The challenge of comparing private and public healthcare
Recently published research suggests that while private sector may be more timely and hospitable to patients, there is little evidence that it is more efficient, accountable, or medically effective than the public sector, and points to an urgent need for more research in this area.
“To achieve universal and equitable access to health care, the public sector must be made to work as the majority provider’’
“The private sector, including both for-profit and social enterprises, already plays and will continue to play a pivotal role in improving the health of the people of Sub-Saharan Africa.”
- International Finance Corporation (2007) The Business of Health in Africa: Partnering with the Private Sector to Improve People's Lives
There is a longstanding and particularly heated debate about the role of the private and public sectors in meeting the healthcare needs of the poor people in developing countries. This debate is increasingly important – governments are faced with the challenge of providing more and better quality healthcare to growing populations, all with increasingly squeezed budgets. Finding the most efficient and cost-effective means of delivery is crucial for achieving this goal.
Lack of evidence to support either side
Despite the highly vociferous nature of the debate, and the extreme importance of providing healthcare services in developing countries, there is an overwhelming lack of rigorous evidence to support either side of the debate.
Making meaningful comparisons between public and private healthcare delivery is challenging. There is very rarely a clear distinction between public and private healthcare delivery. Patients tend to access healthcare from both private and public systems. Similarly, medical workers often work in both public hospitals as well as private clinics. Even within the public system, informal payments are often made to access healthcare, blurring the lines between what can be defined as purely “public”. Similarly, defining what is meant by the “private sector” is equally problematic, ranging from formal for-profit entities such as independent hospitals, to informal entities that may include unlicensed providers, and all the way to non-profit and non-governmental organisations.
The unfortunate result of this is a wide knowledge gap between the rhetoric and the supporting evidence.
Addressing this knowledge gap
A recently published study, “Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review”, set out to address this knowledge gap by collating and analysing the existing available data.
The aim of the research was to try and assess, for a given aspect of healthcare delivery, what differences there were in whether it was provided publicly or privately. The approach employed was a systematic review of the available evidence – the researchers conducted a thorough search of databases of published research on the performance of private and public healthcare providers, and then filtered the data to pull out only those studies which met minimum standards for the quality and rigour of their methodologies. Through this process, the researchers identified 102 studies for analysis.
Summary evidence suggests a more nuanced difference…
The findings of this research suggest a much more nuanced view of the comparative performance of the public and private systems, than the typically polarised debate would suggest.
From the studies evaluated, there was no systematic evidence that the private sector is usually more efficient, accountable, or medically effective than the public sector.
The research does suggest that private sector providers had greater reported timeliness – in Ghana, for example, waiting times among public sector facilities could be longer for the same condition than private sector facilities by one or two hours.
The private sector also provided better hospitality to patients than the public sector. Analysis in several countries suggested that patients in private sector facilities reported preferring the facilities because of shorter waiting periods, longer or more flexible opening hours, and better availability of staff.
The lack of evidence on greater efficiency is perhaps the most surprising aspect, given prevailing assumptions. The studies analysed suggested that in some cases this results in part from perverse incentives within private healthcare for carrying out unnecessary testing and treatment. For example, the prescribing of unnecessary antibiotics, and carrying out unnecessary caesarean sections, were more likely to occur among private than public providers. However, this is not a universal finding – one cited study from Uganda found that both private and public providers prescribed antibiotics incorrectly (including not prescribing them when indicated), and in this study public providers were worse in adhering to national malaria treatment standards.
… but the real issue is the lack of proper evidence
Perhaps a more important finding of the study is that there is a worrying lack of data and evidence to support either side. The data that is available is highly limited and poor in quality - the paper points to a recent independent review of Ghana’s private sector, which referred to the private sector as a ‘‘black box’’ with a dearth of information on delivery practices and outcomes.
The unfortunate result of this is that decisions on healthcare funding are being based on rhetoric and selected evidence, rather than on rigorous evidence. One example cited is the private contracting and social franchise model. These showed potential for expanding private sector coverage to impoverished groups, but conclusions cannot be drawn because no comparisons to the public sector have been made. If these new, innovative delivery models are to be judged a success, and scaled up if successful, there needs to be rigorous evidence to prove that they are more effective than the alternatives, including scaling up public sector funding.
We need to find out what works, and where, so that scarce health budgets can be channelled to the most effective areas, and therefore deliver the best results for patients in developing countries.
There is an opportunity to achieve this if donors, healthcare agencies and providers commit to producing more rigorous data on the performance of public and private systems, and making such data widely available.