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Abstract
Objective This paper provides a systematic review of evidence of government purchase of health services from private providers through stand-alone contracting-out (CO) initiatives and CO insurance schemes (CO-I) on health service utilisation in Eastern Mediterranean Region (EMR) to inform universal health coverage 2030 strategies.
Design Systematic review.
Data sources Electronic search of published and grey literature on Cochrane Central Register of Controlled Trials, PubMed, CINHAL, Google Scholar and web, including websites of ministries of health from January 2010 to November 2021.
Eligibility criteria Randomised controlled trials, quasi-experimental studies, time series, before–after and endline with comparison group reporting quantitative utilisation of data across 16 low-income and middle-income states of EMR. Search was limited to publications in English or English translation.
Data extraction and synthesis We planned for meta-analysis, but due to limited data and heterogeneous outcomes, descriptive analysis was performed.
Results Several initiatives were identified but only 128 studies were eligible for full-text screening and 17 met the inclusion criteria. These included CO (n=9), CO-I (n=3) and a combination of both (n=5) across seven countries. Eight studies assessed interventions at national level and nine at subnational level. Seven studies reported on purchasing arrangements with non-governmental organisations, 10 on private hospitals and clinics. Impact on outpatient curative care utilisation was seen in both CO and CO-I, positive evidence of improved maternity care service volumes was seen mainly from CO interventions and less reported from CO-I, whereas data on child health service volume was only available for CO and indicated negative impact on service volumes. The studies also suggest pro-poor effect for CO initiatives, whereas there was scarce data for CO-I.
Conclusion Purchasing involving stand-alone CO and CO-I interventions in EMR positively impact general curative care utilisation, but lacks conclusive evidence for other services. Policy attention is needed for embedded evaluations within programmes, standardised outcome metrics and disaggregated utilisation data.
- health policy
- human resource management
- quality in health care
- public health
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This is the first systematic evaluation of government purchase of health services from private providers in the Eastern Mediterranean Region, through both stand-alone contracting-out measures and contracting-out under insurance.
It shows positive impact on general curative care utilisation of both stand-alone contracting and contracting-out under insurance, whereas stand-alone contracting-out also demonstrates improved utilisation maternity services.
Use of diverse metrics and lack of baselines or comparison groups restrained the meta-analysis.
Data gaps were particularly seen for insurance initiatives, with standardised metrics and more robust evaluation designs required in roll-out of insurance initiatives.
Introduction
In the Eastern Mediterranean Region (EMR), there has been a steady proliferation of government funded programmes that purchase services to expand access to affordable health services.1 These domestically driven programmes are largely financed by country governments, have grown incrementally to comprise of small scale to more extensive arrangements and involve private providers to varying extents.
According to WHO, the EMR has a population of 679 million and includes 22 member states from which 6 are high-income countries, 4 are upper-middle-income countries, 7 low-income and middle-income countries (LMICs) and 5 low-income-countries (LIC) (box 1).2 The exponential growth of formal private providers in the EMR has helped to fill gaps in the provision of health services particularly where government systems are strained or weakly functional.3 Private providers are a substantial source of hospital, diagnostic, specialist outpatient and general ambulatory care services in the region. Private providers account for 70%–90% of ambulatory care visits in Pakistan, Somalia, Egypt, Afghanistan and Lebanon, 35%–45% in Yemen, Sudan, Jordan and Iraq, and one-fifth of the visits in the remaining countries.4 Private providers are a growing source of inpatient care and the proportion of hospital beds within the private sector varies from 7% to 3%,1 with higher proportions in Egypt, Lebanon, Jordan and Morocco.4
: Categorization of EMR countries by income l
High income: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and UAE.
Upper middle income: Iraq, Jordan, Lebanon and Libya.
Lower middle income: Djibouti, Egypt, Islamic Republic of Iran, Morocco, Pakistan, Tunisia and Occupied Palestinian Territory.
