Understanding the roles of faith-based health-care providers in Africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction

Sunday, 1st of November 2015

Understanding the roles of faith-based health-care providers in Africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction

Jill Olivier et al.

Best viewed at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2960251-3/fulltext

This is the first in a Series of three papers about faith-based health care

Introduction

In 2002, World Bank President James Wolfensohn said “half the work in education and health in sub-Saharan Africa is done by the church…but they do not talk to each other, and they do not talk to us.”¹x1Kitchen, M. World must coordinate efforts, end waste, says Wolfensohn. UN Wire, ; 2002See all References Somehow, faith-based providers of health and education had disappeared off the policy and evidence map. This situation occurred despite the fact that Islamic hospitals and Christian missionary hospitals were some of the first modern health-care providers to be established.²x2Green, A, Shaw, J, Dimmock, F, and Conn, C. A shared mission? Changing relationships between government and church health services in Africa. Int J Health Plann Manage. 2002; 17: 333–353

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See all References In many low-to-middle income countries, even after colonisation ended and despite massive health-systems reconfigurations, faith-based health providers (FBHPs) have maintained a strong presence. However, FBHPs have been neglected by the worlds of research and policy for decades, mainly as a result of a general refocusing on public health provision and also since the historical (and sometimes present) drivers of faith-based health provision have been treated with mistrust, especially in connection with the controversies around health care provided with the underlying intent to proselytise (see Tomkins and colleagues review on controversies in this Series).³x3UNFPA. Guidelines for engaging faith-based organizations (FBOs) as agents of change. The United Nations Population Fund, New York; 2009See all References However, in the past decade, bilateral and multilateral donors, the UN agencies, and country governments have pushed towards better understanding of FBHPs.³x3UNFPA. Guidelines for engaging faith-based organizations (FBOs) as agents of change. The United Nations Population Fund, New York; 2009See all References^, ⁴x4UNAIDS. Partnership with faith-based organizations: UNAIDS strategic framework. Joint United Nations Programme on HIV/AIDS; December, Geneva; 2009See all References^, ⁵x5GFTAM. Report on the involvement of faith-based organizations in the Global Fund. The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva; 2008See all References

Here, we review the available evidence with a focus on sub-Saharan Africa and Christian FBHPs because little evidence is available for other contexts or other kinds of faith-based groups at present. Even with this focus, robust or systematic evidence is restricted, and substantial confusion and conflicting anecdotes exists in the published work on FBHPs.⁶x6Olivier, J. “An FB-oh?”: mapping the etymology of the religious entity engaged in health. in: JR Cochrane, B Schmid, T Cutts (Eds.) When religion and health align: mobilising religious health assets for transformation. Cluster Publications, Pietermaritzburg; 2011: 24–42See all References Reports of the comparative advantages of FBHPs versus other public and secular providers (such as the possible reach, trust and access in communities, quality care, longevity, or service to poor people) are rarely substantiated and are usually balanced by reports of possible comparative weaknesses (such as poor human resource management, absence of financial sustainability, poor record keeping, or preferential service to particular religious groups).⁷x7Olivier, J and Wodon, Q. Layers of evidence: discourses and typologies of faith-inspired community responses to HIV/AIDS in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 25–51See all References The objective of this Series paper is to present what is more strongly supported by evidence, as a background for other reviews that follow, and include the caveat that more detailed assessments of health systems interactions are preferable and urgently needed. We cover a broad terrain of evidence and introduce empirical analyses done by some of the investigators of this paper.⁸x8Olivier, J, Leonard, GSD, and Schmid, B. The cartography of HIV and AIDS, religion and theology: a partially annotated bibliography. The Collaborative for HIV and AIDS, Religion and Theology, Pietermaritzburg; 2014See all References^, ⁹x9in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References^, ¹⁰x10in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 2: the comparative nature of faith-inspired health care provision in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References^, ¹¹x11in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References^, ¹²x12Olivier, J, Schmid, B, and Cochrane, JR. The semi-bounded field of religion and public health: an ongoing review and bibliography. The International Religious Health Assets Programme, Cape Town; 2014See all References Our Series paper is followed by two more that discuss faith-linked controversies in global health, including sexual and reproductive health, harm reduction, violence against women, and end-of-life care; and five sets of recommendations for how public and faith sectors might collaborate more effectively to achieve health-related goals.

Increased attention has been paid to faith-based entities engaged in health from a policy level during the past decade
Little systematic and similar data is available relating to faith-based, non-profit health providers
Data from household surveys suggest lower market shares than commonly assumed, but higher levels of satisfaction than in public facilities
Faith-based health providers play an important part in many countries in Africa, particularly in fragile or weakened health systems
However, many faith-based health providers show signs of weakness and little ability to adapt to their changed health systems contexts and financial constraints
Appreciation of health providers contribution to health care is tempered by lingering controversies tied to faith-based social engagement (which are discussed in more detail in later parts of this Series)
Broad generalisations about faith-based organisations or the faith sector should be avoided
More detailed health systems research is necessary (eg, research that unpacks how exactly faith-based health providers contribute [or do not] to universal health coverage at a country level)
More detailed policy implementation strategies relating to faith-based providers are needed (eg, specific strategies for improved public–private partnership with faith-based providers)

One of the main challenges to any kind of generalisable interpretation of faith-based health care is that the world of faith-based entities implicated in health is diverse and complex.⁶x6Olivier, J. “An FB-oh?”: mapping the etymology of the religious entity engaged in health. in: JR Cochrane, B Schmid, T Cutts (Eds.) When religion and health align: mobilising religious health assets for transformation. Cluster Publications, Pietermaritzburg; 2011: 24–42See all References^, ⁷x7Olivier, J and Wodon, Q. Layers of evidence: discourses and typologies of faith-inspired community responses to HIV/AIDS in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 25–51See all References What is frequently termed the faith sector at a policy level includes, among others, faith-based civil society organisations, informal faith-based programmes, initiatives and community-based organisations, larger national and international non-governmental organisations, congregations such as places of worship, religious leaders, faith-based health-care facilities, and denominational and interdenominational health networks such as the Christian Health Associations, which are national umbrella networks of FBHPs. The bulk of evidence on the role of FBHPs in health is predominantly on their role in the response to HIV/AIDS,¹³x13WFDD. Global health and Africa: assessing faith work and research priorities. World Faiths Development Dialogue for the Tony Blair Faith Foundation, Washington DC; 2012See all References^, ¹⁴x14ARHAP. Appreciating assets: the contribution of religion to universal access in Africa. Report for the World Health Organization by the African Religious Health Assets Programme, Cape Town; 2006See all References which places restrictions on those seeking to understand specific health systems functioning or effects. At the turn of the 21st century, no one really knew how many faith-based entities existed or what they were doing towards health and development goals, and despite the launch of several mapping and scoping studies,¹⁰x10in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 2: the comparative nature of faith-inspired health care provision in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References evidence is still fragmented.

