Monday, April 2, 2012

[EQ] Private versus public strategies for health service provision for improving health outcomes in resource-limited settings

Private versus public strategies for health service provision for
improving health outcomes in resource-limited settings

Dominic Montagu, Andrew Anglemyer, Mudita Tiwari, Katie Drasser, George W. Rutherford, Tara Horvath, Gail E. Kennedy
Lisa Bero, Nirali Shah, Heather Kinlaw

Global Health Sciences, University of California, San Francisco, CA - July 2011

Available online at:

“……….Private healthcare providers deliver a significant proportion of healthcare services in low- and middle-income countries (LMIC). Poorer patients get sick and go without care more frequently, and spend more of their incomes on private healthcare than the wealthy.

Based on evidence from demographic health surveys (DHS), private healthcare providers deliver a significant proportion of healthcare services in low- and middle  income countries (LMIC). Some of the reasons for seeking care from private providers cited by patients include better and more flexible access to providers, shorter waiting times, greater sensitivity to patient needs, and greater confidentiality. In many cases, governments fail to create systems to remove or penalize publicly funded staff who offer low-quality services to patients. As a result, patients seeking quality care may turn to private care.

For the purpose of this review, we have used the definitions of ‘private’ providers given within the surveyed literature so long as it approximates the more formal definitions. In contrast to services offered by government employees, private healthcare services involve a spectrum of providers and institutions, including nonprofit or religious institutions. Private-sector services vary by country and range from sophisticated tertiary care facilities comparable to the highest of international standards, to individual doctors and nurses practicing out of one-room clinics and unqualified providers offering services that are neither regulated nor monitored.

Private providers – institutions or individuals – are distinguished in economic terms from the public sector by their ownership characteristic. As such, a private provider’s profits or losses accrue to the owner, rather than to the government or society. In practice, ‘private’ providers are often described as health practitioners who are not directly controlled by government authorities and regulations.

The private sector is particularly important for the poor. Poorer patients get sick and go without care more frequently, and spend proportionately more of their incomes on private healthcare than the wealthy. What this means for public health, and for the health of the poor in particular, depends upon the quality of care and the affordability of care provided – two topics which have been the subject of many studies, often with conflicting results.

This review will be of value to stakeholders both inside and outside the research community, helping public health practitioners, policy makers, donor agencies and global health institutions in making evidence-based decisions on healthcare and healthcare policy. Should private-sector doctors, clinics or hospitals provide better care than their government counterparts, then the focus of quality assurance must initially be within government and private providers could be considered for hire or contracting as a means of expanding government-funded care. If private providers have worse outcomes than government alternatives, then training, regulation or suppression of private practice should be considered.


We have focused in this review upon comparable health outcomes. The objective of this study is to determine the health outcomes from services delivered to the poor by private for-profit, private non-profit and public-sector providers, and the trade-offs between private for-profit, private non-profit and public-sector sources of care for low and middle-income countries (LMIC). The review asks what is known regarding the relative morbidity or mortality….”


Executive summary

1 Background

2. Methods used in the review

2.1 User involvement

2.2 Identifying and describing studies

2.3 Quality assurance

2.4 Data extraction

2.5 Quality assessment

2.6 Methods for synthesis

2.7 Deriving conclusions and implications

3. Search results

4. Synthesis results

4.1 Further details of studies included in the synthesis

4.2 Synthesis of evidence

4.3 Synthesis: quality assurance results

4.4 Summary of the results of the synthesis

6. Conclusions and recommendations

7. References


Appendix 1.1: Authorship of this report

Appendix 2.1: Search strategy

Appendix 3.1: Study details

Appendix 4.1: Forest Plots

Appendix 4.2: GRADE summary of evidence

Appendix 4.3: GRADE evidence profiles


“……This is a systematic review and meta-analysis using both Cochrane Collaboration and GRADE methods. The Cochrane Collaboration is an international network of healthcare professionals, researchers and consumers committed to developing and maintaining comprehensive, regularly updated systematic reviews of healthcare interventions. The GRADE approach is a systematic method of assessing the quality of studies included in a systematic review and developing recommendations or guidelines based upon the evidence. It has been adopted by the British Medical Journal (BMJ), the Infectious Diseases Society of America (IDSA), the World Health Organization (WHO), and numerous other agencies and organizations for use in assessing evidence quality and developing guidelines.

We included randomized controlled trials (RCTs), other types of controlled intervention studies, and observational studies that explored the impact of public and private healthcare provision in LMIC for this analysis. We limited the analysis to studies which reported on direct measures of improved health/health status/survival such as mortality or morbidity, lifestyle factors where evidence indicates an effect on the above, and/or adverse health effects of use of public or private healthcare.

Risk of bias in the included observational studies was assessed using the Newcastle- Ottawa Quality Assessment Scale (NOQAS). An overall assessment of the quality of evidence (high, moderate or low) was assigned to each main outcome in all included studies using the GRADE approach.


A meta-analysis for some outcomes was carried out, because we identified a sufficient number of studies to provide an acceptable body of evidence to examine the intervention. We assessed the extent of heterogeneity in results across comparable studies using forest plots, the I2 statistic and the Chi2 test.

Where there was evidence of heterogeneity, a random-effects model was applied. Data synthesis was performed using RevMan 5. We provided a summary estimate and 95% confidence interval and generated a forest plot for each meta-analysis. We performed subgroup analyses by stratifying studies by factors that might be a source of bias or potentially added substantially to heterogeneity between studies for any outcome for which we found multiple comparable studies…..”




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