Comparative performance of public and private sector delivery of BCG vaccination: Evidence from Sub-Saharan Africa

Background

The private sector is an important source of health care in the developing world. However, there is limited evidence on how private providers compare to public providers, particularly for preventive services such as immunizations. We used data from Sub-Saharan Africa (SSA) to assess public–private differences in Bacillus Calmette–Guérin (BCG) vaccine delivery.

Methods and findings

We used demographic and health surveys from 102,629 children aged 0–59 months from 29 countries across SSA to measure differences in BCG status for children born at private versus public health facilities (BCG is recommended at birth). We used a probit model to estimate public–private differences in BCG delivery, while controlling for key confounders. Next, we estimated how differences in BCG status evolved over time for children born at private versus public facilities. Finally, we estimated heterogeneity in public–private differences based on wealth and rural–urban residency. We found that children born at a private facility were 7.1 percentage points less likely to receive BCG vaccine in the same month as birth than children born at a public facility (95% CI 6.3–8.0; p < 0.001). Most of this difference was driven by for-profit private providers (as opposed to NGOs) where the BCG provision rate was 10.0 percentage points less than public providers (95% CI 9.0–11.2; p < 0.001) compared to only 2.4 percentage points for NGOs (95% CI 1.0–3. 8; p < 0.01). Moreover, children born at private for-profit facilities remained less likely to be vaccinated up to 59 months after birth. Finally, public–private differences were more pronounced for poorer children and children in rural areas.

Conclusions

The for-profit private sector performed substantially worse than the public sector in providing BCG vaccine to newborns, resulting in a longer duration of vulnerability to tuberculosis. This disparity was greater for poorer children and children in rural areas.