Wednesday, June 20, 2012

[EQ] Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries:
A Systematic Review

“…reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries….”

Sanjay Basu
1,2,3*, Jason Andrews 4, Sandeep Kishore 5, Rajesh Panjabi 6, David Stuckler 3,7

1 Department of Medicine, University of California, San Francisco, California, United States of America, 2 Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California, United States of America, 3 Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, 4 Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America, 5 Tri-Institutional MD-PhD Program, Weill Cornell Medical College/Rockefeller University/Sloan-Kettering Institute, New York, New York, United States of America, 6 Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America, 7 Department of Sociology, Cambridge University, Cambridge, United Kingdom
Academic Editor: Rachel Jenkins, King's College London, United Kingdom

PLoS Medicine – 19 June 2012 - Volume 9 -| Issue 6 - e1001244

Available online at:

“……Private sector healthcare delivery in low- and middle-income countries is sometimes argued to be more efficient, accountable, and sustainable than public sector delivery. Conversely, the public sector is often regarded as providing more equitable and evidence-based care. We performed a systematic review of research studies investigating the performance of private and public sector delivery in low- and middle-income countries.

Methods and Findings

Peer-reviewed studies including case studies, meta-analyses, reviews, and case-control analyses, as well as reports published by non-governmental organizations and international agencies, were systematically collected through large database searches, filtered through methodological inclusion criteria, and organized into six World Health Organization health system themes:
accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency.

Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries.

Comparative cohort and cross-sectional studies suggested that providers in the private sector more frequently violated medical standards of practice and had poorer patient outcomes, but had greater reported timeliness and hospitality to patients. Reported efficiency tended to be lower in the private than in the public sector, resulting in part from perverse incentives for unnecessary testing and treatment. Public sector services experienced more limited availability of equipment, medications, and trained healthcare workers.

When the definition of “private sector” included unlicensed and uncertified providers such as drug shop owners, most patients appeared to access care in the private sector; however, when unlicensed healthcare providers were excluded from the analysis, the majority of people accessed public sector care.
“Competitive dynamics” for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff.


Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients….”


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