October, 2016 - SUPPORT Summary of a systematic review | print this article |

Does contracting out services improve access to care in low- and middle-income countries?1

Contracting out of health services is a formal contractual relationship between the government and a non state provider to provide a range of clinical or preventive services to a specified population. A contract document usually specifies the type, quantity and period of time during wich the services will be provided on behalf of the government. Contracting in is the contracting of external management to run public services, which is another particular type of contracting.

 Key messages

  • Contracting out services to non state not for profit providers may increase access to and utilisation of health services.
  • Patient outcomes may be improved and household health expenditures reduced by contracting out.
  • None of the included studies presented evidence on whether contracting out was more effective than making a similar investment in the public sector. We are therefore uncer-tain of the effects of investing in contracting out compared to an equivalent investment in public sector health services.

 

Background

Contracting is a financing strategy to spend public sector funds to deliver services. Selective contracting out of services in low and middle income countries to the private sector is often a component of reform packages promoted by bilateral and multilateral agencies. Often both the private for profit and private not for profit sectors are important and well resourced providers of healthcare services. The motivation for contracting with the private sector is both to utilize these resources in the service of the public sector and to improve the efficiency of publicly funded services.

 

 



About the systematic review underlying this summary

Review objectives: To assess the effects of contracting out healthcare services in health services utilisation, equity of access, health expenditure and health outcomes.
Type Of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, controlled before-after studies and interrupted time series studies of contracting out of healthcare services (a formal contractual relationship between government and non-state providers) One controlled before-after study, one interrupted time series study, and one cluster randomised trial
Participants Populations that would potentially access health services (users and non-users) as well as health facilities in low- and middle-income countries

Bolivia: A neighbourhood in the capital city of la Paz

Pakistan: The population of the rural district of Rahimyar Khan

Cambodia: Six districts of the country (two contracted out and four run by the government). It also evaluated a non-reported number of districts con-tracted in

 

Settings Not limited to any level of healthcare delivery Two studies (Pakistan, Cambodia) evaluated a contracting out motivated by weaknesses or absence of public system. Both took place in mostly rural areas. One study (Bolivia) included a programme based in an urban setting consisting of a network of eight health centres and one hospital
Outcomes Objective measures of health services utilisation, access to care, healthcare expenditure, health outcomes or changes in equity   Health services utilisation and access to care (three studies), health expenditure (one study) and health outcomes (one study). No studies were found that measured changes in equity of access
Date of most recent search: April 2006
Limitations: This is a well-conducted systematic review with only minor limitations, but the last search for studies was in 2006.

Lagarde M, Palmer N. The impact of contracting out on health outcomes and use of health services in low and middle-income countries. Cochrane Database of Systematic Reviews 2009, Issue 4. 


To assess the effects of contracting out healthcare services in health services utilisation, equity of access, health expenditure and health outcomes.

Lagarde M, Palmer N. The impact of contracting out on health outcomes and use of health services in low and middle-income countries. Cochrane Database of Systematic Reviews 2009, Issue 4.

Summary of findings

Three studies were found. All of them measured outcomes related to health services utilisation. Only one of them assessed patient outcomes and health expenditures.

In the three studies, the effects could be attributed to causes unrelated to the intervention. One study had baseline differences between groups. Additionally, contracted districts received and used more financial resources (85% more than government districts). The districts compared in another study were not equivalent, and a concurrent extension of an insurance scheme probably contributed to increasing demand. The third study did not report information about possible confounders.

 

  • Contracting out services to non-state not-for-profit providers may increase access to and utilisation of health services. The certainty of this evidence is low.
  • Patient outcomes may be improved and household health expenditures reduced by contracting out. The certainty of this evidence is low.

 

Contracting out of health services to non-state not-for–profit providers

People:  General population
Settings
:  Rural and urban settings in low- and middle-income countries (Bolivia, Cambodia and Pakistan)
Intervention
: Contracting out of health services to private not-for–profit organisations
Comparison
: No intervention
Outcomes Impact Certainty of the evidence
(GRADE)
Health services
utilisation

In one study, there were differences in two of eight outcomes measured (an absolute increase of 21% and 19% in use of public facilities and uptake of vitamin A).
In another study, deliveries attended by health personnel increased by 20.8%. There was no effect in the duration of hospital stay or in bed occupancy.
The third study showed an increase of nearly 4,100 visits per day (0.33 visits per capita per year), but the effect faded with time.