The magnitude of faith-based health services in Africa

The first kind of evidence usually sought at a policy level in relation to FBHPs is their comparative magnitude against other health providers. The magnitude of the diverse faith sector can be counted in several different ways. For example, thousands of faith-based community-based organisations and non-governmental organisations have been reported to contribute to all aspects of HIV/AIDS response¹⁵x15Smith, A and Kaybryn, J. HIV and maternal health: faith groups activities, contributions and impact. Joint Learning Initiative on Faith and Local Communities, London; 2013See all References (eg, WHOs 2004 World Health Report estimated that faith-based organisations [FBOs] account for about 20% of the agencies working on HIV/AIDS).¹⁶x16WHO. The World health report 2004: changing history, community participation in public health. World Health Organization, Geneva; 2004See all References Basic self-provided estimates of health facilities owned by faith-based groups show a similar scale. For example, The Salvation Army provides health services in 124 countries through 73 hospitals, 56 specialist clinics, 135 health centres, and 64 mobile clinics.¹⁷x17Pallant, D. Global health provision for development: the Salvation Armys experience. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 2: the comparative nature of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 89–100See all References In sub-Saharan Africa, the various Christian Health Associations operate and represent thousands of hospitals and clinics.¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References The Adventist Church operates 173 hospitals and sanatoriums, and 216 clinics and dispensaries worldwide.¹⁹x19General Conference of Seventh-day Adventists. Seventh-day Adventist yearbook for 2012. Office of Archives, Statistics, and Research - General Conference of Seventh-day Adventists (GCSDA), Silver Spring, MD; 2012See all References The Catholic Church operates an estimated more than 5300 hospitals worldwide.²⁰x20Holy See. Statistical yearbook of the church 2010. Libreria Editrice Vaticana, Vatican City; 2010See all References^, ²¹x21See all References^, ²²x22See all References^, ²³x23Grills, N. The paradox of multilateral organizations engaging with faith-based organizations. Glob Gov. 2009; 15: 505–520See all References^, ²⁴x24See all References^, ²⁵x25CAFOD. Review of the year 2005–2006. Catholic Agency for Overseas Development, London; 2006See all References

At a local level, a few studies directly compare faith-based entities against their equivalent secular entities. One example is the mapping of the Mukuru settlement in Kenya²⁶x26Blevins, J, Thurman, S, Kiser, M, and Beres, L. Community health assets mapping: a mixed method approach in Nairobi. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 76–90See all References that reported 194 programmes working on HIV/AIDS, of which a third were classified as faith based. Birdsall analysed the South African National AIDS Database that lists registered organisations working in HIV/AIDS and about one in ten of those were self-identified as faith based.²⁷x27Birdsall, K. Faith-based responses to HIV/AIDS in South Africa: an analysis of the activities of faith-based organisations (FBOs) in the national HIV/AIDS database. Centre for AIDS Development, Research and Evaluation, Johannesburg; 2005See all References More generally, faith-based entities have been identified as being active in all aspects of public health, such as immunisation,²⁸x28Olivier, J. Local faith communities and immunization for systems strengthening: scoping review and companion bibliography. Report for the Joint Learning Initiative on Faith and Local Communities, London; 2014See all References antimalaria campaigns,⁷x7Olivier, J and Wodon, Q. Layers of evidence: discourses and typologies of faith-inspired community responses to HIV/AIDS in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 25–51See all References child and maternal health services,¹⁵x15Smith, A and Kaybryn, J. HIV and maternal health: faith groups activities, contributions and impact. Joint Learning Initiative on Faith and Local Communities, London; 2013See all References^, ²⁹x29Chand, S and Patterson, J. Faith-based models for improving maternal and newborn health. USAID-ACCESS, Baltimore, MD; 2007See all References^, ³⁰x30Widmer, M, Betran, AP, Merialdi, M, Requejo, J, and Karpf, T. The role of faith-based organizations in maternal and newborn health care in Africa. Int J Gynaecol Obstet. 2011; 114: 218–222

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See all References and tuberculosis,³¹x31Bohnett, T and Zambra, C. Experiences and issues at the intersection of faith and tuberculosis. World Faiths Development Dialogue and Berkley Center for Religion, Peace and World Affairs, Washington, DC; 2010See all References although the comparative magnitude of this activity is not known.

Local congregations and informal faith-based initiatives and volunteer groups engage in health care in a different way. The Pew Research Centre estimated that in 2012, 84% of the worlds population considered itself as religiously affiliated,³²x32The Pew Research Center. The global religious landscape: a report on the size and distribution of the worlds major religious groups as of 2010. The Pew Research Center, Washington DC; 2012See all References and the worlds main religions share a belief in the importance of caring for the sick (again, noting the controversies around drivers such as proselytisation, which often accompany this belief).³³x33Olivier, J and Paterson, GM. Religion and medicine in the context of HIV and AIDS: a landscaping review. in: B Haddad (Ed.) Religion and HIV and AIDS: charting the terrain. University of KwaZulu-Natal Press, Scottsville, South Africa; 2011: 25–52See all References Congregations are an important entry point for primary care and support, as are informal and community-based volunteer initiatives.³⁴x34Foster, G. Study of the response by faith-based organisations to orphans and vulnerable children. World Conference of Religions for Peace/United Nations Childrens Fund, New York and Nairobi; 2004See all References^, ³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References For example, a study of the response of different local faith communities to orphans and vulnerable children in six African countries reported more than 9000 volunteers informally supporting more than 156 000 children within the study cohort.³⁴x34Foster, G. Study of the response by faith-based organisations to orphans and vulnerable children. World Conference of Religions for Peace/United Nations Childrens Fund, New York and Nairobi; 2004See all References In Zambia and Lesotho, a religious health-asset mapping study done for WHO reported the expected FBHP facilities and faith-based non-governmental organisations but also reported hundreds of local and mostly informal initiatives in each site mapped.⁹x9in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References

These examples depict a varied contribution of faith-based entities to health generally, but some clarity on the relative contribution of faith-based biomedical health provision versus other public and private provision exists. In most African countries, Islamic hospitals and Christian missionary facilities were among the first biomedical health-care providers and often established the first health systems.³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References This history is not without controversy in view of the complex connections between FBHPs, proselytisation, and ties to colonial powers. However, in terms of magnitude, at the time of independence from colonial rule, many FBHPs dominated the health systems in terms of number of facilities and magnitude of services.¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References However, since independence, FBHPs have experienced substantial shifts in this role. New national governments took a strong governance role and public systems expanded rapidly amidst a series of health sector reforms. Governance of most FBHPs was transferred from international denominational bodies to local churches, resulting in substantially reduced support from traditional sources and sometimes reduced growth of FBHP services.¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References