Low income: Afghanistan, Somalia, Sudan, Syrian Arab Republic and Yemen.
Purchasing arrangements with private providers in the EMR involve government funding to deliver subsidised or free services, based on formal service agreements on scope and duration of services, with some level of oversight by the government. Access to affordable care is key goal for these arrangements, however, private provider purchasing initiatives in the LMIC have grown over the years often without a concerted universal health coverage (UHC) strategy.5 6
A recent landscape analysis has outlined two main private provider purchasing models in the EMR: (1) government stand-alone contracting-out (CO) initiatives with private providers delivering primary, diagnostic and secondary care and (2) CO under government-funded insurance scheme (CO-I) of private hospital/facilities, alongside public sector and parastatal hospitals.7 Demand side initiatives such as social franchising, voucher schemes are less commonly seen and are often implemented by non-governmental organisations (NGO) with funding from development partners.7
Purchasing from private providers through stand-alone CO and also CO-I interventions have been underway in EMR countries of Egypt,8 Iran,9 Pakistan,10 11 Jordan.12 CO of private providers under insurance schemes is underway in Lebanon,13 Tunisia,14 Sudan15 and Morocco,16 whereas CO as the primary intervention was seen mainly in Afghanistan.17
The WHO has urged EMR members that purchasing modalities from private providers should be effectively optimised towards UHC.18 An important starting point would be to gauge evidence from existing government purchasing programmes and identify evidence gaps that need to be addressed. We attempt to fill this knowledge gap by conducting a systematic review to assess the impact of CO and CO-I arrangements on service utilisation. The primary objective is to assess the quantitative impact on healthcare utilisation, with the secondary objective to assess relative impact on service utilisation impact for the poor. Whereas individual studies of purchasing interventions have been published from EMR countries, a regional impact synthesis has not been conducted and there is generally a dearth of regional reviews addressing EMR’s priorities.19 This synthesis of evidence is intended to serve as a preliminary analysis and supportive evidence for the WHO’s regional resolution on private sector engagement for advancing UHC.18 Our intent is not to judge whether CO is better than usual direct government delivery, but rather to assess whether government managed purchasing interventions have improved healthcare utilisation, consolidating what is known and highlighting evidence gaps for addressing within UHC strategies.
Methods
We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology for conducting the systematic review.20
Objectives
The objective of this systematic review was to assess government CO interventions involving private providers in terms of impact on health service utilisation. We focused our analysis on purchasing arrangements involving stand-alone CO and CO-I to deliver affordable health services. These arrangements are defined as following:
Types of interventions
We included studies comprising of purchasing arrangements involving CO and contracting under insurance schemes. All studies explicitly mentioned a formal agreement between the government and private providers (eg, private hospitals and clinics, individual family practitioners, private companies and NGOs) to deliver health services. Agreements specified the population, geographical area, time period, amount of government funding (full or co-financing) and management of the purchasing arrangement (with or without explicit targets).
Studies with demand side interventions such as vouchers, social marketing and social franchising were excluded from this review.
Stand-alone CO
CO involves government purchase of health services from private providers under a formal agreement specifying the population group, time period and funds.21 Under stand-alone contracting initiatives payment is made for a package of health services, often loosely specified in LMICs.22 Payment is usually made for a package of service, usually through block payments or capitation payments to contracted providers, Beneficiaries are the populations residing in catchments served by the health facilities. CO can take the form of service delivery and management contracts21—under service delivery contracts the government funds private providers to deliver services from private health facilities, while under management contracts private providers are paid to manage government facilities to deliver the required services.23
CO under insurance
Insurance is a system of financing that uses pooled funds to pay for health services specified by the insurance package by purchasing services from private providers, parastatal or government providers. Funds are managed by a third party insurance provider, beneficiaries are predefined and contracted providers are reimbursed for individual services used at health facilities by defined beneficiaries usually through fixed case rate payments.24
Pooled funds are used to purchase services from private health providers in addition to public health providers for a defined service package, defined beneficiaries and are managed by the government or an insurer working under the government. The scope of the review included non-universal voluntary insurance schemes as well as universal mandatory health insurance schemes, as long as these were wholly or substantially funded by the government.
