Background to the debate

The global burden of disease falls disproportionately upon the world's low-income countries, which are often struggling with weak health systems. Both the public and private sector deliver health care in these countries, but the appropriate role for each of these sectors in health system strengthening remains controversial. This debate examines whether the private sector should step up its involvement in the health systems of low-income countries.

Background: 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. This review is focused on comparing health outcomes in private versus public care settings. It seeks to summarize what is known regarding the relative morbidity or mortality outcomes that result from treatment by public or private providers in LMIC.Methods: 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.Results: Twenty-one studies met our inclusion criteria and explicitly compared health outcomes between the public and private sectors. Of those, 17 were cohortstudies, from 9 countries. Eleven studies were conducted in lower-middle-incomecountries ($996–$3,945 GNI per capita) and 10 studies from upper-middle-incomecountries ($3,946–$12,195 GNI per capita). Eighteen studies were conducted inurban settings. Fifteen of the 21 studies provided mortality for a health outcome,and studies examined a wide range of diseases, with tuberculosis (TB) being themost 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. Conclusions: 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 andprivate 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 providerswould appear to be an acceptable option. Governments must consider appropriateprofit margins, regulations and training for private providers.Further research is needed in this area, and should include low-income countriesand rural settings. Diseases of the poor – notably malaria and childhood illnesses – are largely absent from the current literature, with the exception of one study onHIV/AIDS and six on TB.