Despite these great changes, nowadays (panel) a (problematic) perception exists that anywhere from 30% to 70% of health-care services are provided by faith-based entities of various forms worldwide and in Africa. Although some historical and empirical basis for these statements exists, the origins of such estimates are poorly acknowledged, and these estimates are often overstated.³⁶x36Olivier, J and Wodon, Q. Playing broken telephone: assessing faith-inspired health care provision in Africa. Dev Pract. 2012; 22: 819–834

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See all References^, ³⁷x37Wodon, Q, Olivier, J, Tsimpo, C, and Nguyen, MC. Market share of faith-inspired health care providers in Africa. Rev Faith Int Aff. 2014; 12: 8–20

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See all References^, ³⁸x38McGilvray, J. The quest for health and wholeness. German Institute for Medical Mission, Tübingen; 1981See all References

Panel

Past and often problematic examples of market-share estimates for faith-based health care

WHO¹⁶x16WHO. The World health report 2004: changing history, community participation in public health. World Health Organization, Geneva; 2004See all References

“Faith-based organisations…account for around 20% of the total number of agencies working to combat HIV/AIDS.”

Christoph Benn (The Global Fund to Fight AIDS, Tuberculosis, and Malaria)³⁹x39Benn, C. Why religious health assets matter. ARHAP: Assets and Agency Colloquium. African Religious Health Assets Programme, Pietermaritzburg, South Africa; 2003: 3–11See all References

“Faith-based organisations in many African countries provide between 30% and 50% of institutional health care.”

Katherine Marshall and Richard Marsh (The World Bank)⁴⁰x40Marshall, K and Marsh, R. Millennium challenges for faith and development leaders. World Bank, Washington, USA; 2003See all References

“Across Africa, for example, faith-based organisations provide up to 50% of health and education services, especially in poor, remote areas.”

PEPFAR⁴¹x41PEPFAR. The presidents emergency plan for AIDS relief: community and faith-based organisations. (PEPFAR) The Presidents Emergency Plan for AIDS Relief, Washington, USA; 2005http://www.pepfar.gov/reports/progress/76864.htm. ()See all References

“In certain nations, upwards of 50% of health services are provided through faith-based institutions, making them crucial delivery points for HIV/AIDS information services.”

Tearfund⁴²x42Tearfund. Faith untapped: why churches can play a crucial role in tackling HIV and AIDS in Africa. http://www.tearfund.org/webdocs/Website/Campaigning/Policy%20and%20research/Faith%20untapped.pdf; 2006. ()See all References

“Faith groups provide on average 40% of the health care in many African countries.”

Bandy and colleagues (WHO)⁴³x43Bandy, G, Crouch, A, Haenni, C et al. Building from common foundations: the World Health Organization and faith-based organizations in primary healthcare. World Health Organization, Geneva; 2008See all References

“Faith-based organisations are major health providers in developing countries, providing an average of about 40% of services in sub-Saharan Africa…”

The United Nations Population Fund³x3UNFPA. Guidelines for engaging faith-based organizations (FBOs) as agents of change. The United Nations Population Fund, New York; 2009See all References

“Moreover, there is clearly an important parrallel faith-based universe of development, one which provides anywhere between 30–60% of health care and educational services in many developing countries.”

The World Bank⁴⁴x44See all References

“In many African countries, you provide 30–70% of the health services, and in post-conflict countries, the majority of primary education services.”

Vitillo (CAFOD)²¹x21See all References

“Such strongly held values have inspired faith-based organisations to provide some 50% of health-care services in many developing countries. The Vaticans Pontifical Council on Health Care estimates, in fact, that at least 25% of all HIV/AIDS-related services are sponsored by the Catholic Church.”

Summary from Olivier and Wodon⁴⁵x45Olivier, J and Wodon, Q. Market share of faith-inspired health care providers in Africa: comparing facilities and multi-purpose integrated household survey data. in: J Olivier, Q Wodon (Eds.) Strengthening the evidence for faith-inspired health engagement in Africa, vol 1: The role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, Washington, DC; 2012: 11–26See all References (note that the basis for these estimates are largely unknown).

During the past two decades, many attempts have been made to synthesise such evidence, especially for sub-Saharan Africa and anglophone countries.²³x23Grills, N. The paradox of multilateral organizations engaging with faith-based organizations. Glob Gov. 2009; 15: 505–520See all References^, ²⁹x29Chand, S and Patterson, J. Faith-based models for improving maternal and newborn health. USAID-ACCESS, Baltimore, MD; 2007See all References^, ³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References^, ⁴⁶x46De Jong, J. Nongovernmental organizations and health delivery in sub-Saharan Africa. Population and Human Resources Department, The World Bank, Washington, DC; 1991See all References^, ⁴⁷x47See all References^, ⁴⁸x48See all References^, ⁴⁹x49Gilson, L, Sen, PD, Mohammed, S, and Mujinja, P. The potential of health sector non-governmental organizations: policy options. Health Policy Plan. 1994; 9: 14–24

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See all References^, ⁵⁰x50Leonard, KL. Do faith-based NGOs represent a replicable example for the delivery of public services? An application to health care delivery in developing countries. Faith Econ. 2008; 52: 1–10See all References^, ⁵¹x51Hanson, K and Berman, P. Non-government financing and provision of health services in Africa: a background paper. United States Agency for International Development, Washington, DC; 1994See all References^, ⁵²x52Hecht, RM and Tanzi, VL. The role of non-governmental organizations in the delivery of health services in developing countries background paper prepared for the World Development Report. World Bank, Washington, DC; 1993See all References^, ⁵³x53Kawasaki, E and Patten, JP. Drug supply systems of missionary organizations identifying factors affecting expansion and efficiency: case studies from Uganda and Kenya. Boston University for the World Health Organization, Boston, MA; 2002http://archives.who.int/PRDUC2004/Resource_Mats/Africa_papers/Drug%20Supply%20Systems%20of%20Missionary%20Organizations.doc. ()See all References^, ⁵⁴x54Robinson, M and White, G. The role of civic organisations in the provision of social services: towards synergy. World Institute for Development Economics Research, The United Nations University, Helsinki; 1997See all References^, ⁵⁵x55Rookes, P and Rookes, J. Commitment, conscience or compromise: the changing financial basis and evolving role of Christian health services in developing countries. LAP Lambert Academic Publishing, Saarbrucken, Germany; 2012See all References^, ⁵⁶x56Turshen, M. Privatizing health services in Africa. Rutgers University Press, New Brunswick; 1999See all References These assessments of the role of FBHPs are based on partial datasets and usually rely on rough counts of the number of hospital beds held by Christian Health Association versus the public health system.³⁶x36Olivier, J and Wodon, Q. Playing broken telephone: assessing faith-inspired health care provision in Africa. Dev Pract. 2012; 22: 819–834

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See all References All of these investigators highlight the limits of such syntheses (table 1). The countries shown in this Series paper tend to have a representative national faith-based health network such as a Christian Health Associations, and the estimates are based on self-reports of the number of facilities or hospital beds networked by the Christian Health Associations versus the public sector. These figures rarely factor in the presence of the private for-profit sector and rarely include other FBHPs that are not in-network (such as the Islamic health providers that are largely invisible). These countries are African states that have a historically higher presence of FBHPs, which is why a Christian Health Association is present (table 1).

