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Cochrane Database Syst Rev. 2009 Oct 7;(4):CD008133. doi: 10.1002/14651858.CD008133.

The impact of contracting out on health outcomes and use of health services in low and middle-income countries.

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Health Policy Unit, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT.



Recent literature on the lack of efficiency and acceptability of publicly provided health services has led to an interest in the use of partnerships with the private sector to deliver public services.


To assess the effectiveness of contracting out healthcare services in improving access to care in low and middle-income countries and, where possible, health outcomes.


We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, in addition to development studies and economic databases. We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature. The original searches were conducted between November 2005 and April 2006. An updated search in MEDLINE was carried out in May 2009.


Contracting out health services is defined as the provision of healthcare services on behalf of the government by non-state providers. Studies had to include an objective measure of at least one of the following outcomes: health care utilisation, health expenditure, health outcomes or equity outcomes. Studies also needed to use one of the following study designs: randomised controlled trial, non-randomised controlled trial, interrupted time series analysis or controlled before and after study.


We made an attempt to present results from the different studies in a systematic way, however due to the diversity of sources, contexts and methods used, we undertook a narrative synthesis.


Three studies met our inclusion criteria (one after re-analysis of data). These studies suggest that contracting out services to non-state providers can increase access and utilisation of health services. One study found a reduction in out-of-pocket expenditures and improvement in some health outcomes. However, methodological weaknesses and particularities of the reported programme settings limit the strength and generalisability of their conclusions.


Three studies suggest that contracting out may be an appropriate response to scale up service delivery in particular settings, such as post-conflict or fragile states. Evidence was not presented on whether this approach was more effective than making a similar investment in the public sector, as there was not an exact control available in any of the settings. In addition, the introduction of non-state providers into some settings and not others also brings many potentially confounding variables, such as the presence of additional management expertise or expatriate doctors, which may improve drug supply or increase utilisation.

[Indexed for MEDLINE]

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