Demand side purchasing schemes, such as vouchers,25 social marketing,26 social franchising,27 were excluded from the scope of review.
Private providers
The private health providers are defined as organisations and individuals that are neither owned nor directly controlled by the government and are involved in provision of health services.28 The focus of this review was on CO and CO under insurance interventions that wholly or substantially purchased services from private health providers and included hospitals, clinics, individual private practitioners, private companies and non-profit organisations.
Geographical boundaries
We restricted our study to purchasing programmes operating in LMICs as defined by the World Bank,2 in the EMR of the WHO.
Types of outcome measures
Evaluation of at least one of the selected outcomes indicators:
Primary outcomes
Service volume at health facilities for either general or specified health services.
Service utilisation population based: measured as visits made by individuals to health facilities for either general or specified health services over a given time period.
Secondary outcomes
Equitable utilisation of health services: measured as relative disparity in healthcare utilisation by socioeconomic status of individuals; urban–rural residence of individuals; education status of individuals.
Types of studies
The following study designs were considered for inclusion in the review:
Randomised controlled trials (RCTs) individual and cluster.
Non-randomised quasi experimental studies with clearly defined experimental and comparison groups.
Time series studies in which data are derived at least three times points (interrupted time series—ITS).
Before-and-after studies with a comparison/controlled before-and-after studies (CBA) to assess the effect of an intervention by comparing the outcomes prior to its use and after.
Cross-sectional correlational studies.
Endline studies with a control group.
We included studies focusing on clinical, promotive and preventive health services only. Studies on ancillary health services, dental services, commodity only provision were excluded from the analysis.
Time boundaries
We focused on recent data and restricted the search to evaluations published 2010 onwards till November 2021. Search was limited to evaluations published in English or availability of an English translation.
Types of participants
The participants included users and non-users of health facilities participating in CO or CO-I.
Types of outcomes
Primary outcome: health service utilisation
This refers to health service utilisation at population level. It was measured by the number of patient visits and the service volume at health facilities for general and specified services.
Secondary outcomes: equitable utilisation of health services
This refers to the relative disparity in health service utilisation based on individual’s socioeconomic background (ie, income, education, urban or rural residence).
Search methods
Published and grey literature was systematically searched to identify evaluations of government purchasing programmes that met definitions for contracting and insurance schemes.21 23 24 The search for eligible published studies was made in the following electronic databases: Cochrane Central Register of Controlled Trials in the Cochrane Library; PubMed; CINHAL; Google Scholar. In addition, we manually screened the reference list of included studies and relevant systematic reviews to capture relevant studies that may have not emerged in the electronic search.
The search for grey literature focused on published reports, unpublished reports and documents. A targeted search was conducted on the following databases and websites: World Bank Group, Global Index Medicus, Google web and the official Ministry of Health websites of countries in the EMR.
For inclusion eligibility, the evaluations had to meet the set of inclusion criteria for geography, type of intervention, study design, study participant, outcome measures. The search covered publications from 2010 up to the date of the final searches in November 2021. Detailed criteria are provided in online supplemental table S1.
Supplemental material
Our search strategies comprised a combination of MESH terms and free-text key terms that included “Government”, OR “Government Programs” OR “Public Sector”, AND “Contracting” OR “Contracting-out”, OR “Contracts”, OR “Service contracts”, OR “Primary care contracts”, OR “Hospital Contracts”, “OR “Concessional Arrangement”, OR “Public-Private Partnerships”, “OR “National Health Insurance”, OR “Social Health Insurance” OR “Government Health Insurance” Or “Insurance Program” AND “Private Sector” OR “Private providers” OR “ Family Practice” OR “Family Practice Models” AND (Iran OR Jordan OR Kuwait OR Lebanon OR Libya OR Syria OR Tunisia OR Afghanistan OR Djibouti OR Egypt OR Iraq OR Morocco OR Pakistan OR Somalia OR Sudan OR Yemen OR “Eastern Mediterranean Region” OR EMR OR “Mediterranean region” OR Mediterranean). Detailed search strings are provided in online supplemental table S2.