Table 1

Basic data on estimated national faith-based health networks (NFBHN) market share by country

On the basis of little evidence, FBHPs are present in many countries in Africa, usually in countries with otherwise weak health systems (table 1). The graphic example of this is the Democratic Republic of the Congo, a fragile state where a consortium of local FBHPs and other partners operate more than half of the national health system.²⁹x29Chand, S and Patterson, J. Faith-based models for improving maternal and newborn health. USAID-ACCESS, Baltimore, MD; 2007See all References

At a policy level, these poorly substantiated comparative magnitude estimates cause discord and have been detrimental to collaboration.³⁶x36Olivier, J and Wodon, Q. Playing broken telephone: assessing faith-inspired health care provision in Africa. Dev Pract. 2012; 22: 819–834

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See all References For example, when estimates for this particular set of countries are stretched to represent the whole of Africa, the figures are distorted (because the countries not represented in table 1 tend to have a lower market share), and this tends to result in immediate push-back at policy level. Limitations to comparisons based on number of hospital beds also exist because this might be misleading if levels of use differ between providers and do not take primary care into account.⁵¹x51Hanson, K and Berman, P. Non-government financing and provision of health services in Africa: a background paper. United States Agency for International Development, Washington, DC; 1994See all References Furthermore, what these market share estimates mask are other nuanced and important characteristic differences, such as differences in patterns of governance or access. For example, many anecdotes suggest that individuals might walk past cheaper public facilities to access FBHPs,⁹x9in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References but there are only a few severely outdated analyses of user preference or comparative access to interrogate or verify such anecdotes.⁷³x73Mwabu, GM. Health care decisions at the household level: results of a rural health survey in Kenya. Soc Sci Med. 1986; 22: 315–319

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See all References^, ⁷⁴x74World Bank. Country population and health sector reviews (1983–1992). The World Bank, Washington, DC; 1983See all References^, ⁷⁵x75Banda, EEN and Simukonda, HPM. The public/private mix in the health care system in Malawi. Health Policy Plan. 1994; 9: 63–71

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See all References

In the absence of more up-to-date access-related data, analysis of household surveys can provide a piece of the puzzle about the patterns of choice and use between different components of the health system.³⁷x37Wodon, Q, Olivier, J, Tsimpo, C, and Nguyen, MC. Market share of faith-inspired health care providers in Africa. Rev Faith Int Aff. 2014; 12: 8–20

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See all References The Mainstay International reference and the US Demographic and Health Surveys do not separately identify FBHPs from other private providers, although some efforts have been made to extrapolate the FBHPs out of this large sample (which is inclusive of markets for self-medication, traditional practitioners, and drug peddlers).³⁷x37Wodon, Q, Olivier, J, Tsimpo, C, and Nguyen, MC. Market share of faith-inspired health care providers in Africa. Rev Faith Int Aff. 2014; 12: 8–20

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See all References More precise data are available for a subset of countries where multipurpose household surveys separately identify FBHPs from other private “secular” providers.³⁷x37Wodon, Q, Olivier, J, Tsimpo, C, and Nguyen, MC. Market share of faith-inspired health care providers in Africa. Rev Faith Int Aff. 2014; 12: 8–20

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See all References^, ⁴⁵x45Olivier, J and Wodon, Q. Market share of faith-inspired health care providers in Africa: comparing facilities and multi-purpose integrated household survey data. in: J Olivier, Q Wodon (Eds.) Strengthening the evidence for faith-inspired health engagement in Africa, vol 1: The role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, Washington, DC; 2012: 11–26See all References In the 14 African countries in which this differentiation is possible, analysis reported the pooled average use-based market share of FBHPs was at about 6%. However, this estimate is almost certainly on the low side because some countries where faith-based provision is large, such as the Democratic Republic of the Congo, are missing from the sample. Also, household surveys might underestimate the market share of FBHPs if households do not know whether a provider is public or private, or whether it is faith-based or not, and mistakenly assume that a FBHP is a public provider (common with FBHPs that frequently act more public than private, often receiving public funding and taking on the responsibilities of a district hospital). When looking through this very different lens of understanding health-care use (where the entire representative sample is larger and includes more entities, so the portion held by all parties is automatically smaller), the estimates tend to be much lower. Despite these caveats, engagement with household datasets of this sort is one of the only systematic and comparative data methods available at this time. This approach highlights the massive array of actors to consider in policy discussion about the faith sector engaged in health.

These different ways of viewing the magnitude of faith-based health provision are not really comparable; bed counts cannot be adjusted by broad household-use estimates. However, by consideration of these different kinds of data, some important points emerge for those seeking to understand the importance of FBHPs in Africa.³⁷x37Wodon, Q, Olivier, J, Tsimpo, C, and Nguyen, MC. Market share of faith-inspired health care providers in Africa. Rev Faith Int Aff. 2014; 12: 8–20

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See all References^, ⁴⁵x45Olivier, J and Wodon, Q. Market share of faith-inspired health care providers in Africa: comparing facilities and multi-purpose integrated household survey data. in: J Olivier, Q Wodon (Eds.) Strengthening the evidence for faith-inspired health engagement in Africa, vol 1: The role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, Washington, DC; 2012: 11–26See all References First, estimates based on hospital bed counts often do not factor in private secular hospital beds because these are often not known, even to the government. Second, the popular estimates based on comparison of numbers of hospital beds does not adequately measure primary health-care level or community outreach. Third, estimates of market share based on facilities-based care does not account for the role of a wide range of other private providers of care such as shops or markets for self-medication, traditional (religious) practitioners, and drug peddlers. Such considerations are important in view of the high use of such providers in these health systems.⁷⁷x77Bennett, S, Quick, JD, and Velásquez, G. Public–private roles in the pharmaceutical sector: implications for equitable access and rational drug use. The World Health Organization, Geneva; 1997See all References Fourth, the present estimates for magnitude of faith-based health care in Africa and the world are based on a select group of countries that have a strong historical footprint of faith-based provision. When estimates are provided for Africa, or the world, these seldom include the countries that have a low prevalence of FBHPs (eg, many Muslim-majority countries or South Africa, where FBHPs were nationalised into the public system), suggesting that regional or worldwide estimates in particular should be treated with caution. Finally, some of the post-conflict countries where FBHPs are known to have a large footprint owing to government failure, such as the Democratic Republic of the Congo, are not yet properly represented.

