Contracting out to improve the use of clinical health services and health outcomes in low‐ and middle‐income countries


William Odendaal1, Kim Ward2, Jesse Uneke3, Henry Uro‐Chukwu4, Dereck Chitama5, Yusentha Balakrishna6, Tamara Kredo7

1. Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
2. School of Pharmacy, University of the Western Cape, Cape Town, South Africa
3. African Institute for Health Policy and Health Systems, Ebonyi State University, Abakaliki, Nigeria
4. Social Mobilization and Disease Control, National Obstetrics Fistula Centre, Abakaliki, Nigeria
5. School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
6. Biostatistics Unit, South African Medical Research Council, Durban, South Africa
7. Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa

Odendaal  WA, Ward  K, Uneke  J, Uro‐Chukwu  H, Chitama  D, Balakrishna  Y, Kredo  T. Contracting out to improve the use of clinical health services and health outcomes in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2018, Issue 4. Art. No.: CD008133. DOI: 10.1002/14651858.CD008133.pub2

Access the full text article here: DOI: 10.1002/14651858.CD008133.pub2/full

What is the aim of this Review?

This Cochrane Review aims to assess the effects of contracting out healthcare services. Cochrane researchers searched for all relevant studies to answer this question. Two studies met their criteria for inclusion in the Review.

Key messages

Contracting out healthcare services may make little or no difference in people’s use of healthcare services or to children’s health, although it probably decreases the amount of money people spend on health care. We need more studies to measure the effects of contracting out on people’s health, on people's use of healthcare services, and on how well health systems perform. We also need to know more about the potential (negative) effects of contracting out, such as fraud and corruption, and to determine whether it provides advantages or disadvantages for specific groups in the population.

What was studied in the Review?

When governments contract out healthcare services, they give contracts to non‐governmental organisations to deliver these services.

Contracting out healthcare services is common in many middle‐income countries and is becoming more common in low‐income countries. In many of these countries, government‐run services are understaffed or are not easily accessible. Private healthcare organisations, on the other hand, often are more widespread and sometimes are well funded by international donors. By contracting out healthcare services to these organisations, governments can make healthcare services accessible to more people, for example, those in rural and remote areas.

However, contracting out might be a more expensive way of providing healthcare services when compared with services provided by governments themselves. Some governments may find it difficult to manage non‐governmental organisations and to ensure that contractors deliver high‐quality, standardised care. The process of giving and managing contracts may create opportunities for fraud and corruption.

What are the main results of the Review?

The review authors found two studies that met the criteria for inclusion in this Review. One study was from Cambodia. This study compared districts that contracted out healthcare services versus districts that provided healthcare services that were run by the government. The second study was from Guatemala. This study assessed what happened before and after preventive, promotional, and basic curative services were contracted out. These studies showed that contracting out:

• probably makes little or no difference in children’s immunisation uptake, women’s use of antenatal care visits, or women’s use of contraceptives (moderate‐certainty evidence);

• may make little or no difference in the number of children who die before they are one year old, or who suffer from diarrhoea (low‐certainty evidence); and

• probably reduces the amount of money people spend on their own health care (moderate‐certainty evidence).

Included studies did not report the effect of contracting out on fairness (equity) in the use of healthcare services nor on side effects such as fraud and corruption.

How up‐to‐date is this Review?

The review authors searched for studies that had been published up to April 2017.