Study identification and extraction
Three reviewers (AA, FS and WJ) independently reviewed the title/abstracts of all identified studies using Covidence software.29 Studies found eligible were further assessed in duplicates using full texts. A senior reviewer (SZ) reviewed all the included studies and resolved any disagreements. A standardised data extraction sheet was used to derive the information by three researchers (AA, FS and WJ) including study design, geographical location, description and scale of initiative or scheme, details of type of service and providers, outcome data and study limitations.
Assessment of risk of bias
Two reviewers (JKD and FS) independently assessed the quality and risk of bias of each study. For RCTs, we used the Cochrane Risk of Bias tool,30 to judge as ‘high’, ‘low’, or ‘unclear’ risk of bias for randomisation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective reporting and other biases. For non RCTs, we used the Cochrane Effective Practice and Organisation of Care criteria,31 and studies were judged as ‘high’, ‘low’ or ‘unclear’ risk of bias for allocation sequence generation, allocation concealment, baseline outcome measurements, baseline characteristics, prevention of knowledge in allocated interventions, contamination, selective reporting and other biases.
Data analysis
Key characteristics of included studies were described in terms of the scale of implementation, beneficiaries and service providers. SZ, AA, WJ and FS narratively synthesised information on maternal and reproductive health, child health, outpatient and inpatient visits, and relative utilisation by disadvantaged groups and this was done in duplicate. For studies that reported outcomes of service utilisation in percentages (%); percentage difference was determined between preintervention and postintervention, and between intervention and control group by calculating the absolute value of difference between the percentages; whereas studies with results in means and SD, the mean difference (MD) was reported. Due to variation in reported outcomes and outcome measures, a meta-analysis could not be performed.
Patient and public involvement
There was no patient and public involvement in our study.
Results
We identified a total of 8197 deduplicate studies (8091 studies in published literature; 106 studies in the grey literature) through a comprehensive database search. Full texts of 128 studies were screened for eligibility (116 from published literature and 12 studies from grey literature). We excluded 101 full texts (67 wrong study design, 32 wrong interventions, 1 wrong setting and 1 wrong outcome). Studies that reported on larger health reforms without attributing effects to stand-alone CO or CO-I were excluded. A few evaluations were excluded as they composed of a summary but not the full paper. Finally, a total of 17 studies were included in our analysis (figure 1, online supplemental table S3).
PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Study designs
Out of 17 studies, 7 were ITS,32–38 4 were endline with comparison,39–42 3e cross-sectional correlational,43–45 2 were CBA46 47 and 1e was cluster RCT.48 Seven studies were conducted in Iran,32 34–39 four in Pakistan,33 40–42 three in Afghanistan46–48 and one each in Egypt, Tunisia and Jordan43–45 (table 1).
Study characteristics
Interventions
The 17 studies reported on 11 CO programmes across 7 countries—CO interventions from Iran, Pakistan, Afghanistan (9 studies), CO-I interventions from Egypt, Jordan and Tunisia (4 studies) and combination of CO and CO-I interventions from Iran (4 studies). Eight studies assessed interventions at national level, while nine at subnational level. Seven studies reported on purchasing arrangements involving NGOs, 10 studies on purchasing arrangements involving private hospitals and clinics (table 2).
Purchasing initiatives in regional LMICs
Outcomes
Nine studies reported on outpatient services, while four reported on hospitalisation and four reported both outpatient and hospitalisation services. Fifteen studies reported on primary outcome (utilisation), two reported on both primary and secondary outcomes, while two studies reported only secondary outcome.