These factors suggest that overestimation and underestimation are common, so care is warranted when using such figures. The suggested comparative advantage factors that are sometimes said to be characteristic of FBHPs cannot be examined through such estimates. Consider whether the number of facilities owned by a faith group is more or less important than whether they are providing quality health care to poor people in support of goals such as universal health coverage? If even a handful of FBHPs were present, but were managing to provide a particular kind of access to a particular population, this would be important. But such consideration would need a vastly different evidence base than is available at present. We recommend a refocusing away from estimates of comparative magnitude, first towards the establishment of basic comparative and systematic evidence and, second, towards more complex systems analysis.

Financing and other support

Most FBHPs have experienced major changes in their health systems configuration and their financial resourcing in the last decades.¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References Around the time of independence, most African FBHPs have had to source new support from local governments and international donors because their traditional funding pools dried up (mainly as a result of the independence movements within local religious bodies).¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References^, ³⁸x38McGilvray, J. The quest for health and wholeness. German Institute for Medical Mission, Tübingen; 1981See all References FBHPs now commonly finance their services with a combination of government resources, user fees from patients, development assistance from bilateral and multilateral donors, and funding and in-kind contributions from within-country faith groups and local communities.⁷x7Olivier, J and Wodon, Q. Layers of evidence: discourses and typologies of faith-inspired community responses to HIV/AIDS in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 25–51See all References^, ⁷⁸x78Olivier, J and Wodon, Q. Increased funding for AIDS-engaged faith-based organizations in Africa?. Rev Faith Int Aff. 2014; 12: 53–71

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See all References Although this diverse landscape undoubtedly affects how FBHPs operate, the services they offer, and who they serve, little comprehensive tracking of these funding streams exists. Information systems are often weak in these contexts (FBHPs are usually reluctant to share financial data) and the highly decentralised nature of FBHP networks makes reliable resource tracking only possible when it is done at the facility level.³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References A key source of funding, the user fees received from patients, is totally hidden at an evidential level.

Although some FBHPs are reluctant to align themselves too closely with governments²x2Green, A, Shaw, J, Dimmock, F, and Conn, C. A shared mission? Changing relationships between government and church health services in Africa. Int J Health Plann Manage. 2002; 17: 333–353

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See all References^, ³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References most are now becoming more integrated with their national health systems through alignment of priorities, contracts, and service-level agreements.⁵⁸x58See all References^, ⁷⁹x79Gilson, L, Adusei, J, Arhin, D, Hongoro, C, Mujinja, P, and Sagoe, K. Should African governments contract out clinical health services to church providers?. in: S Bennett, B McPake, A Mills (Eds.) Private health providers in developing countries: serving the public interest?Zed Books, London; 1997See all References In most cases, a closer financial relationship with the government, usually through the Ministry of Health, has resulted in improved public–private awareness, if not always robust partnership. For example, partnership agreements have been forged between the Ministries of Health and several Christian health associations such as those in Chad, Malawi, Uganda, Tanzania, Zambia, Lesotho, Benin, Ghana, Kenya, and Cameroon.¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References^, ⁵⁸x58See all References These agreements usually state the terms of a reciprocal relationship, where the FBHPs commit to supporting public health sector goals and priorities (in particular, serving poor people in hard-to-reach areas), and in return, the government commits to some kind of financial compensation, often in the form of salary support, and usually negotiated to match bed-based market-share estimates. However, in many of these countries, partnerships are strained, for example when service-level agreements are not fulfilled or finance and human management systems do not work together.⁵⁸x58See all References

Development assistance for health from abroad can come to FBHPs through national strategies from bilateral and multilateral donors. The Christian Health Associations of Zambia has been a primary recipient of The Global Fund to Fight AIDS, Tuberculosis, and Malaria.⁷⁸x78Olivier, J and Wodon, Q. Increased funding for AIDS-engaged faith-based organizations in Africa?. Rev Faith Int Aff. 2014; 12: 53–71

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See all References Such funding can also flow from international non-governmental organisations to FBHPs. Although no assessment has been made of international funding flows to FBHPs, some efforts are being made to track finances from and to faith-based organisations in general. For example, a basic analysis suggested that at least US$1·53 billion of development assistance for health flowed from faith-based non-governmental organisations receiving funds from the US Government, Bill & Melinda Gates Foundation, or the Global Fund to fight AIDS, Tuberculosis, and Malaria; however, this figure cannot be verified so it mainly shows that this funding flow exists.⁸⁰x80Haakenstad, A, Johnson, E, Graves, C, Olivier, J, Duff, J, and Dieleman, JL. Estimating the development assistance to health provided to faith-based organizations, 1990–2013. PLoS One. 2015; 10: e0128389

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See all References Similarly, the assessment of financial flows to FBHPs (as opposed to the broader range of faith-based non-governmental organisations) is restricted and relies on simple analyses.⁷⁸x78Olivier, J and Wodon, Q. Increased funding for AIDS-engaged faith-based organizations in Africa?. Rev Faith Int Aff. 2014; 12: 53–71

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See all References^, ⁸¹x81Birdsall, K and Kelly, K. Pioneers, partners, providers: the dynamics of civil society and AIDS funding in Southern Africa. Centre for AIDS Development, Research and Evaluation and the Open Society Initiative for Southern Africa, Johannesburg; 2007See all References

Donations by other faith groups (local or from abroad) are an important source of support. Anecdotal reports of informal and often unrecorded flows of funds from congregations abroad exists. In 2008, US churches were estimated to have raised $4 billion for overseas ministries, some of which was health focused.⁸²x82Wuthnow, R. Boundless faith: the global outreach of American churches. University of California Press, Berkeley, CA; 2009

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See all References Cash and in-kind contributions from local communities and groups are important, and research shows that many Christian FBHPs depend on irregular emergency support from their local governing denomination.⁵⁵x55Rookes, P and Rookes, J. Commitment, conscience or compromise: the changing financial basis and evolving role of Christian health services in developing countries. LAP Lambert Academic Publishing, Saarbrucken, Germany; 2012See all References^, ⁸²x82Wuthnow, R. Boundless faith: the global outreach of American churches. University of California Press, Berkeley, CA; 2009

