here. Thepublic-hospital sector, catering to the majority of South Africans, faces lower human-resourcing ratios, financial constraints and ageing infrastructure. Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America, Affiliation We did not perform further subanalysis of the highest quality studies as the authors could not agree to a vote-counting approach that would apply across the quantitative and qualitative methods and the six WHO themes captured in literature using different types of outcome variables. In Belgium,publicly-owned hospitals are on average more efficient than their private counterparts. Private health care can be provided through for profit hospitals and self-employed practitioners, and not for profit non-government providers, including faith-based organizations. CNN values your feedback 1. The effectiveness of these regulations of the private sector was found to vary, often depending on public monitoring and enforcement [17],[34],[77]. Faster access to specialists: Private hospitals have a wide range of specialist treatments and the best medical specialists offer faster access to patients who need specialized treatment. Private practitioners had significantly worse knowledge of correct diagnosis and treatment. Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, Affiliation Our review indicates that current data do not support claims that the private sector has been more efficient, accountable, or medically effective than the public sector [8]. As one might expect, nonprofit hospitals on average provide more uncompensated care than for-profit hospitals do. Publicprivate partnerships: International or national associations that have varying degrees of for-profit or nonprofit status, or collaborations between for-profit and government/nonprofit entities to deliver services. Our analysis demonstrates that comparing public and private performance requires a broader framework that includes several moderating factors that go beyond whether ownership is public or private. Several case studies of social franchises [20],[89],[90] found higher care utilization among the lower socioeconomic groups of private franchisers than of control private clinics for contraceptive use, HIV counseling, antenatal care, and vaccination [17],[91],[92]. Several reports observed higher prescription drug costs in the private sector for equivalent clinical diagnoses [33],[36],[53],[67],[93][96]. 2. Competitive dynamics for funding appeared between the two sectors, such that public funds and personnel were redirected to private sector development, followed by reductions in public sector service budgets and staff. The search terms included studies in English, French, Italian, Spanish, Portuguese, or Russian, published from 1 January 1980 through 31 August 2011. The cost burdens of privatization related to an increase in disparities in healthcare coverage and infant mortality between urban and rural areas [79]. First, healthcare services are not universally dichotomized between public and private providers, as some practitioners participate in both state-based and privately owned healthcare delivery systems, and many systems are dually funded or informal. Answer (1 of 5): ADVANTAGES OF PUBLIC HOSPITALS Because they are partly or fully funded by a public municipality, public hospitals accept nearly every type of insurance and are very flexible. 1.Number Of The Facilities According to the 2014 American Hospital Association Annual Survey, there are 5,686 hospitals in the United States. Disagreements between the two reviewers were resolved by consensus among all authors. But around a quarter of people with private health insurance choose to use the public system. Because much of the discussion and data collection on this topic has been performed outside of academic circles by international agencies and non-governmental groups, we supplemented the database search by conducting the same keyword searches on the websites of the WHO library database WHOLIS, the World Bank Documents and Reports repository, the United Nations Children's Fund, the United Nations Development Program, the Bill & Melinda Gates Foundation, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Oxfam International, and the Kaiser Family Foundation Global Health Division. Interviews of Indian patients suggested that several private practitioners who work in both public and private sectors advised patients to visit their private clinics or requested further payments in order to continue providing care in the public clinic [106]. There is considerable ideological debate around whether low- and middle-income countries should strengthen public versus private healthcare services, but in reality, most low- and middle-income countries use both types of healthcare provision. While the NHS aims [] However, the percentage of total visits varied substantially across countries and income levels [15]. This implies that future research in the area should include a focus on how experiential aspects of care are relevant to healthcare seeking and outcomes (such as the likelihood of follow-up among patients requiring return visits) for differently structured care environments. They assessed selected studies against the World Health Organization's six essential themes of health systemsaccessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiencyand conducted a narrative review of each theme. We compared the countries differences in both healthcare costs and performance levels. Within all WHO health system themes, study findings varied considerably across countries and by the methods employed. A recent Supreme Court ruling put freedom of expression above freedom from discrimination. Public hospitals allow you to pull on the resources around you when treating your patients - as many departments exist under one roof. While costs are difficult to