In low- and middle-income countries (LMICs), the private sector-including international donors, non-governmental organizations, for-profit providers and traditional healers-plays a significant role in health financing and delivery. The use of the private sector in furthering public health goals is increasingly common. By working with the private sector through public -: private engagement (PPE), states can harness private sector resources to further public health goals. PPE initiatives can take a variety of forms and understanding of these models is limited. This paper presents the results of a Campbell systematic literature review conducted to establish the types and the prevalence of PPE projects for health service delivery and financing in Southern Africa. PPE initiatives identified through the review were categorized according to a PPE typology. The review reveals that the full range of PPE models, eight distinct models, are utilized in the Southern African context. The distribution of the available evidence-including significant gaps in the literature-is discussed, and key considerations for researchers, implementers, and current and potential PPE partners are presented. It was found that the literature is disproportionately representative of PPE initiatives located in South Africa, and of those that involve for-profit partners and international donors. A significant gap in the literature identified through the study is the scarcity of information regarding the relationship between international donors and national governments. This information is key to strengthening these partnerships, improving partnership outcomes and capacitating recipient countries. The need for research that disaggregates PPE models and investigates PPE functioning in context is demonstrated.
MAIN FINDINGS: The authors included evidence from 16 studies assessing the effectiveness of 13 contracted-out health-service interventions in Sub-Saharan Africa, Latin America and the Caribbean, Europe, South Asia and East Asia and the Pacific. The results of the review are heterogeneous. On the one hand, the authors deduce that contracting-out health services significantly improves access and availability, especially within under-served regions. On the other hand, they fail to find conclusive evidence concerning the impact of contracting-out on other dimensions of health-system performance such as equity, quality and efficiency. Indeed, the authors report that these factors are addressed in only a very few studies, and they highlight the need for more rigorous studies exploring the impact of contracting-out health services on the equity, quality and efficiency of health systems. The authors suggest that the effectiveness and success of contracting-out depend on a range of contextual and contract-design factors. More specifically, they observe that contractual financial incentives and the application of a payment-by-performance scheme have been demonstrated to be key determinants in the success of an intervention.Contextual factors related to the capacity of the public sector to develop the contracted-out services and the degree to which these services complement or replace existing services are also important determinants of the impact of contracted-out interventions on the equity, access, quality and efficiency of health systems. Finally, the authors highlight the need for more research on possible side effects of contracting-out interventions, which so far have been only barely assessed. BACKGROUND: During the past decade, improving the performance of health systems has become a key objective for the governments of many developing countries. Contracting-out is defined as a “contractual arrangement by which the government provides compensation to private providers in exchange for a defined set of health services for specified target population”. By providing incentives to health-care professionals and by fostering competition among health-service providers, contracting-out health-service interventions can improve the quality and efficiency of health-care services, leading to improvements in the performance of the health system. The findings of previous reviews on the effectiveness of contracting-out health services are mixed, and this systematic review aims to shed light on the effectiveness of contracting-out on the four main dimensions of health-system performance: access, equity, quality and efficiency. RESEARCH OBJECTIVES: To assess and synthesise the evidence on the impact of contracting-out interventions on health-system performance in developing countries. METHODOLOGY: The authors included all studies assessing the effectiveness of contracting-out health-care services to private providers in developing countries. As quality criteria, the authors only included studies that used one of the following study designs: experimental, non-randomised controlled designs, before-and-after designs without controls and cross-sectional studies with controls. They conducted a systematic search in published and unpublished literature for relevant studies. They searched the electronic database PubMed, and used the search engine Google. They also searched the websites of relevant organisations, including the World Bank and the World Health Organization, and checked previous reviews in the field and other literature for additional studies.Finally, the authors grouped the results by health-system performance dimension – access, equity, quality and efficiency – and synthesised the results in a narrative format. QUALITY ASSESSMENT: This systematic review has clearly defined inclusion criteria and use appropriate methods for analysis of results. It has some limitations however. The search is not sufficiently comprehensive, and it is not clear whether language bias is avoided. Moreover, although the inclusion criteria in terms of methodology are wide, the authors do not report any systematic assessment of the quality of included studies. The authors acknowledge the weaknesses of the evidence base and do not provide and strong policy conclusions, and this mitigates some of the limitations of the review.
