SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
October, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
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
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.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
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.
| 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
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| 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.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
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 of health services to non-state not-for–profit providers |
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| 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 |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| 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 |
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| 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 |
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| 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 |
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| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
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All of the studies were undertaken in low and middle income countries
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Differences in health systems; patient and physician attitudes to NGOs; and legal restrictions may limit applicability of the findings.
- 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.
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| 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.
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| 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.
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| 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.
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*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 |
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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.
Gabriel Bastías and Gabriel Rada, Pontificia Universidad Catolica de Chile, Santiago, Chile.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: April Harding, Benjamin Loevinsohn, Tomás Pantoja, Maimunah Hamid and Hanna Bergman.
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.
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
