Concentration and fragmentation: analysing the implications of the structure of Georgia's private healthcare market for quality and accessibility

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The private sector is increasingly recognized as playing an important role in health systems in low- and middle-income countries (LMIC), yet policymakers struggle to identify the role of the private sector in relation to their Universal Health Coverage objectives. Developing policies for engaging with private health care providers requires a good understanding of how healthcare markets operate. Markets are described according to their market structure which can range from highly fragmented (a large number of small firms), through to highly concentrated (one or a few large firms, including those where providers have invested in diagnostic facilities or pharmaceuticals). While the risks of excess concentration have long been recognised, evidence is emerging from a number of LMICs about the potential risks to patients of excess fragmentation. These include quality of care, if treatment volumes are too small to be safe or where opportunities for training are absent; or health system risks, arising from the difficulties of purchasing from or regulating large numbers of small providers.The overall aim of this study is to elaborate this conceptual framing of risks of harm from concentration and fragmentation of healthcare markets and develop a set of tools for undertaking healthcare market analysis that can inform policy options for shaping healthcare markets in the context of UHC. We will undertake this research in Georgia, a lower-middle income former soviet country which has undergone extensive privatisation. This award will set the foundation for evaluating future policy changes in Georgia and extendingt the analytic approach to other settings in a future research project. We will achieve this aim through 4 specific research questions: 1. What is the structure and nature of the healthcare market in Georgia: to what extent is the market characterized by fragmentation and concentration, and by horizontal and vertical integration?2. What demand, supply and policy factors are driving this pattern? 3. What are the risks and benefits for patients, and for the health system, of fragmented and consolidated health service provision? 4. What policy levers are available to shape the private healthcare market to better serve the needs of UHC? The study uses a mixed methods approach, collecting qualitative interview data and undertaking quantitative analysis of large social insurance databases. We will describe the Georgian healthcare market in terms of types of business and market structure, explore the reasons for the patterns that we observe, and then construct "theories of harm" which will describe the potential risks to patients and to the health system of fragmentation and concentration. We will use quantitative methods applied to insurance claims data to look at the extent to which key individual outcomes such as price and intensity of treatment, and system level outcomes such as accessibility, approaches to quality assurance and the costs of contracting and regulating, differ by provider business model and market structure. Findings will be presented at a series of structured policy dialogues, to validate our data and interpretations, and to develop potential policy interventions. These will engage a wide variety of health policy stakeholders and consider how to shape private health care markets through for example, changes in regulation and purchasing policies, so that they operate in the interests of UHC.This project is being proposed by a highly experienced, multidisciplinary, international research team with strong connections at the national, regional and global level to support the achievement of research impact. Capacity will be developed in both directions, with Georgian colleagues gaining exposure to approaches to researching the private sector as well as analysis of large administrative datasets, and UK collaborators learning about the nature of privatization in a former Soviet setting.