Risk of bias
The only RCT had unclear risk for random sequence generation, blinding of outcome assessment, attrition bias and selective reporting. However, there was high risk for allocation concealment and blinding of participants and personnel. For other 14 quasi-randomised trials, 11 were at high risk for allocation concealment, while 3 were considered to have unclear risk. Two studies had similar baseline characteristics and were at low risk, while two studies were judged to be at high risk and 10 had insufficient information to permit judgement and, therefore, marked unclear risk. All studies had unclear risk of attrition bias, adequate prevention of knowledge and contamination between study groups. Low risk for selective reporting was noted in all studies (online supplemental figure S1).
CO only
Out of nine studies,32 33 39–42 46–48 four were based in Pakistan,33 40–42 three in Afghanistan46–48 and two in Iran.32 39 Our included studies contain a mix of study designs. Four Pakistan studies consisted of three endline with controls40–42 and one ITS.33 Three Afghanistan studies consisted of two CBAs46 47 and one cluster RCT.48 And two Iran studies consisted of one endline with comparison39 and ITS each.32
Primary outcome
Outpatient visits
We included five studies that reported on outpatient visits.33 39–41 46 Out of them, three were based in Pakistan and found no significant difference between Primary Healthcare Initiati (PPHI) contracted and non-contracted facilities for general outpatient visits. This trend was observed at national and facility level.33 40 However, one study favoured provincial contracting and reported higher general, female and child (<5 years) outpatient visits at contracted facilities compared with those at non-contracted facilities.41 Only one study each was included from Afghanistan and Iran. In Afghanistan, the study noted significantly higher general, female and child (<5 years) outpatient visits at contracted facilities compared with those at non-contracted facilities.46 Similarly, in Iran, higher outpatient visits were noted in the contracted cooperative health centres (CHCs) compared with the non-contracted public health centres (PHCs).39 The results need to be interpreted with caution due to limited studies, lack of matched controls and minimal assessment of outpatient visits at population level.
Maternal and reproductive health
We included six studies that reported on maternity care and/or reproductive health.32 39–42 49 Out of them, three focused on maternity care,31 41 47 one on reproductive health38 and two reported both.40 41 Mixed results were noted in the included studies. Three studies were based in Pakistan,40–42 and found that antenatal care (ANC) and deliveries are higher in national PPHI, provincial and district contracted facilities compared with those that are non-contracted.20–42 However, the use of family planning services remained low in both contracted and non-contracted facilities.40–42 Study based in Iran showed higher utilisation of laboratory and ultrasounds tests during pregnancy in contracted facilities.32 Pap smear screening also increased in contracted CHCs compared with the non-contracted PHCs.39 However, one study reported a potential decline in ANC visits within contracted facilities in Iran.32 In addition, one study from Afghanistan showed no significant difference between contracted and non-contracted facilities in terms of ANC and postnatal care visits (PNC).48
Child health
We included four studies that reported on child health.33 40 41 48 Out of the three studies based in Pakistan, one found no significant change in the treatment of childhood diarrhoea between national PPHI contracted and non-contracted facilities.33 Two studies reported on immunisation volumes. One study reported a decline in immunisation under national PPHI,40 while the other reported a minimal change in immunisation between contracted and non-contracted facilities under provincial contracting.41 One study from Afghanistan compared the impact of a Pay for Performance (P4P) scheme overlaid on contracting payments. Introduction of P4P arrangement in contracted facilities did not result in increase in maternal and child service utilisation at contracted health facilities supported by P4P as compared with contracted health facilities that did not have a P4P arrangement.48 This was attributed to poor understanding of P4P by the recipient staff and potential demand side barriers in accessing services (table 3).
Outcome of contracting studies
Secondary outcome
We included three studies that reported on equitable utilisation of health services. Out of them, two were based in Afghanistan and found that low socioeconomic households had higher odds of attending contracted health facilities,47 and were more likely to have higher outpatient visits for new cases.46 One study from Pakistan noted marginally higher utilisation by the poor for childhood diarrhoea, but no significant change for general outpatient visits33 (table 3).