compare, the Productivity Commission found that general hospital costs (items such as ward nursing, hospital supplies and allied health services) are higher in public than private hospitals (A$2,552 versus A$1,953). Performed the experiments: SB JA. A few key findings reported in articles did not clearly fit into the WHO health system themes, mainly involving recent reports of complex competitive dynamics between private and public health sectors. Financial barriers to care (such as user fees) were reported for both public and private systems. Sexually transmitted disease management in private clinics and drugs shops in Uganda revealed that 93% of cases were not properly managed per national guidelines, and the cure rate was 47% [58]. Only by developing further research on these additional factors will we be able to distinguish when and how private organisations could be a better option for delivering health services. It was estimated that in Mexico, Brazil, and South Africa, unnecessary C-sections increased delivery-related health costs in the private sector by at least 10-fold [23]. Studies must have included data on a population in at least one low- or middle-income country, defined by the 2010 World Bank criteria of having current per-capita gross national income less than or equal to US$12,275 [14]. e1001244. Instead, they rely on political will and budgetary changes: both aspects that can limit their production levels. Parallel results were reported from Viet Nam [48]. The six themes are as follows: accessibility and responsiveness; quality; outcomes; accountability, transparency, and regulation; fairness and equity; and efficiency [13] (Table 1). cesarean section; WHO, Six articles documented that a significant proportion of outpatient services in low- and middle-income countries appeared to be provided by the private sector [15][18]. For example, treatment of infectious diseases in public settings may be more efficient than in private settings because of higher volume, and greater use of systematized protocols due to that higher volume. An exception was a partnership in India that demonstrated increased birth attendant coverage from 27% to 53% over 7 mo among a cohort of 97,000 women [73]. From choosing baby's name to helping a teenager choose a college, you'll make . Higher drug costs are in part associated with disease complications attributable to delayed diagnosis or incorrect disease management [97],[98]. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. The most common incidents involved the unnecessary use of antibiotics for treatment of diarrheal diseases and non-complicated acute respiratory infections [32],[49]. The analysis found that private outpatient clinics often had better drug supplies and responsiveness than public clinics, but the analysis did not assess other dimensions of health system performance (such as accessibility). However, medical and diagnostics costs (which includes items such as x-rays and blood tests) are higher for private hospitals (A$798) than public hospitals (A$542). In Colombia, following major privatization reforms in 1993, population vaccine coverage declined for several diseases in the country, and tuberculosis incidence rose significantly [67]. Tuberculosis and malaria case notification to the public health system was particularly poor among private sector providers as compared to public providers in a number of countries [28],[48],[70]. Public hospital doctors had more positive attitudes towards medical students than their private colleagues. In many of the countries studied, surveillance of disease treatment outcomes among adults, and particularly noncommunicable disease, was found to be limited. How does private and public healthcare work? Visiting professor, Department of Strategy and General Management at Esade Business School. A private hospital also provides more space and flexibility for visitors, with fewer restrictions than a public hospital, depending on clinical need. Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom, The large number of small-scale hospitals and clinics in some sub-Saharan African countries fragmented delivery, such that patient diagnoses and treatment histories were unavailable between institutions [22],[99], often significantly delaying care, and resulting in redundant tests and sometimes administration of incorrect medication to patients. One highly cited secondary analysis reported this outcome as a 17% savings resulting from contracting [101]. One survey-based study using Demographic Health Survey data from 34 sub-Saharan African countries found that privatization was associated with increased access, and reduced disparities in access between rich and poor [86]. A public hospital has a cheaper cost of service. Higher rates of potentially unnecessary procedures, particularly cesarean sections (C-sections), were also reported at private than at public settings [50],[51]. Public sector hospitals outperform their private counterparts when the goal is to reduce financial costs. One analysis of the Peruvian health system found significantly higher rates of C-sections after the privatization of delivery. Abbreviations: Qualitative studies were included if they specified a systematic methodology for interviews, focus group analysis, historical or political science analysis, or ethnographic observation (see Text S2 for the PRISMA checklist). Doctors tended to migrate towards private sector and urban jobs, depriving the public sector and rural areas of physicians [107]. One proposed approach is to link provider compensation with results from patient outcomes, weighted by baseline disease risk in the patient population [111]. When delivering healthcare services, can public hospitals outperform private ones? Conceived and designed the experiments: SB JA DS RP. Although studies report that patients in the private