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

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.

Authors' conclusions: 

This update confirms the findings of the original review. Contracting out probably reduces individual out-of-pocket spending on curative care (moderate-certainty evidence), but probably makes little or no difference in other health utilisation or service delivery outcomes (moderate- to low-certainty evidence). Therefore, contracting out programmes may be no better or worse than government-provided services, although additional rigorously designed studies may change this result. The literature provides many examples of contracting out programmes, which implies that this is a feasible response when governments fail to provide good clinical health care. Future contracting out programmes should be framed within a rigorous study design to allow valid and reliable measures of their effects. Such studies should include qualitative research that assesses the views of programme implementers and beneficiaries, and records implementation mechanisms. This approach may reveal enablers for, and barriers to, successful implementation of such programmes.

Read the full abstract...

Contracting out of governmental health services is a financing strategy that governs the way in which public sector funds are used to have services delivered by non-governmental health service providers (NGPs). It represents a contract between the government and an NGP, detailing the mechanisms and conditions by which the latter should provide health care on behalf of the government. Contracting out is intended to improve the delivery and use of healthcare services. This Review updates a Cochrane Review first published in 2009.


To assess effects of contracting out governmental clinical health services to non-governmental service provider/s, on (i) utilisation of clinical health services; (ii) improvement in population health outcomes; (iii) improvement in equity of utilisation of these services; (iv) costs and cost-effectiveness of delivering the services; and (v) improvement in health systems performance.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, NHS Economic Evaluation Database, EconLit, ProQuest, and Global Health on 07 April 2017, along with two trials registers - and the International Clinical Trials Registry Platform - on 17 November 2017.

Selection criteria: 

Individually randomised and cluster-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies, comparing government-delivered clinical health services versus those contracted out to NGPs, or comparing different models of non-governmental-delivered clinical health services.

Data collection and analysis: 

Two authors independently screened all records, extracted data from the included studies and assessed the risk of bias. We calculated the net effect for all outcomes. A positive value favours the intervention whilst a negative value favours the control. Effect estimates are presented with 95% confidence intervals. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a Summary of Findings table.

Main results: 

We included two studies, a cluster-randomised trial conducted in Cambodia, and a controlled before-after study conducted in Guatemala. Both studies reported that contracting out over 12 months probably makes little or no difference in (i) immunisation uptake of children 12 to 24 months old (moderate-certainty evidence), (ii) the number of women who had more than two antenatal care visits (moderate-certainty evidence), and (iii) female use of contraceptives (moderate-certainty evidence).

The Cambodia trial reported that contracting out may make little or no difference in the mortality over 12 months of children younger than one year of age (net effect = -4.3%, intervention effect P = 0.36, clustered standard error (SE) = 3.0%; low-certainty evidence), nor to the incidence of childhood diarrhoea (net effect = -16.2%, intervention effect P = 0.07, clustered SE = 19.0%; low-certainty evidence). The Cambodia study found that contracting out probably reduces individual out-of-pocket spending over 12 months on curative care (net effect = $ -19.25 (2003 USD), intervention effect P = 0.01, clustered SE = $ 5.12; moderate-certainty evidence). The included studies did not report equity in the use of clinical health services and in adverse effects.