Differences in performance of public and private providers of ophthalmology services globally: a systematic review

Background and aims The optimal ownership model for delivering ophthalmology services remains contested across healthcare systems. This systematic review aims to synthesise primary empirical evidence comparing the performance of public and private ophthalmology providers across five domains: clinical outcomes, patient safety, responsiveness and experience, efficiency and resource use, and equity. Methods We systematically searched MEDLINE (Ovid), Embase (Ovid) and EconLit (EBSCOhost) from 1 January 2000 to 17 June 2025, with an updated search to 3 May 2026, supplemented by reference lists and Google Scholar. Primary empirical studies directly comparing performance between public and private ophthalmology providers across our five domains were included, appraised for methodological quality and synthesised narratively. Results 27 studies met the inclusion criteria: 21 from high-income countries, including the USA, UK, Canada, Denmark, the Netherlands, Austria, Australia and New Zealand, and six from low- and middle-income settings, including Lebanon, Nigeria, Bangladesh, Brazil, Malaysia and South Africa. Clinical outcomes were broadly comparable between public and private providers, and where differences in clinical outcomes or patient safety existed, studies often attributed these to differences in case-mix or data completeness. Private providers were associated with shorter waiting times and higher procedural volumes but more often treated patients with lower clinical complexity and were disproportionately located in wealthier regions. Private-equity acquisition was associated with higher volumes of routine surgery, reduced provision of complex retinal surgery and greater use of optometrists to expand capacity. Conclusions Ownership was most clearly associated with differences in efficiency, responsiveness and equity of access rather than in the clinical quality of care. Further research is needed from low- and middle-income settings, where the relationship between ownership and performance may differ substantially. PROSPERO registration number CRD420261298831.