sector experience better timeliness and hospitality, studies suggest that providers in the private sector more frequently violate accepted medical standards and have lower reported efficiency. A major argument in favour of the private sector providing public services is that it could increase service efficiency. As Hanson and colleagues note, A strengthened evidence base on the performance of the public and private health sectors is essential to guide decision-makers towards policy choices that are appropriate for their contexts [11]. This is because private hospitals have more financial resources to invest in the latest medical technology and equipment. Some of this difference may be because private hospital treatment is more likely to be planned (elective surgery), for which the risk of infection is lower. Of 1,178 potentially relevant unique citations, data were obtained from 102 articles describing studies conducted in low- and middle-income countries. Around 30% of all hospital births occur in private hospitals. We found evidence that the provision of health services is cheaper if provided by the public sector. Hence, the conclusions of the report appear to be disputed by the data within the report. Is the Subject Area "Health care facilities" applicable to this article? The review also identifies several areas of focus for quality improvement. Similar findings were reported from Cambodia [66]. In Bangladesh, for example, public providers ranked lower than private providers on scale-based surveys in which patients assessed the diagnostic explanation given them, courtesy of staff, cleanliness of facilities, capacity building, and the availability of certain medical inputs [36]. In this context, simply defining what is private or public is not straightforward. In 2009-2010, there were almost 1.9 million elective surgery procedures 661,000 in public hospitals and 1.2 million in private hospitals. Both sides of the public versus private healthcare debate draw on selected case reports to defend their viewpoints, but there is a widely held view that the private health system is more efficient than the public health system. Criticizing such efforts, the international nonprofit organization Oxfam, in its report Blind Optimism, concluded that to achieve universal and equitable access to health care, the public sector must be made to work as the majority provider [5]. Some studies suggested there was a systematic bias against indigent patients in terms of both quality and access. Yes In Ghana, new private services in urban middle- and upper-socioeconomic populations were found to reduce revenues for public sector hospitals that also provided care to poorer populations [22]. Technological change & digital transformation, public organisations in the healthcare sector, Creative Commons Attribution 4.0 International license. Out of the 102 relevant studies included in their comparative analysis, 59 studies were research studies and 13 involved meta-analysis, with the rest involving case reports or reviews. To help make your stay as pleasant as possible, many hospitals also provide extra services such as hair dressing and beauty, and laundry facilities. Our study has important implications for future research and policy. However, there were three exceptions: Namibia, Tanzania, and Zambia, where private sectors are majority providers even when only licensed personnel are counted. This opens up another question: if private organisations providing public services could lower costs and increase efficiency, what would happen to their public counterparts? On the contrary, Taiwan, and particularly Belgium, Spainand Italy the four remaining countries in our study rank much worse in terms of public sector performance. When deciding whether to use the private system, being aware of the costs and having appropriate cover is key. Despite the lack of data about private sector performance, recent initiatives by the World Bank's International Finance Committee are underwriting the expansion of private sector services among low- and middle-income countries. Yes Financial barriers to care, particularly user fees, were reported to be prevalent in both private and public systems. Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America, Affiliations The list was longest in New South Wales, where patients waited an average of 49 days. Poor data availability was observed in another systematic collection from several countries' privatepublic partnerships for sexual and reproductive health services. A World Bank study in Ghana concluded that there was no systematic evidence indicating whether user fees in the public sector were different than in the private sector [78]; however, the data presented showed that out-of-pocket user fees for patients were highest for private not-for-profit, lowest for public, and intermediate for private self-financed providers [22]. Our goal is to understand how the private or public nature of a given healthcare delivery institution may impact core healthcare delivery goals. Reports from Africa and Laos suggest ineffective and sometimes harmful pharmaceuticals are being distributed in the private sector [56],[57]. Please see later in the article for the Editors' Summary, 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. Our systematic review of comparative analyses of public and private healthcare systems in low- and middle-income countries found strengths and limitations in both sectors for each of six main WHO health systems framework themes. 