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

Basu, Sanjay; Andrews, Jason R; Kishore, Sandeep P.; Panjabi, Rajesh; Stuckler, David

doi:10.1371/journal.pmed.1001244

Cited by 552 publications

(490 citation statements)

References 78 publications

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“…It is also possible that because private for-profit facilities need to maximize their profit, private facilities are more likely than public facilities to be more responsive in order to attract more clients. A systematic review of public and private healthcare systems’ performance in LMICs suggested that public health facilities lack timeliness and hospitality to patients [44]. …”

Section: Discussionmentioning

confidence: 99%

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

Awoke

Negin

Möller

et al. 2017

Global Health Action

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Background: Previous studies investigating factors associated with healthcare utilization by older Ghanaians lack distinction between public and private health services. The present study examined factors associated with public and private healthcare service use, and the resulting perceived health system responsiveness. Objectives: To identify factors associated with public and private healthcare utilization among older adults aged 50 and older in Ghana; and to compare perceived differences in health system responsiveness between the private and public sectors. Methods: Cross-sectional data was analyzed from the World Health Organization Study on global AGEing and adult health (SAGE) Wave 1 in Ghana. Using Andersen’s conceptual framework, public and private outpatient care utilization was examined using multinomial logistic regression to estimate and identify predictor variables associated with the type of outpatient healthcare facility accessed. Health system responsiveness was compared using chi-square tests. Results: Of 2517 respondents who used outpatient care in the 12 months preceding interview, 51.7% of respondents used a public facility, 17.8% a private facility, and 30.5% used other facilities. Older age group, higher education and higher wealth were associated with the use of private outpatient healthcare services. Using public outpatient care facilities was associated with having health insurance. Respondents with two or more chronic conditions were more likely to use public and private outpatient care than other facilities. Perceived health system responsiveness was better in private for-profit than in public and private not-for-profit healthcare facilities. Conclusions: This study suggested that higher wealth and multimorbidity were significant predictors of public and private outpatient healthcare utilization; however, health insurance was a predictor only for the use of public facilities. Future mixed-method studies could further elucidate factors influencing the choice of public and private outpatient healthcare use.

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Section: Discussionmentioning

confidence: 99%

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

Awoke

Negin

Möller

et al. 2017

Global Health Action

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“…This meant that the majority of those receiving services from the government-owned institutions were the poor. This entails the risk of ‘poor services for poor people’, although a clear difference between the sectors in terms of quality or efficiency cannot be shown [38]. …”

Section: Discussionmentioning

confidence: 99%

The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis

Obermann

Jowett

Kwon

2018

Global Health Action

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Background: Achieving Universal Health Coverage (UHC) has by now become a key health policy goal in many countries and some form of National Health Insurance (NHI) is often used for this. The Philippines has had more than 50 years’ experience with social health insurance and in 1995 established PhilHealth, the country’s national health insurer. Objectives: Analyzing the role of the Philippine NHI scheme in moving towards UHC, identifying potential avenues for improvement as well as indicating challenges and areas for further development. Methods: This paper is based on a mixed methods approach including extensive literature search, data from PhilHealth and other sources, and key informant interviews with staff at PhilHealth, health care providers, and policy experts at national and international level. Results: Major achievements were the expansion of population coverage using an earmarked revenue source (‘Sin Tax’), the introduction of the no-balance-billing to prevent co-payments, and the Health Facilities Enhancement Program to improve quality. The share of PhilHealth in total health expenditures is still only 14%, managing quality and cost of providers remains insufficient, the benefit coverage does not reflect the country’s burden of disease, and financial protection for PhilHealth members is low. The UHC bill would provide a massive jump forward as all Filipinos would then be automatically enrolled in and thus entitled to the benefits of PhilHealth. Conclusions: For expanding a contribution-based NHI beyond formal employment there needs to be a large increase in budget transfers to cover for citizens unable to contribute. The Philippine UHC bill shifts from the idea of contribution leading to entitlement to the idea of citizenship leading to entitlement and can thus be seen as a paradigmatic change in thinking about NHI. There are three areas that we believe are of key importance in developing further NHI: (i) governance, (ii) financial impact, and (iii) strategic purchasing.

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“…From the perspective of UHC, we are interested in the extent to which the presence of private providers impacts on overall efficiency, and hence on the extent to which a given level of health expenditure can cover a population with a range of services. A number of studies, focusing on the treatment of specific conditions, suggest that private treatment results in higher service costs, and thus potential inefficiency (3,5,18,19). Higher rates of potentially unnecessary and expensive procedures, such as caesarean sections, are one source of higher costs (18).…”

Section: Efficiencymentioning

confidence: 99%

“…The heterogeneity and complexity of the sector make any judgement about performance complex and nuanced (2). Despite these difficulties, a number of studies have attempted to assess private sector performance usually through comparisons with the public sector (3,4). Most focus on specific types of private providers and discuss factors which influence prov performance, but overall conclusion regarding such factors is challenging.…”

Section: Introductionmentioning

confidence: 99%

Performance of private sector health care: implications for universal health coverage

2016

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While the private sector is an important health care provider in many low and middle income countries (LMICs), its role in relation to progress towards Universal Health Coverage (UHC) varies. Drawing on a review of the published and grey literature, we explore the factors that affect private sector contribution to UHC: i.e. we are interested in the overall impact on system outcomes such as . Evidence on the performance of both the private and public healthcare sectors is used to examine the characteristics of private providers that are associated with their performance, and the implications for how these factors might interrelate to influence progress towards UHC. Studies of private sector performance have focused on three main dimensions: quality, equity of access, and efficiency. We found that the characteristics of patients, the structures of both the public and private sectors, and the regulation of the sector influence the types of health services delivered, and outcomes. Combined with characteristics of private providers including their size, objectives, and technical competence the interaction of these factors influences how the sector performs within different contexts. Changing the performance of the private sector will require interventions which target the sector as a whole, rather than individual providers alone. In particular, the performance of the private sector appears to be intrinsically linked to the structure and performance of the public sector, which suggests that deriving population benefit from the private health sector requires a regulatory response focused on the health sector as a whole. Key messages The critical policy relevant question about the private sector is not its performance in isolation, or relative to the public sector, but the extent to which it supports or detracts from progress towards Universal Health Coverage  There is a dearth of evidence on factors affecting system level performance, reflecting the complexity and heterogeneity of the private health sector and the difficulty in exploring the inter-relationships of factors at the system level, and their effect on overall performance.  Deriving population benefit from the private health sector will require interventions which target the sector as a whole, rather than individual providers alone.

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

Abstract: A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries.

Cited by 552 publications

References 78 publications

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

Predictors of public and private healthcare utilization and associated health system responsiveness among older adults in Ghana

The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis

Performance of private sector health care: implications for universal health coverage

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