Elsevier

The Lancet

Volume 388, Issue 10044, 6–12 August 2016, Pages 606-612
The Lancet

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

https://doi.org/10.1016/S0140-6736(16)00343-3Get rights and content

Summary

Although the private sector is an important health-care provider in many low-income and middle-income countries, its role in progress towards universal health coverage varies. Studies of the performance of the private sector have focused on three main dimensions: quality, equity of access, and efficiency. 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 affects how the sector performs in different contexts. Changing the performance of the private sector will require interventions that target the sector as a whole, rather than individual providers alone. In particular, the performance of the private sector seems to be intrinsically linked to the structure and performance of the public sector, which suggests that deriving population benefit from the private health-care sector requires a regulatory response focused on the health-care sector as a whole.

Introduction

Although the private sector is an important source of health-care provision in many low-income and middle-income countries, its role varies widely across countries.1 The heterogeneity and complexity of the sector make any judgment about performance complex and nuanced.2 Despite these difficulties, several studies3, 4 have attempted to assess private sector performance, usually through comparisons with the public sector. Most focus on specific types of private providers and discuss factors that affect providers' performance, but making overall conclusions about such factors is challenging. Most such studies include a small sample or narrow range of providers, but individual performance ranges widely and depends substantially on the context in which providers are operating. Furthermore, a narrow focus on individual performance rather than on the overall effect of a particular provider on health care misses what might be the most important implications of a changing public–private mix of health-care providers. Private providers might provide excellent quality individually, but if they absorb a disproportionate share of the health workforce and are inaccessible to most of the population, their overall contribution might still be assessed as negative; alternatively, they might train high quality health staff who are later employed in more accessible public provision systems. It is these relations between private sector behaviour and population health outcomes that shape the implications for universal health coverage.

This principle suggests that whether the private sector or the public sector performs best is a sterile question. An assessment of the contribution of any one provider depends on its effect on the system as a whole, including whether it fills gaps left by other providers or creates new ones. Such a contribution depends on a host of economic and social factors. A dearth of research at this level indicates the complexities inherent in exploring these relations.

We reviewed the evidence of important individual factors, which are well researched but might be misleading because they are presented in isolation, and consider the implications for universal health coverage. We aim to develop a conceptual framework theorising the links between individual performance characteristics and system-level effects that determine progress towards universal health coverage. By identifying factors that affect private sector performance as a whole, we aim to stimulate debate about how overall private sector performance affects system-level outcomes, and the types of interventions that can be implemented to support universal health coverage.

Key messages

  • The crucial policy 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 about factors affecting the overall performance of health systems, showing the complexity and heterogeneity of the private health-care sector and the difficulty in exploring the relations between factors, and their effect on overall performance.

  • Deriving population benefit from the private health-care sector will require interventions that target the sector as a whole, rather than individual providers alone.

Section snippets

Performance of the private health-care sector: quality, equity, and efficiency

We used three general outcome measures to assess the performance of the private health-care sector: quality, equity, and efficiency. We selected these terms because they are widely used and encompass many other terms, such as responsiveness and access. Despite the heterogeneity of the private sector, many studies were not clear about the type of private provider when reporting on performance, instead grouping all providers together. As a result, some performance assessments apply to only one or

Provider characteristics affecting performance

Three groups of individual features seem to be important in driving the performance of individual providers: organisational objectives, competence of staff, and size of organisation.

The organisational objectives of private providers vary. Providers are typically divided into for-profit and not-for profit, with the former focusing largely on shareholder dividends or partner shares, aiming to maximise financial gain, and the latter having a mandate to protect the health of a specific population.20

Health system factors affecting private sector performance

Several health system factors affect the functioning of the private sector as a whole: the structure and performance of the public health-care sector, the structure of the private sector, the characteristics of patient demand for health care, and regulation of the private health-care sector. Individual factors are then linked to these system factors. We limit our discussion to factors that can be regarded as directly part of the health system rather than broader societal influences such as

Implications for universal health coverage

The objective of universal health coverage suggests that rather than focus only on the productivity or quality of individual or a specific group of private providers, it is important to understand not only what factors influence the overall performance of a health system, but also how these factors interact (figure). Understanding these interactions can then help the development of policy and interventions that focus on different parts of the private (and public) sector, with the aim of

Search strategy and selection criteria

We searched PubMed, Evidence-Based Medicine Reviews, and Google Scholar for the terms “private sector” OR “private provider” OR “private practitioner” AND role OR performance AND quality OR efficiency OR equity AND “developing country” OR “low and middle income country”. We also searched the reference lists of identified articles for additional relevant literature. We reviewed the titles and abstracts of peer-reviewed articles and grey literature. We included qualitative and quantitative

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