CO under insurance
Out of three studies, one study was conducted in each of Egypt, Tunisia and Jordan.43–45 All of them were cross-sectional correlational studies.
Primary outcome
Outpatient and inpatient visits
We included two studies that reported on outpatient visits in Tunisia and Jordan.44 45 The study from Tunisia assessed the effect of two insurance schemes, formal Mandatory Health Insurance and state subsidised (MAS) insurance, on the utilisation of outpatient and inpatient visits.44 The study reported an increase in outpatient and inpatient among the insured population compared with the uninsured. However, significant variations in the effect of these schemes were observed across services and areas.44 In addition, the study from Jordan also reported that the mean number of outpatient visits increased over time in the insured population compared with the uninsured.45
Maternal and child health
One study reported on maternal and child health in Egypt.43 The study noted a marginal increase in the utilisation of maternity services (such as ANC, PNC and facility births) in the insured population compared with the uninsured. However, a decline was noted in the rate of newborn check-up among the insured population over non-insured.
Secondary outcome
We included one study that reported on the equitable utilisation of health services in Tunisia.44 The study assessed utilisation differentials for the disadvantaged by analysing hospitalisation among urban insured versus rural insured populations.44 Mean annual number of consultations and hospitalisation days is higher in insured versus uninsured populations (table 4).
Outcome of contracting out under insurance studies
Combined CO and insurance
All the five studies were based in Iran and were ITS. All studies reported on the combined effect of CO and insurance of primary healthcare on inpatient admissions.34–38 The studies were conducted in rural and urban settings. Three studies were from a rural setting and reported an increase in annual inpatient hospitalisation rates among the hospital insured population covered also by family practitioner contracts compared with a population only covered by hospital insurance.35–37 Two studies were from an urban setting and reported a decline in volume of inpatient admission in hospitals serving insured populations covered by family practice schemes compared with populations only covered by hospital insurance34 38 (table 4).
The utilisation of health services by socioeconomic class was not reported in these studies.
Discussion
The review synthesised regional evidence on utilisation of government managed purchasing interventions of CO and CO-I mechanisms that provide subsidised or free services to a greater extent from private providers. Despite a proliferation in domestically driven purchasing interventions a regional synthesis had not been undertaken, hence we set out to provide an EMR perspective, consolidate what is known and underscore evidence gaps to contribute preliminary lessons to support the current regional policy thrust on private provider engagement for UHC 2030.
The review highlights several initiatives by country governments that involved purchase of private sector providers to deliver health services in EMR, although few have been scientifically published and even fewer met the criteria for the review. Purchasing initiatives not included in the review are provided in online supplemental table S4. Seventeen studies,32–48 inclusive of 15 published articles and 2 grey literature reports, met the criteria for the systematic review assessment, eligible studies were confined to only 6 regional countries—Afghanistan, Pakistan, Iran, Egypt, Tunisia and Jordan—whereas eligible literature was not reported from other regional states. The evidence reviewed composed of nine studies involving CO stand-alone interventions,32 33 39–42 46–48 three studies on CO-I43–45 and five studies on combined CO-I.34–38
Impact on outpatient curative care utilisation is largely seen as a result of both CO and CO-I interventions. There is indicative positive evidence of improved maternity care service volumes mainly from CO interventions and less reported from CO-I interventions. Data on child health service volume are thin and indicate a negative impact on service volumes, whereas data on reproductive health services are scanty and inconclusive. Despite unfavourable estimates for child vaccination, a meaningful conclusion cannot be drawn as these could be due to demand-side constrains rather a decrease in utilisation. Supplementing insurance with primary care contracting out was reported by three studies with increased hospital utilisation in rural areas and decreased hospital use in urban setting. Evaluation metrics from studies did not provide standardised indicators across purchasing interventions to allow for meta-analysis of pooled data. Overall, we found stronger evidence on utilisation impact for stand-alone CO initiatives and weaker evidence for CO-I initiatives.
