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Private healthcare no more efficient, accountable or effective than public sector in LMICs


A systematic review conducted by Sanjay Basu of the University of California, San Francisco and colleagues re-evaluated the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries (LMICs). Reporting in this week's PLoS Medicine, the authors found that the studies they evaluated 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.

There is considerable debate around whether LMICs should strengthen public versus private healthcare services, and this study reviewed the existing evidence on performance of private and public sector delivery of care.

Using databases and a comprehensive key word search, Basu and colleagues identified and reviewed published data, assessing selected studies against the World Health Organization's six essential themes of health systems--accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency--and conducted a narrative review of each theme.

The researchers found that each system has its strengths and weaknesses. In both the public and the private sector there were financial barriers to care, such as user fees. Although patients in the private sector experienced better timeliness and hospitality, providers in the private sector more frequently violated accepted medical standards and have lower reported efficiency.

The authors highlight that "private sector healthcare systems tended to lack published data by which to evaluate their performance, have greater risks of low-quality care, and serve higher socio-economic groups, whereas the public sector tended to be less responsive to patients and lack availability of supplies.... Both public and private sector systems had poor accountability and transparency".


Funding: No direct funding was received for this study. The authors were personally salaried by their institutions during the period of writing (though no specific salary was set aside or given for the writing of this paper).

Competing Interests: The authors have no competing financial interests. SB, JA, SK and RP are employed at academic medical centers, which receive public sector research finances but also receive revenue through private sector fee-for-service medical transactions and private foundation grants. RP serves on the board of a nonprofit organization (Tiyatien Health) that provides health services in Liberia with approval from and in collaboration with the government and through receipt of private foundation funding, but has received no compensation for this role. SB and JA serve on the board of a nonprofit organization (Nyaya Health) that provides health services in rural Nepal using funds received from both private foundations and the Nepali government; they have also not received compensation for these roles.

Citation: Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 9(6): e1001244. doi:10.1371/journal.pmed.1001244

Sanjay Basu
Department of Medicine
University of California
San Francisco
United States of America

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