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See all References Several studies have emphasised that the informal community levels are where substantial religious health assets lie, visible in capacities such as volunteering and small financial and material grants.⁹x9in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References^, ³⁴x34Foster, G. Study of the response by faith-based organisations to orphans and vulnerable children. World Conference of Religions for Peace/United Nations Childrens Fund, New York and Nairobi; 2004See all References^, ⁸³x83Haddad, B, Olivier, J, and De Gruchy, S. The potential and perils of partnership: Christian religious entities and collaborative stakeholders responding to HIV and AIDS in Kenya, Malawi and the DRC. Africa Religious Health Assets Programme, Cape Town; 2008See all References A study of faith-based HIV/AIDS initiatives in six African countries reported that more than half of the initiatives identified were run without any external support.³⁴x34Foster, G. Study of the response by faith-based organisations to orphans and vulnerable children. World Conference of Religions for Peace/United Nations Childrens Fund, New York and Nairobi; 2004See all References In countries where Islam is prevalent, Zakat and other direct payments from Islamic communities play a part in the funding of such initiatives (noting the substantial controversies sometimes linked to this kind of support, in particular the possible ties to politicised Islam). In Christian Zambia, a health mapping study reported a local Islamic group paying for the upkeep of a wing of the local government hospital, which shows the various forms health-care support can take.⁹x9in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012See all References^, ³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References

Reach to poor people and cost for households

A preferential option for poor and vulnerable people is often a central stated tenet of the major faiths³³x33Olivier, J and Paterson, GM. Religion and medicine in the context of HIV and AIDS: a landscaping review. in: B Haddad (Ed.) Religion and HIV and AIDS: charting the terrain. University of KwaZulu-Natal Press, Scottsville, South Africa; 2011: 25–52See all References and also a worldwide priority of universal health care and public health. Many FBHPs were established with the stated intention to serve poor people in hard-to-reach locations, although this intent is at times controversially linked to other missionary drivers such as proselytism. Whatever the intent, some evidence substantiates the resulting presence of FBHPs in remote rural areas in Africa. More than 20 years ago in a World Bank analysis, De Jong noted that mission-based health facilities were located in poor, remote areas, either because of a commitment to serve the underprivileged or because they were filling a gap in areas not already met by government services.⁴⁶x46De Jong, J. Nongovernmental organizations and health delivery in sub-Saharan Africa. Population and Human Resources Department, The World Bank, Washington, DC; 1991See all References Similar statements have been made at a high level, especially in relation to sub-Saharan Africa,¹⁸x18Dimmock, F, Olivier, J, and Wodon, Q. Half a century young: challenges facing Christian Health Associations in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington DC; 2012: 71–103See all References^, ⁵²x52Hecht, RM and Tanzi, VL. The role of non-governmental organizations in the delivery of health services in developing countries background paper prepared for the World Development Report. World Bank, Washington, DC; 1993See all References^, ⁸⁴x84Parry, S. Responses of the faith-based organisations to HIV/AIDS in sub-saharan Africa. World Council of Churches and (EHAIA) Ecumenical HIV/AIDS Initiative in Africa, Geneva; 2003https://www.oikoumene.org/en/resources/documents/wcc-programmes/justice-diakonia-and-responsibility-for-creation/ehaia/other-documents/responses-of-the-faith-based-organisations-to-hivaids-in-sub-saharan-africa. ()See all References including in policy dialogue on Burundi,⁵¹x51Hanson, K and Berman, P. Non-government financing and provision of health services in Africa: a background paper. United States Agency for International Development, Washington, DC; 1994See all References Ghana,⁶³x63Christian Health Association of Ghana. Annual report: June 2005–May 2006. Christian Health Association of Ghana, Accra; 2006http://www.chag.org.gh/index.php/publications-reports/annual-reports. ()See all References Kenya,⁸⁵x85Muriithi, P, Munguti, N, Ayah, R, and Ongore, D. A situational analysis study of the faith-based health services vis-a-vis the government health services. Ministry of Health Republic of Kenya, Christian Health Association of Kenya and German Technical Cooperation, Kampala; 2007See all References Malawi,⁸⁶x86Ward, N, Kaybryn, J, and Akinola, K. Faith in the system: the impact of local HIV responses on strengthening health systems in Malawi and Chad. Tearfund, Teddington, UK; 2010See all References Senegal,⁸⁷x87Knowles, JC, Yazbeck, AS, and Brewster, S. The private sector delivery of health care: Senegal. Health Financing and Sustainability Project, Bethesda, MD; 1994See all References Tanzania,⁶⁸x68Todd, S, Brubaker, G, Chand, S et al. Human resources-geographical information systems data development and systems implementation for the Christian Social Services Commission of Tanzania: final report, USAID & The Capacity Project. http://www.intrahealth.org/files/media/human-resources-geographical-information-systems-data-development-and-systems-implementation-for-the-christian-social-services-commission-of-tanzania-final-report/hr_gis_cssc_tanzania.pdf; 2009. ()See all References^, ⁸⁸x88Christian Social Services Commission. Christian Health Association at crossroad towards achieving health Millenium Development Goals. Christian Health Associations Conference, January 16–18, 2007. Christian Social Services Commission, Dar es Salaam; 2007: 28See all References Zambia,⁵⁴x54Robinson, M and White, G. The role of civic organisations in the provision of social services: towards synergy. World Institute for Development Economics Research, The United Nations University, Helsinki; 1997See all References^, ⁷²x72Nussbaum, S. The contribution of Christian congregations to the battle with HIV and AIDS at the community level. Global Mapping International for Oxford Centre for Mission Studies, Colorado Springs, CO; 2005See all References^, ⁸⁹x89Mogedal, S and Steen, SH. Health sector reform and organizational issues at the local level: lessons from selected African countries. J Int Dev. 1995; 7: 349–367

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See all References^, ⁹⁰x90Green, A and Matthias, A. Where do NGOs fit in? Developing a policy framework for the health sector. Dev Pract. 2005; 5: 313–323

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See all References However, whether FBHPs can prioritise provision to the rural poor in the face of their present financial and systems contexts is a growing question.

