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Summary box
Many African countries have adopted UHC as a goal, but progress has been slow in translating these goals into equitable and quality health services. The ALM Declaration by the African Union aims to enhance cooperation between the public and private sectors to achieve UHC and health security.
Governmental difficulties in engaging the private sector arise from ineffective governance and regulatory arrangements. The lack of comprehensive data on the private health sector and a historical focus on specific diseases rather than a holistic health systems approach contribute to this challenge
A shift in mindset is needed, viewing the private health sector as a co-investor and thought partner in health systems, formalizing relationships, creating regulatory certainty, and repositioning people as central to public-private engagement in health policy.
Introduction
Most African countries have adopted universal health coverage (UHC) as a goal in their national health policies. Yet, progress in translating goals into equitable and quality health services, and increased financial protection, has been slow. The African Union’s (AU) ‘Addis Ababa Commitment toward Shared Responsibility and Global Solidarity for Increased Health Financing Declaration’1—also known as the ALM Declaration—seeks to galvanise greater cooperation between the public and private sectors for delivering equitable health for all, and to safeguard health security.
Greater cooperation necessitates greater understanding of the characteristics and contributions of the private sector to healthcare.2 However, many governments are ill-equipped to engage the private sector because their existing governance and regulatory arrangements are not designed to effectively manage and coordinate pluralist health systems.3 The limited evidence on the costs and impacts of private sector engagement (PSE)4 may also contribute to engagement inertia. While previous work on PSE has largely been vertically driven, often focused on specific diseases or conditions, a health systems approach is needed. This needs to be led by government and cannot be delegated to partners.3
This ambition aligns with the 2020 WHO strategy on ‘Engaging the private health service delivery sector through governance in mixed health systems’.2 The strategy redresses a critical health system governance gap for the effective engagement of the private sector in health in the context of UHC.
To better understand approaches to engagement, and governance of the private sector in health in their regions, the WHO Eastern Mediterranean and African regional offices undertook a joint landscaping analysis.3 The qualitative study was conducted between December 2020 and May 2021 and entailed key informant interviews, supplemented by desk review of relevant literature. The landscaping had a secondary aim of contextualising the governance behaviours outlined in the WHO strategy. In this commentary, we highlight key findings from this publication.
Align structures
Government recognises all state and non-state entities and resources in the health system and works to harness and coordinate those to achieve policy objectives.
The public sector is typically well structured; however, its very delineation may create disconnects for PSE. While there is recognition of fragmentation within the private sector, a similar lens has not been used with the public sector. There is also reportedly mixed appetite in countries for honest reflection on the role of the private, for-profit sector in healthcare service delivery or its relationship with the public sector. As such, country demand for aligning structures varies across and within the African region and between countries.
Build understanding
Government facilitates information gathering and sharing about all elements of service provision in the health system.
Given the heterogeneity of the private sector in health, it is difficult to capture its composition and contributions to healthcare.5 To overcome this constraint, private sector assessments have been conducted in many contexts, often supported by external agencies. More routine sources of data exist but are often not comprehensive, and in many contexts, do not incorporate data from the private sector.4 Further, data are not used for information exchange between sectors. As affirmed through the landscaping, there remains a data lacuna between the public and private sectors, despite both sectors having large reservoirs of data.
Foster relations
Government establishes mechanisms that allow all the relevant stakeholders to participate in policymaking and planning.
The landscaping established that demand for public–private dialogue mechanisms remains high within the African context. As affirmed, dialogue has often lagged behind efforts to build understanding through private sector assessments and other guidance. Healthcare federations have emerged on the health landscape and have assumed a central interlocutor function; however, they may not reflect the evolution and diversity of the private sector.6
Enable stakeholders
Government authorises and incentivises health system stakeholders to align their activities and further leverage their capacities, for national health goals.
The landscaping focused on two key policy instruments: regulation and contracting. While regulation was viewed as a key tool for health service accountability,7 there were challenges cited of too much and too little regulation, which, in both instances, limit private sector participation in health system goals.8 There was recognition that government needs to understand the sector they are trying to regulate to improve compliance. Contracting was also a widely cited tool for engaging the private sector in health systems goals; however, capacity to engage in formal contracts varied and challenges remained. These included a continued lack of trust between the sectors and procedural issues, such as delays in reimbursement and limited capacity to contract.
Nurture trust
Government leads the establishment of transparent, accountable and inclusive institutions at all levels to build trust.
A key lever in accountability, the consumer, is not leveraged in many African contexts. Trust is needed between public and private entities to nurture consumer trust in the health system.9 A lack of regular dialogue was found to hinder trust between sectors despite the existence of formal structures. This reportedly pushed issues to implementation which further deepened mistrust over time. Given the lack of constancy in engagement and entrenched mistrust, there was recognition of the need for additional intervention through intermediaries.
Deliver strategy
Government establishes the priorities, principles and values for the health system, and works out how to translate these priorities, principles and values into practice.
The review showed that most countries have inclusive health strategies that define roles for the private sector in health. This has mainly focused on ‘legacy’ structures with the faith-based sector and less on private-for-profit health entities. Strategies are often not monitored or evaluated (or implemented in some contexts).
