Patterns differ by type of private sector facility, with less than 10% of sick children in the poorest quintile visiting a private clinic in Kenya, Haiti and Liberia, compared with 25%–40% of those in the richest quintile in those same countries. Use of private sector pharmacies, by contrast, is much more equitable, especially in the Dominican Republic, Ghana, Kenya and Nigeria. However, many childhood illnesses are not treated in the formal medical sector, revealing an unmet need for quality care.
Across the 12 comparison countries, more than one-third of all children did not receive treatment for diarrhea. Over 50% of children with fever/ARI in Haiti and Mali received no treatment, or treatment from an unqualified source. The proportion of children who received no treatment for fever/ARI was strongly negatively correlated with wealth status in Haiti, Liberia, Mali and Senegal, with a similar finding for no treatment for diarrhea only present in Haiti. It can be argued that not all episodes of diarrhea or fever require formal medical care. In fact, promotion of appropriate home treatment of diarrhea with oral rehydration solution has been part of global recommendations since the 1970s, and has been estimated to reduce 93% of all diarrheal mortality in children under 5 with 100% coverage . However, given that almost 40% of under 5 mortality is caused by diarrheal disease, respiratory infection and malaria, the inequity in the proportion of children who do not receive any treatment necessitates further investigation .
The private sector is not a homogeneous entity. It contains different types of providers, ranging from formal medical clinics, to registered pharmacies, drug sellers, general retailers, faith-based and non-governmental organizations, and can be for profit or non-profit. As we have seen in our analyses, there is substantial variation in outpatient care-seeking through the private sector across countries [15, 22, 30]. A deeper examination of the total relevance of the private sector in providing care for specific services, plus the relative usage of the private sector by wealth group and urban/rural residence, can help policymakers direct resources towards improving coverage for needed interventions.
Several systematic reviews have examined the use of the private sector in outpatient health services, including whether private sector providers improve coverage, have quality services or provide services efficiently and equitably [31,32,33,34]. Others have examined inequity in health services provision, with notable efforts such as the Countdown to 2015 or meta-analyses of national household survey data for inequity, specifically for child health or FP services [1, 5, 35, 36]. Few have combined both lines of inquiry, and investigated the use of the private sector by wealth status [13, 14, 21]. Of these, Campbell et al., and Grepin aggregate data from 57 and 70 countries, respectively, masking variation, while Hotchkiss focuses only on contraceptives. Our analyses focused on two types of services which are routinely provided in the private sector, and which are services that usually require a payment. Data is disaggregated by country to allow for more nuanced analyses. Improvement in use of FP and diarrhea and fever/ARI services for those in need, who have been shown to be more likely to be poor, will lead to lower mortality and morbidity among women and children [1, 28, 37, 38].