Household surveys from the 14 African countries mentioned in this Series paper can be used as a basic first assessment of the extent to which FBHPs manage to reach poor people.⁹¹x91Olivier, J and Wodon, Q. Mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa: a brief overview. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 1–6See all References^, ⁹²x92Coulombe, H and Wodon, Q. Mapping religious health assets: are faith-inspired facilities located in poor areas in Ghana?. Econ Bull. 2013; 33: 1615–1631See all References In table 2, each row shows the share of the services provided by a specific type of provider that is used by households in five quintiles of wellbeing, from the poorest to the richest. None of the three types of providers (whether public, faith based, or private secular) serve poor people more than wealthier groups in absolute terms. However, although the households use of facilities-based health care by wealth quintile shows private secular providers are the least pro poor, FBHPs seem to serve poor people slightly more than public providers (with 17% of patients in the poorest quintile).

Table 2

Use of facilities-based health care by wealth quintile, average for 14 African countries (%)

These results are affirming for modern-day FBHPs, especially when one considers the resource constraints they now face. However, policy-level dialogue that suggests FBHPs serve only poor people is being challenged. FBHPs often find themselves in a changed health system, with public sectors increasingly oriented towards serving poor people and developing public primary care in remote areas. Also, although many FBHPs might have been historically located in remote and poor areas, profound changes have occurred in the geography of poverty in many countries.⁹³x93Tsimpo, C and Wodon, Q. Differences in the private cost of health care between providers and satisfaction with services: results for sub-Saharan countries. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 91–101See all References Faith-based clinics and hospitals that were established in rural areas find themselves surrounded by urban (sometimes wealthier) communities as a result of the combined effects of migration and population growth and because mission settlements often transformed into commercial community hubs.

Another key consideration is cost recovery (sometimes described as Robin Hood payment mechanisms). Many FBHPs need to recover a large share of their costs through user fees and, as such, could become (on average) more expensive for households than public facilities, which might be a barrier for very poor people (note, however, that FBHPs often have sliding-scale cost recovery mechanisms). We looked at the cost ratio for households for each type of provider (based on the same data and analysis as table 2), and on average FBHPs were more expensive for households than public facilities (table 3).⁹³x93Tsimpo, C and Wodon, Q. Differences in the private cost of health care between providers and satisfaction with services: results for sub-Saharan countries. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 91–101See all References These figures can in part be explained by the fact that FBHPs usually do not benefit from the same level of subsidisation from the state. They are also shown here to be more expensive than the category of private secular providers, but this might be expected in such surveys as this category also includes traditional healers, peddlers, chemical stores, and other low cost health-care providers to which poor people might turn to. This heterogeneity in the private secular sector explains why the average cost of care in that sector is low and also why the sectors use in very poor people is substantial.

Table 3

Average cost ratio for households of health-care providers by household wealth quintile for eight African countries (%)

These broad comparisons of use and costs for households are across all types of facilities within one of the three sectors (public, faith based, and private secular) and across all types of consultations.⁹³x93Tsimpo, C and Wodon, Q. Differences in the private cost of health care between providers and satisfaction with services: results for sub-Saharan countries. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 91–101See all References The fact that different providers have different services explains part of the differences in cost. Although faith groups were involved with conceptualising primary health care in the 1970s, in practice they tend to be heavily hospital centric, which makes FBHP systems (and services) more expensive.¹⁷x17Pallant, D. Global health provision for development: the Salvation Armys experience. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 2: the comparative nature of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 89–100See all References The comparative cost ratio of FBHPs is lower for the bottom three quintiles than for other groups (table 3). This result might support the argument made by FBHPs that they are making efforts to keep their costs affordable for poor people through cost-recovery strategies.⁹¹x91Olivier, J and Wodon, Q. Mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa: a brief overview. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 1–6See all References^, ⁹³x93Tsimpo, C and Wodon, Q. Differences in the private cost of health care between providers and satisfaction with services: results for sub-Saharan countries. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 91–101See all References But this claim is only lightly shown, and again, the lesson is that more robust evidence is needed in relation to the routine systems functioning of FBHPs, which might include activities to keep costs low and services accessible to poor people in resource-constrained environments. We also advise steering away from the broad question of whether all FBHPs in the world have a preferential option for poor people or not, as this is largely futile in the face of local differences.

Quality of services

Understanding of the characteristic nature and quality of services provided by FBHPs is crucial, eclipsing magnitude as a policy issue, since even small pockets of quality provision to poor people in areas where other services do not reach would be a more important concern than whether they compete in size or number of beds with the public sector across the whole system. In the absence of other systematic data, quality can be proxied in a rudimentary way by rates of patient satisfaction. Although satisfaction is only a partial measure of quality (and not as robust as other measures such as clinical outcomes, which are not available), it is important because it affects access and the demand for care in households. A systematic review of published work on comparative satisfaction with faith-based versus other health-care providers in Africa noted that most of the available empirical evidence showed FBHPs enjoying higher satisfaction rates from their clients than other health providers (particularly other public facilities), although this evidence was varied and usually qualitative.⁹³x93Tsimpo, C and Wodon, Q. Differences in the private cost of health care between providers and satisfaction with services: results for sub-Saharan countries. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 91–101See all References

Household survey data can again provide some clues, with data from six countries where FBHPs enjoy higher satisfaction rates than both public and private secular facilities (table 4). These data support the anecdotal evidence of perceived higher quality of care that can be found in FBHPs.

Table 4

Average satisfaction rates with health-care services across wealth quintiles in six African countries (%)

What drives the higher satisfaction rates with FBHPs? Most studies show that it might not directly be religion that makes the difference. Although FBHPs have in the past been accused of religious favouritism (only serving clients of the same religion), this is not apparent in present studies, suggesting that direct proselytism is restricted (or at least has been constrained by integration with the public system), and access is not commonly denied based on religious terms.⁹⁴x94Gemignani, R, Tsimpo, C, and Wodon, Q. Making quality care affordable for the poor: faith-inspired health facilities in Burkina Faso. Rev Faith Int Aff. 2014; 12: 30–44

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See all References Few indications suggest that patients are choosing FBHPs by their own religious affiliation. But the secondary effects of religion and in particular a religious organisational culture in these FBHPs does seem to have an effect. For example, in Burkina Faso, the reasons that led patients to choose FBHPs are not immediately related to religion itself, but seem to be driven by lower out-of-pocket costs for households and then by perceptions of a higher quality of service than public health providers.⁹⁴x94Gemignani, R, Tsimpo, C, and Wodon, Q. Making quality care affordable for the poor: faith-inspired health facilities in Burkina Faso. Rev Faith Int Aff. 2014; 12: 30–44

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See all References In Ghana, perceptions of high quality are by far the most dominant factor for patients and also for health workers choice of employer.³⁷x37Wodon, Q, Olivier, J, Tsimpo, C, and Nguyen, MC. Market share of faith-inspired health care providers in Africa. Rev Faith Int Aff. 2014; 12: 8–20