Low

Healthcare
expenditure
One study found that household health expenditures diminished; although it was difficult to assess the size of effects (the authors suggested a reduction of between US$ 15 and $56 in annualized individual curative care spending).

Low

Patient outcomes One study found that the probability of individuals reporting that they had been sick in the past month was reduced. There was also a decrease in the incidence of diarrhoea in infants.

Low

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All of the studies were undertaken in low and middle income countries

 

  • In the three included studies, the contracts were carried out with non-governmental organisations (NGOs), no studies were found that evaluated contracts with private for profit providers.
  • The studies provided very little description of the actual measures implemented by the contractor (management, organisation, salaries, and incentives) to achieve the goals established in the contract.

 


Differences in health systems; patient and physician attitudes to NGOs; and legal restrictions may limit applicability of the findings.

 

  • Contracting can be a potentially effective strategy in particular settings but it may be difficult for governments to re-deploy public funds to private providers when available funds are already committed to public services.
  • Factors that need to be considered to asses whether the intervention effects are likely to be transferable include:

- The availability of not-for-profit organizations to carry out the contracts;

- The capacity within the public sector to set up and monitor the contracts.

 


EQUITY
The included studies did not provide data regarding any differential effects of contracting out for disadvantaged populations.

Depending on the population to which the contracted services are targeted, contracting could have a positive or negative impact on equity. If NGOs are available to deliver services in underserved or rural areas not covered by public-funded services, contracting could be expected to reduce inequities. On the other hand, if NGOs do not serve disadvantaged populations, contracting out could increase inequities.

In the long term, the contracting out of health services could constitute a disincentive to the strengthening of public provision of services in underserved areas.

 


ECONOMIC CONSIDERATIONS
The findings of the studies provide little evidence of the long term desirability of contracting out.

While contracting out appears effective as a means to scale up service delivery rapidly in small areas, there are potential constraints that face these schemes in the longer term. It is unclear whether capacity exists among non-state providers to scale up their service delivery efforts. There are also concerns that a focus on contracting out may encourage donors to bypass failing or fragile states, thereby overlooking building the institutional capacity of the local health system (including Ministries of Health) as either a steward or a service delivery organisation.

 

  • In the long run it is not clear if contracting out is a more effective or efficient way of improving access to health services compared with a programme aimed at strengthening public sector healthcare delivery in specific underserved areas.

MONITORING & EVALUATION
Some of the improvements observed in the included studies may be attributable to other factors, such as the intervention of an international NGO in an area.

If a decision is made to contract out services, the impacts of contracting out compared to strengthening the public sector should be rigorously evaluated before scaling up. Both anticipated benefits and unintended adverse effects should be monitored.

 

  • A key aspect of the monitoring of contracting out is evaluating the capacity of the health system to adequately undertake this task

 


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Loevinsohn B, Harding A. Contracting for the Delivery of Community Health Services: A Review of Global Experience: World Bank, 2004.

 

Palmer N, Strong L, Wali A, Sondorp E. Contracting out health services in fragile states. BMJ 2006; 332:718-21.

 

Palmer N, Mills A. Contracts in the real world - case studies from Southern Africa. Soc Sci Med 2005; 60(4):2505-14.

 

This summary was prepared by

Gabriel Bastías and Gabriel Rada, Pontificia Universidad Catolica de Chile, Santiago, Chile.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: April Harding, Benjamin Loevinsohn, Tomás Pantoja, Maimunah Hamid and Hanna Bergman.

 

This review should be cited as

Lagarde M, Palmer N. The impact of contracting out on health outcomes and use of health services in low and middle-income countries. Cochrane Database of Systematic Reviews 2009, Issue 4.

 

The summary should be cited as

Bastías G, Rada G. Does contracting out services improve access to care in low- and middle-income countries? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org

 

Keywords

 

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, health care contracting

 



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