Paul Garner and colleagues conducted a systematic review of 80 studies to compare
the quality of private versus public ambulatory health care in low- and
In developing countries, the private sector provides a substantial proportion
of primary health care to low income groups for communicable and
non-communicable diseases. These providers are therefore central to
improving health outcomes. We need to know how their services compare to
those of the public sector to inform policy options.
Methods and Findings
We summarised reliable research comparing the quality of formal private
versus public ambulatory health care in low and middle income countries. We
selected studies against inclusion criteria following a comprehensive
search, yielding 80 studies. We compared quality under standard categories,
converted values to a linear 100% scale, calculated differences
between providers within studies, and summarised median values of the
differences across studies. As the results for for-profit and not-for-profit
providers were similar, we combined them. Overall, median values indicated
that many services, irrespective of whether public or private, scored low on
infrastructure, clinical competence, and practice. Overall, the private
sector performed better in relation to drug supply, responsiveness, and
effort. No difference between provider groups was detected for patient
satisfaction or competence. Synthesis of qualitative components indicates
the private sector is more client centred.
Although data are limited, quality in both provider groups seems poor, with
the private sector performing better in drug availability and aspects of
delivery of care, including responsiveness and effort, and possibly being
more client orientated. Strategies seeking to influence quality in both
groups are needed to improve care delivery and outcomes for the poor,
including managing the increasing burden of non-communicable diseases.
Please see later in the article for the Editors' Summary
The provision of private (“for-profit” hospitals and
self-employed practitioners, and “not-for-profit” non-government
providers, including faith-based organizations) versus public health care
services in low and middle income countries raises considerable ideological
debate. Ideological arguments aside—which can be very passionate on
both sides—there is general agreement that improving the quality of
both public and private health care could have a major impact on improved
health outcomes, especially as the private sector is so widely used in low
and middle income countries. For example, almost three quarters and half of
children from the poorest households of South Asia and sub-Saharan Africa,
respectively, seek health care from a private provider when they are ill.
Private providers are also increasingly responsible for outpatient care for
As a result of the mixed health care system in many low and middle income
countries, adequate oversight and stewardship of the mixed system from the
national government is essential yet often missing.
Why Was This Study Done?
An understanding of how quality and performance in the private sector
compares with that in the public sector would help governments to prioritize
where they need to concentrate their efforts. So, for example, if the
private sector is generally providing poorer quality care than the public
sector, then there is an imperative to improve the quality and outcomes; on
the other hand, if the quality of care offered by the private sector is
good, the policy priority is to influence the market to further improve
access to such health care for low income groups.
In order to help with this comparison, the researchers wanted to
systematically identify and summarize the results of studies that directly
compared the quality of care offered by public providers with the one
offered by “formal” private providers (recognized by law) and
“informal” private providers (providers that are not legally
recognized, such as lay health workers and shop keepers). For the purposes
of this study the researchers focused their comparison on the private and
public provision of outpatient care in low and middle income countries.
What Did the Researchers Do and Find?
In their literature review, the researchers searched for relevant studies
reported in English, French, or German and published between January 1970
and April 2009. Only studies that compared private and public outpatient
medical services in the same country, at the same time, using the same
methods, and which met particular quality criteria, were included in the
analysis. The researchers also had strict criteria for including qualitative
studies, and they retrieved the full text of articles, contacted study
authors where appropriate, and verified with a second researcher most
(80%) of the extracted study data. In order to evaluate and compare
the studies, the researchers converted study values to a linear 100%
scale, calculated differences between providers within studies, and
summarized the median values of the differences across studies.
The researchers identified a total of 8,812 relevant titles and abstracts and
found 80 studies that included direct quantitative comparisons of public and
private formal providers. Ten studies included qualitative data. Most
studies were conducted after 1990, and mainly in sub-Saharan Africa
(n = 39) and Asia and the Pacific
(n = 23). Most studies did not
report socio-economic status of public and private service users, and only
five studies presented data by different income groups. No study compared
the same individual providers working in public and private care settings.
Only two studies compared public providers and private informal providers,
so the authors excluded these from subsequent analysis.
For the formal sector, since the results for “for-profit” and
“not-for-profit” providers were similar, the researchers decided
to combine the results. Overall, the researchers found that the median
values indicated that many services, irrespective of whether public or
private, scored low (less than 50%) on infrastructure, clinical
competence, and practice. Generally, the private sector performed better in
relation to drug supply, responsiveness, and effort, but there was no
detectable difference between provider groups for patient satisfaction.
Furthermore, a synthesis of qualitative data suggested that the private
sector may be more client-centered.
What Do These Findings Mean?
Based on the findings of this review, there is a clear need to consider the
quality of primary health services in both the public and private sector in
order to improve health outcomes in low and middle income countries. These
findings also indicate that, for some aspects of care, on average the
private sector provided better quality services. The overall low quality of
care in both the formal private and public sector found in this review is
worrying, and calls for the governments of low and middle income countries
to find and implement effective strategies to improve the quality in both
sectors. This is particularly important given the increasing volume of
conditions that require relatively sophisticated, long-term ambulatory
medical care, such as non-communicable diseases.
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine
Perspective by Jishnu Das
WHO has more information on health service delivery in low- and middle-income
WHO has more information on noncommunicable diseases
The World Bank's World Development Report for 2004 addresses health
care for poor people