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

What do we want to know?

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 outcomes that result from treatment by public or private providers in LMIC.

Who wants to know and why?

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.

What did we find?

Twenty-one studies met our inclusion criteria and explicitly compared health outcomes between the public and private sectors. Of those, 17 were cohort studies, from 9 countries. Eleven studies were conducted in lower-middle-income countries ($996–$3,945 GNI per capita) and 10 studies from upper-middle-income countries ($3,946–$12,195 GNI per capita). Eighteen studies were conducted in urban settings. Fifteen of the 21 studies provided mortality for a health outcome, and studies examined a wide range of diseases, with tuberculosis (TB) being the most represented.

A meta-analysis of all studies exploring the impact of healthcare type and mortality showed that patients in a private healthcare setting are less likely to die than patients in a public healthcare setting (OR 0.60; 95% CI 0.41–0.88). The pooled analysis showed that patients in a private healthcare facility are more likely to have unsuccessfully completed TB treatment than patients in a public healthcare facility (OR 2.04; 95% CI 1.07–3.89). Regardless of outcomes, the quality of evidence is rated, by objective measures, as either low or very low.

What are the implications?

More evidence is needed to compare health outcomes between the public and private sectors. Governments and researchers can play a critical role in improving the evidence base for decision making about the contributions of the public and private sectors in a given country’s health system.

Governments should encourage data collection in both public and private settings that would permit ongoing comparison of clinical data. When government facilities are absent or insufficient, contracting with private-sector facilities or providers would appear to be an acceptable option. Governments must consider appropriate profit margins, regulations and training for private providers.  

Further research is needed in this area, and should include low-income countries and rural settings. Diseases of the poor – notably malaria and childhood illnesses are largely absent from the current literature, with the exception of one study on HIV/AIDS and six on TB.

How did we get these results?

We conducted a systematic review of studies evaluating the impact of public and private healthcare provision. We performed meta-analyses on data within identified studies, in order to estimate the effects of type of healthcare provision on identified health outcomes.

The EPPI-Centre reference number for this report is 1912.
This report should be cited as: Montagu DD, Anglemyer A, Tiwari M, Drasser K, Rutherford GW, Horvath T, Kennedy GE, Bero L, Shah N, Kinlaw HS (2011) Private versus public strategies for health service provision for improving health outcomes in resource-limited settings. San Francisco, CA: Global Health Sciences, University of California, San Francisco.

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