Lagarde Mylene, Palmer Natasha
Health Policy Unit, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT.
Cochrane Database Syst Rev. 2009 Oct 7(4):CD008133. doi: 10.1002/14651858.CD008133.
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.
AUTHORS' 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.
近期有关公共提供的卫生服务缺乏效率和可接受性的文献引发了人们对于利用与私营部门建立伙伴关系来提供公共服务的兴趣。
评估在低收入和中等收入国家将医疗服务外包在改善医疗服务可及性方面的有效性，并在可能的情况下评估对健康结果的影响。
我们检索了广泛的国际数据库，包括Cochrane对照试验中心注册库（CENTRAL）、MEDLINE和EMBASE，此外还检索了发展研究和经济数据库。我们还搜索了众多国际机构、组织和大学的网站及在线资源，以查找相关的灰色文献。最初的检索于2005年11月至2006年4月进行。2009年5月在MEDLINE进行了更新检索。
将医疗服务外包定义为非国家提供者代表政府提供医疗服务。研究必须至少对以下结果之一进行客观测量：医疗服务利用、卫生支出、健康结果或公平结果。研究还需采用以下研究设计之一：随机对照试验、非随机对照试验、中断时间序列分析或前后对照研究。
我们试图以系统的方式呈现不同研究的结果，然而由于所使用的来源、背景和方法的多样性，我们进行了叙述性综述。
三项研究符合我们的纳入标准（一项是在对数据进行重新分析之后）。这些研究表明，将服务外包给非国家提供者可增加医疗服务的可及性和利用率。一项研究发现自付费用有所减少，一些健康结果有所改善。然而，所报告项目设置的方法学弱点和特殊性限制了其结论的力度和普遍性。
三项研究表明，外包可能是在特定环境（如冲突后或脆弱国家）扩大服务提供的一种适当应对措施。由于在任何环境中都没有确切的对照，因此未提供关于这种方法是否比在公共部门进行类似投资更有效的证据。此外，在某些环境而非其他环境引入非国家提供者也带来了许多潜在的混杂变量，例如额外管理专业知识或外籍医生的存在，这可能会改善药品供应或提高利用率。