Demonstration of relative utilisation by the poor or disadvantaged was limited to four studies—three studies of CO interventions showed positive utilisation in the poor while the only study from CO-I showed higher utilisation in urban insured versus rural insured beneficiaries Although specific measurements for the poor versus non-poor are limited, suggestive pro-poor effects can be inferred for stand-alone CO initiatives as utilisation took place in disadvantaged settings. There is scanty pro-poor evidence for insurance interventions.
Global systematic reviews of CO stand-alone interventions in LMICs show moderate to weak evidence of improved utilisation,49 50 whereas less restricted reviews by Liu et al and Loevinsohn,23 51 similarly noted a positive utilisation effect. Moreover, with respect to insurance schemes, a global review by Acharya et al52 notes dearth of evidence on improved utilisation and relative utilisation by the poor remains weak, whereas review by Erlangga et al53 shows improvement in utilisation of curative care but an unclear effect on preventive care.
There are limitations that are worth identifying. To minimise publication bias, a comprehensive search including grey literature was conducted, although not exhaustive since we restricted our search to sources that were accessible electronically. The grey literature included facility assessment reports. Some purchasing initiatives might have been missed due to lack of scientific evaluations and reporting. Evidence is heterogeneous as outcomes reported lack consistency of indicators. We do not know if improved utilisation, when seen, is reflective of increased service coverage or simply a shift from other providers. Quality of services has not been examined and could be an important predictor of utilisation. We assumed service utilisation took place at no or nominal payment by beneficiaries and did not assess changes in out-of-pocket expenditure at point of utilisation. Lastly, the context is likely to have a strong influence on both the manner of implementation and success of intervention and, therefore, any generalisation should be undertaken with caution.
This is the first regional systematic review, to our knowledge, to assess the impact of CO purchasing arrangements on service utilisation in the EMR, making it an important contribution to the field. Importantly, the contracting interventions were not confined to fragile states and humanitarian contexts as often reported from global reviews, but implemented in middle income and LMICs during periods of political stability and predominantly with domestic financing. The emerging lessons are hence contextually more translatable for action planning by EMR states for effective service utilisation and targeting benefits towards the poor.
The review provides a preliminary analysis and supportive evidence for WHO regional resolution on private sector engagement for advancing UHC.18 There are three important lessons for policy makers in the EMR. First, technical assistance and resourcing for measurement of effects should be embedded within purchasing initiatives to provide adaptive lesson learning, redesign and course correction. Second, impact on outpatient curative care utilisation is largely demonstrated but formative work is required on how other health services can be more effectively tied to curative care volumes. Third, insurance schemes need disaggregated comparative measurement on service utilisation at private providers versus public sector to inform choice of contracted-out providers. Future research would benefit by a complementing realist review,54 on why CO and CO-I interventions worked or did not work when applied in different contextual settings, by examining purchasing modalities as well as key determinants related to provider readiness and patient preferences.
Conclusion
Despite proliferation of domestically funded large scale initiatives in the EMR involving contracting of private providers for affordable health access there has been an evidence gap of systematic regional synthesis of impact. Purchasing involving stand-alone CO interventions and CO-I interventions in the EMR positively impact general curative care utilisation, suggested positive impact on various indicators of maternity care but scant evidence on other services. Policy attention is needed for embedded evaluations within programmes to inform design changes for achieving greater breadth in service utilisation, support for standardised outcome metrics, as well as more disaggregated utilisation data by private providers.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @AwadMATARIA
Contributors SZ was responsible for the overall content of the paper. SZdesigned the study with HS, AM; AA, WJ and FS carried out the online search, initial review and extraction; SZ and JKD carried out the second review of papers and crafted the analysis, AT and HS contributed contextual material from the region and technical insights, SZ, JKD, WJ, AA, FS, HS, AT and AM contributed to drafts of the paper and reviews. All authors have read and approved the submitted paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Disclaimer The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.