The role of the private sector in low- and middle-income countries has been the subject of heated debate in both the academic literature and policy circles (Hanson et al. 2008). Even agreement on the size of the private sector is hard to come by (Wagstaff 2013). Those in favour of an expansion in the role of the private sector argue that market forces improve the efficiency and responsiveness of health services. Advocates of a strong public sector point towards the inequitable nature of private sector provision and the fact that markets often fail in health – for example in the provision of preventive care. Despite these differences, both camps would agree that more evidence on the performance of public and private health providers is needed to inform the debate on the relative merits of the two sectors.

The diversity of the private sector can make simple comparisons with public providers difficult to interpret. Nevertheless, there have been a number of efforts to review the broad literature. One expansive review found that the private providers had poorer patient outcomes and were more likely to flout standards, but were responsive to patients (Basu et al. 2012). Perverse incentives for unnecessary care in the private sector meant efficiency was lower than in the public sector. Availability of inputs (e.g. trained healthcare workers) was typically worse in the public sector. A second review focused on the quality of ambulatory health care found that many services, irrespective of whether public or private, scored low on infrastructure, clinical competence and practice (Berendes et al. 2011). The private sector performed better in relation to drug supply, responsiveness and effort. No difference between provider groups was detected for patient satisfaction or competence. Both reviews are notable for the lack of cross-country evidence on the performance of public and private providers.