Considerations
The landscaping study affirmed the range of private sector actors engaged in health service delivery in Africa. While their diversity and attraction—their drawing power—has evolved over time, public sector structures have remained relatively static. More attention has been paid to reducing atomisation of the private sector, with less attention to fragmentation within the public sector, particularly in devolved healthcare delivery contexts, and the limitations this poses to PSE. The findings further affirmed the importance of intermediary roles in supporting member states to more effectively engage the private sector in health. This includes building from existing initiatives such as efforts to address regulation at a continental and regional level. The findings also affirmed the importance of robust governance of the whole health system. This is good for both the private and public sectors, but most importantly, people.
Considerations are provided to build more inclusive and effective governance of the health system as a whole, underpinned by robust monitoring, evaluation, learning and knowledge management.
Private sector as co-creator and thought partner
Recognise the breadth of the private sector and the myriad roles it plays in health systems. These encompass both formal and informal actors ranging from drug shops to specialised hospitals, comprising both for-profit and non-profit entities, domestic and foreign. Increasingly, non-traditional health actors are also part of service delivery and may include global commercial brands, banks, logistics and tech companies. All should be held accountable to improve or maintain health outcomes and avoid unnecessary or ineffective care.
Shift mindsets to private sector as a co-investor and thought partner in health systems. This mindset shift is needed at different levels of the health system and along the healthcare value chain. While traditionally the private sector has been viewed as a source of financing to be tapped, particularly in light of contracting donor resources in many African contexts, governments should reorient their outlook to one of knowledge exchange and co-creation with the private sector as a means of unlocking innovation and advancing health system maturity.
Government as orchestrator and modulator of the private sector
To instil greater accountability between sectors, there is need to formalise and organise sectoral engagement. Atomised relationships between and within the public and private sectors divide up accountability relationships and loosen accountability chains. There is greater need to formalise relationships with the private sector so that they can be onboarded into health reforms and policy implementation. A more coherent and organised ‘whole sector’ approach should be taken to PSE.
Create greater regulatory certainty for the private sector in regional and national health systems. This should strike a balance between too much and too little regulation so that private sector participation in health system goals is facilitated. Regional approaches to regulatory system strengthening for some aspects of the healthcare value chain, such as medicines, have shown promise and could be extended to other areas, such as vaccine development. Private sector perspective should be solicited as part of regulation. In general, greater digitisation of regulatory processes is recommended to improve transparency and compliance.
People at the centre of health systems
People should be repositioned as central to PSE in public policy. The efforts of both sectors should establish a foundation of trust between people and the health system, irrespective of point of care. Government should set standards that provide a compelling vision and ‘rules of engagement’ for all actors for more responsive, resilient and equitable health systems. Where the public sector has pursued private sector initiatives, the rationale has not always been that of equity. This needs to remain a primary objective of public policy and PSE.
Reinforce roles and peer engagement
Reinforce the role of professional associations in PSE in public policy. As the landscaping attested, associations are a ubiquitous and often underused resource in PSE in many African contexts. They can be more deliberately engaged and supported to work with the public sector to develop and institutionalise conventions, norms, behaviours and ethics within health systems.
Reinforce good practice to build effective PSE and promote peer learning. There is opportunity to learn from practice and reinforce good practice. A number of regional bodies and initiatives can be harnessed for this purpose, including WHO regional offices, the AU regional economic communities and the Africa Healthcare Federation among others. Cataloguing and coordinating these initiatives are important to ensure coherent technical and political support that meets the needs of countries in their engagements. There was demand expressed through the landscaping for more regional dialogue, greater emphasis on collective work and the establishment of a learning platform.
Frame engagement and ground this in data and evidence
Build governance behaviours for PSE in health systems strengthening and public policy. The landscaping highlighted the human element of public and private engagement and its vagaries. While individual countries have taken different stances on engaging the private sector in health, there was overarching recognition of the need for improved governance, grounded in data and evidence. These sentiments resonate with the recently launched WHO strategy, ‘Engaging the private health service delivery sector through governance in mixed health systems’.
Conclusions
The private sector can be a valuable partner in achieving UHC if effectively governed. The study highlights the need for better governance to align private sector strategies with government goals for UHC. While attention has been focused on reducing fragmentation in the private sector, there is a call to address similar challenges within the public sector to enhance private sector engagement in public policy. This study emphasizes the evolving diversity of private sector actors in health service delivery in Africa and underscores the role of intermediaries in facilitating effective engagement. It also stresses the importance of robust governance for the entire health system, benefiting both private and public sectors, and ultimately improving population health. In times of crisis, collaborative approaches that prioritize the ‘public’ at the core of health systems and public-private engagement are essential.
Data availability statement
All data relevant to the study are included in the article.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Correction notice This article has been corrected since it published online to reflect the correct order of authors.
Contributors All authors contributed to the concept and development of the commentary. GA wrote the first draft, and all authors reviewed the commentary and made substantial contributions to revisions. All authors reviewed and approved the final version.
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 author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
Author note The landscaping report can be found https://www.who.int/publications/i/item/9789240047273. Towards better engagement of the private sector in health service delivery: a review of approaches to private sector engagement in Africa. Geneva: World Health Organization; 2022. Licence: CC BY-NC-SA 3.0 IGO. This includes the methodology and the ethics information.