1901), Lexpertise universitaire, lexigence journalistique. A data extraction method was designed by three reviewers (S. B., J. Furthermore, we found evidence that many publicprivate initiatives involve public sector funding being dedicated to monitoring and preventing corruption in the private sector. International patients requiring surgery, for example; be it a simple procedure or a complex medical treatment are admitted within a couple of days. No, Is the Subject Area "Privatization" applicable to this article? Several World Bank studies found significant fragmentation in purchasing and distribution across and within the public and private sectors, resulting in higher drug prices and redundant treatments that increase overall healthcare costs [22],[99]. A systematic review of data from publicprivate partnerships (including arrangements among governments and private, for-profit contractors) found few reported data that were of sufficient quality to assess the impact of partnership services and programs [72]. While its unlikely anything will go wrong during a caesarean birth, all types of surgery carry a small risk of infections and other complications. However, in practice, studies comparing the performance of private and public sectors are difficult to implement, for several reasons. Hosted by Sabrina Tavernise. This means that, unlike private practice workers, knowledge outside of your speciality is nearly always available from other medical professionals. To access private healthcare, you have two main options. Several studies disaggregated utilization by income levels, tending to find that the private sector predominantly serves more affluent populations. Similar privatization in some parts of South Africa were associated with a 13% to 32% cost increase in overall health spending, without associated increases in coverage or indications [94]; costs of prescriptions were significantly lower in the public sector, likely due to generic substitution, prepackaging of medications, and use of treatment protocols [95]. Similar poor adherence to guidelines in prescription practices, including subtherapeutic dosing, by private sector providers has been associated with a rise in drug-resistant malaria in Nigeria [47]. Treatment. The U.S. Department of Veterans Affairs takes care of about 9 million veterans at 1,255 facilities. Ideally, analyses should be comparative and should include a counterfactual in order to make causal claims about the effects of the particular benefits of providing services in one sector or the other. One recent independent review of Ghana's private sector referred to the private sector as a black box, with a dearth of information on delivery practices and outcomes [22]. Your hospital stay is likely to be slightly shorter in a private hospital (5.1 days, on average) than a public hospital (5.7 days). Private sector advocates have pointed to evidence that the private sector is the main provider, as many impoverished patients prefer to seek care at private clinics [1]. However, while national vital statistics databases collected from public sector clinics and hospitals were widely available, they varied considerably in quality according to external assessments [22],[71]. In some cases, however, the services in differing sectors undermined performance of one or both sectors. In addition, public STCs did better than hospitals, but private ones outperformed them as well. https://doi.org/10.1371/journal.pmed.1001244.t002. 7. We also compared recent attitudes in the private hospital with those obtained in 2012. Contracting of public healthcare services to private providers has also been estimated by the World Bank to reduce costs of and waiting times for contracted services [36],[101], although the effects of contracting differ markedly by the type of healthcare service and across countries [17],[102]. Specifically, for-profit hospitals with between 100 and 249 beds and those with more than 400 beds had lower technical efficiency scores compared with their non-profit peers. 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). This step was particularly important for acquiring data from the private sector, since such data are relatively unavailable in the peer-reviewed academic literature. Recently, as the global economic recession has put major constraints on government budgetsthe major funding source for healthcare expenditures in most countriesdisputes between the proponents of private and public systems have escalated, further fuelled by the recommendation of International Monetary Fund (an international finance institution) that countries increase the scope of private sector provision in health care as part of loan conditions to reduce government debt. Earlier studies on privatisation tend to give a higher performance ranking to public services provided by privately-owned organisations, but this performance gap has attenuated over the last few years. Analyzed the data: SB JA. While most reports described income-based stratification in access, one report described stratification based on gender in addition to income. A., and D. S.). Comfort Once a patient does get admitted to a Singapore hospital room, what can they expect? Standard data describing each study were also extracted, including the country where the study was performed, study period, study methodology, number of included participants, primary and secondary outcome measures and end points, and study limitations. One review in Ghana indicated that the key public agency in charge of such regulation was unable to identify a large number of private providers in order to assess accreditation and quality: 2,612 of 11,430 drug shops were registered but had not received licenses [22]. It is also important to address conflicts of interest from physician-induced demand, particularly when prescribers are also drug store owners. But because public hospitals deal with emergencies and acute care, they found it a stressful environment, where the nursing staff were overworked. In Asia, public hospitals experience higher costs per patient than those that are owned privately, while in Australia, there are no differences in costs between public and private hospitals.