The purpose of this study is to review the research literature on the effectiveness of contracting-out of primary health care services and its impact on both programme and health systems performance in low- and middle-income countries. Due to the heightened interest in improving accountability relationships in the health sector and in rapidly scaling up priority interventions, there is an increasing amount of interest in and experimentation with contracting-out. Overall, while the review of the selected studies suggests that contracting-out has in many cases improved access to services, the effects on other performance dimensions such as equity, quality and efficiency are often unknown. Moreover, little is known about the system-wide effects of contracting-out, which could be either positive or negative. Although the study results leave open the question of how contracting-out can be used as a policy tool to improve overall health system performance, the results indicate that the context in which contracting-out is implemented and the design features of the interventions are likely to greatly influence the chances for success.
BACKGROUND: There has been a growing interest in the role of the private for-profit sector in health service provision in low- and middle-income countries. The private sector represents an important source of care for all socioeconomic groups, including the poorest and substantial concerns have been raised about the quality of care it provides. Interventions have been developed to address these technical failures and simultaneously take advantage of the potential for involving private providers to achieve public health goals. Limited information is available on the extent to which these interventions have successfully expanded access to quality health services for poor and disadvantaged populations. This paper addresses this knowledge gap by presenting the results of a systematic literature review on the effectiveness of working with private for-profit providers to reach the poor. METHODS: The search topic of the systematic literature review was the effectiveness of interventions working with the private for-profit sector to improve utilization of quality health services by the poor. Interventions included social marketing, use of vouchers, pre-packaging of drugs, franchising, training, regulation, accreditation and contracting-out. The search for published literature used a series of electronic databases including PubMed, Popline, HMIC and CabHealth Global Health. The search for grey and unpublished literature used documents available on the World Wide Web. We focused on studies which evaluated the impact of interventions on utilization and/or quality of services and which provided information on the socioeconomic status of the beneficiary populations. RESULTS: A total of 2483 references were retrieved, of which 52 qualified as impact evaluations. Data were available on the average socioeconomic status of recipient communities for 5 interventions, and on the distribution of benefits across socioeconomic groups for 5 interventions. CONCLUSION: Few studies provided evidence on the impact of private sector interventions on quality and/or utilization of care by the poor. It was, however, evident that many interventions have worked successfully in poor communities and positive equity impacts can be inferred from interventions that work with types of providers predominantly used by poor people. Better evidence of the equity impact of interventions working with the private sector is needed for more robust conclusions to be drawn.
In low- and middle-income countries (LMICs), the private sector-including international donors, non-governmental organizations, for-profit providers and traditional healers-plays a significant role in health financing and delivery. The use of the private sector in furthering public health goals is increasingly common. By working with the private sector through public -: private engagement (PPE), states can harness private sector resources to further public health goals. PPE initiatives can take a variety of forms and understanding of these models is limited. This paper presents the results of a Campbell systematic literature review conducted to establish the types and the prevalence of PPE projects for health service delivery and financing in Southern Africa. PPE initiatives identified through the review were categorized according to a PPE typology. The review reveals that the full range of PPE models, eight distinct models, are utilized in the Southern African context. The distribution of the available evidence-including significant gaps in the literature-is discussed, and key considerations for researchers, implementers, and current and potential PPE partners are presented. It was found that the literature is disproportionately representative of PPE initiatives located in South Africa, and of those that involve for-profit partners and international donors. A significant gap in the literature identified through the study is the scarcity of information regarding the relationship between international donors and national governments. This information is key to strengthening these partnerships, improving partnership outcomes and capacitating recipient countries. The need for research that disaggregates PPE models and investigates PPE functioning in context is demonstrated.
Systematic Review Question»Other systematic review or not clear
