Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematic review Journal Article


Authors: Basu, S.; Andrews, J.; Kishore, S.; Panjabi, R.; Stuckler, D.
Article Title: Comparative performance of private and public healthcare systems in low- and middle-income countries: A systematic review
Abstract: Introduction: 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. Conclusions: 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. Please see later in the article for the Editors' Summary. © 2012 Basu et al.
Keywords: treatment outcome; review; comparative study; organization and management; health care quality; standard; health care cost; health service; systematic review; health care system; world health organization; developing countries; developing country; funding; health care delivery; quality of health care; delivery of health care; productivity; income; lowest income group; health services accessibility; private sector; public sector; private health care system; public health care system
Journal Title: PLos Medicine
Volume: 9
Issue: 6
ISSN: 1549-1277
Publisher: Public Library of Science  
Date Published: 2012-01-01
Start Page: e1001244
Language: English
DOI: 10.1371/journal.pmed.1001244
PROVIDER: scopus
PMCID: PMC3378609
PUBMED: 22723748
DOI/URL:
Notes: --- - "Export Date: 4 September 2012" - "Art. No.: e1001244" - "Source: Scopus"
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  1. Sandeep   Kishore
    18 Kishore