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See all References^, ⁹⁵x95Wodon, Q. Faith, human development, and service delivery: the cases of education and health in Ghana and Burkina Faso. Catholic University of America, Washington, DC; 2012See all References In many of the available studies, the quality of the services provided is perceived as high because of a particular attention paid to the dignity of patients, sometimes articulated as more compassionate care than received elsewhere, such as in other public health facilities. Again, this comparison of quality care is poorly substantiated, as are its drivers or causes. One study in Uganda did find that FBHPs have a higher performance than that of staff in other public facilities, attributed mainly to their intrinsic motivation, with staff driven to work for longer hours and sometimes for less pay, by the faith-based organisational ethos.⁹⁶x96Reinikka, R and Svensson, J. Working for God? Evaluating service delivery of religious not-for-profit health care providers in Uganda. World Bank; May 20, Washington, DC; 2003

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See all References Several other hypotheses have been suggested, such as different governance structures, community ownership, intrinsic values and organisational cultures promoted among the health workers, or low patient–health worker ratios enabling more time to be spent per consultation.⁷x7Olivier, J and Wodon, Q. Layers of evidence: discourses and typologies of faith-inspired community responses to HIV/AIDS in Africa. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington DC; 2012: 25–51See all References^, ⁵⁵x55Rookes, P and Rookes, J. Commitment, conscience or compromise: the changing financial basis and evolving role of Christian health services in developing countries. LAP Lambert Academic Publishing, Saarbrucken, Germany; 2012See all References^, ⁵⁸x58See all References^, ⁹³x93Tsimpo, C and Wodon, Q. Differences in the private cost of health care between providers and satisfaction with services: results for sub-Saharan countries. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 3: mapping, cost, and reach to the poor of faith-inspired health care providers in sub-Saharan Africa. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 91–101See all References^, ⁹⁶x96Reinikka, R and Svensson, J. Working for God? Evaluating service delivery of religious not-for-profit health care providers in Uganda. World Bank; May 20, Washington, DC; 2003

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See all References However, the connection between faith-based values and health systems performance needs substantially more attention to be able to inform policy-level action.

Conclusion

This Series paper has deliberately focused on the growing evidence of the nature of health care provided by faith-based health providers in Africa. The comparative weaknesses and potential negative effects associated with some FBHPs should be known. For example, contrasting with the above emerging evidence, published work commonly states that FBHPs can be of poorer quality than their public counterparts in some locations and that they sometimes have weak governance (such as financial and human resource management) as a result of managers being hired because they are a said to be good Christians rather than skilled health-service managers.³⁵x35Schmid, B, Thomas, E, Olivier, J, and Cochrane, JR. The contribution of religious entities to health in sub-Saharan Africa. Study for the Bill and Melinda Gates Foundation. African Religious Health Assets Programme, Cape Town; 2008See all References Additionally, although religion is described mainly as a positive value, when theology mixes with health-service policy, negative health effects have been noted, most strongly documented in relation to sexual and reproductive health.¹⁵x15Smith, A and Kaybryn, J. HIV and maternal health: faith groups activities, contributions and impact. Joint Learning Initiative on Faith and Local Communities, London; 2013See all References^, ⁷⁹x79Gilson, L, Adusei, J, Arhin, D, Hongoro, C, Mujinja, P, and Sagoe, K. Should African governments contract out clinical health services to church providers?. in: S Bennett, B McPake, A Mills (Eds.) Private health providers in developing countries: serving the public interest?Zed Books, London; 1997See all References However, the slowly emerging evidence on FBHPs suggests that they are not simply a health systems relic of a bygone missionary era, but still have relevance and a part to play (especially in fragile health systems), even if we still know little about exactly how they function.

The main conclusion is that more and improved data are needed to provide support at management and policy levels on every aspect relating to how FBHPs routinely function within their health systems. We need to move away from broad generalisations of the magnitude and character of FBOs and instead find out how different kinds of FBHPs operate within different contexts and systems. Rather than relying on basic proxies, we need to understand in a more complex manner, the interactions of management practice, organisational culture, pharmaceutical supply, cost recovery, and human resource management, and how these affect (clinical) quality, satisfaction, and use, and then how this affects access, reach to poor people, and broader goals such as universal health care.

For the presence of FBHPs to be invisible in some contexts is no longer acceptable, in particular fragile and post-conflict states where their role seems to be potentially important. Non-Christian providers, non-mainstream religious groups, and non-anglophone contexts are worryingly absent from the present analyses (particularly as there seems to be a substantial growth in Muslim health-care provision in some regions of Africa).⁹⁷x97Foley, EE and Babou, CA. Hôpital Matlaboul Fawzaini: at the intersection of diaspora, faith, and science in Touba, Senegal. in: J Olivier, Q Wodon (Eds.) Strengthening faith-inspired health engagement, vol 1: the role of faith-inspired health care providers in sub-Saharan Africa and public-private partnerships. The World Bank, HNP Discussion Papers, Washington, DC; 2012: 41–59See all References Furthermore, increased information gaps are found in regions such as South and Central America, Asia Pacific, and eastern Europe.

This missing information is urgently needed if FBHPs are to align with their national governments in a way that strengthens the system.

Search strategy and selection criteria

We based this Series paper on the assessment of peer-reviewed and grey literature that introduces some recognisable evidence to the specialty relating to the importance and unique characteristics of faith-based health providers (FBHPs) in Africa. We searched in Medline, Google Scholar, EBSCO, and World Bank data archives for publications in English and French between Jan 1, 2000, and May 31, 2014, with more than 40 search terms (variations of “faith” and “health”) and a geographical focus on Africa and low-income and middle-income country contexts.

We also drew from three other more detailed systematic reviews in which some of the authors of this Series paper participated and on interviews and engagement with key researchers with an established record in this area. This report draws on the review and empirical work recorded in a three-volume collection that focuses on the role of FBHPs in Africa. From this work, the analyses of factors such as the satisfaction of patients, extent to which FBHPs reach poor people, and their cost for households were done. Additionally, material was taken from two systematic review projects in progress, one that has been collecting materials (peer reviewed and grey in English and French) relating to religion and HIV/AIDS since 2008, and the other that has been collecting material on religion and public health since 2006. These two databases include material from 1980, to 2014, with the search terms “religion”, “public health”, and “HIV/AIDS” (each with several variations), and each containing several thousand distinct entries.

Contributors

JO and QW jointly conceptualised, wrote, and edited this Series paper, as well as the group of studies on which this paper is based (a World Bank programme) to which CT, RG, MS, HC, FD, and MCN contributed substantive content. EJM, JLD, and AH contributed to the review of this paper and HH to the organisation of the work. All authors reviewed and approved the final version.

Declaration of interests

The authors declare no competing interests.