Government purchasing initiatives involving private providers in the Eastern Mediterranean Region: a systematic review of impact on health service utilisation

Shehla Zaidi, Jai K. Das, Wafa Jamal, Ammarah Ali, Faareha Siddiqui, Aya Thabet, Hassan Salah, Awad Mataria

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1 Citation (Scopus)


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.

Original languageEnglish
Article numbere063327
JournalBMJ Open
Issue number2
Publication statusPublished - 22 Feb 2023


  • health policy
  • human resource management
  • public health
  • quality in health care


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