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.