This conclusion, from a review by Paul Garner from the Liverpool School of Tropical Medicine, Liverpool, UK and colleagues and published in this week's PLoS Medicine, stresses the pressing need for national governments to find and implement effective strategies to improve the quality of healthcare provided in both sectors in order to improve health outcomes in low and middle income countries.

In their review, the authors systematically identified, summarized, and scored the results of studies that directly compared the quality of outpatient care in low and middle income countries offered by public providers with the care offered by ''formal'' private providers (recognized by law) and ''informal'' private providers (providers that are not legally recognized, such as shopkeepers).

The authors found that overall many services, irrespective of whether public or private, scored low (less than 50%) on infrastructure, clinical competence, and practice. Generally, the formal private sector performed better in relation to drug supply, responsiveness, and effort, but there was no detectable difference between health provider groups for patient satisfaction.

The authors put their findings in context: "Many efforts to improve the quality of ambulatory care are restricted to the public sector on the grounds that public funds should be reserved for the public sector because that is where the poor turn for their health care. But concentrating on the public sector misses a large proportion, the majority in some cases, of the providers used by the poor."

They continue: "Raising the quality of care delivered by private, as well as public, providers would, in fact, be a pro-poor intervention as it would improve the effectiveness of the money the poor spend on health care."

In an accompanying Perspective article, Jishnu Das (uninvolved in the research) from the World Bank and the Centre for Policy Research, New Delhi, India says: "The review reflects a logical initial focus in the literature on individual providers rather than the interactions between providers; going forward, broadening the discussion on quality to health care markets can generate valuable insights for policy."

He continues: "Such market-level analysis can help answer policy questions ranging from regulatory issues to the trade-off between access and quality."

Funding: This research was funded by the UK Department for International Development for the benefit of the poor in developing countries.

Note: If no author is given, the source is cited instead.

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