Data-driven governance and the private sector in mixed health systems

This study investigated the barriers and facilitators for psychiatrists in managing mental health patients under a Chinese context and a mixed private-public health system. Two focus group interviews were conducted to explore the in-depth opinions of psychiatrists in Hong Kong. The themes identified from the focus groups were investigated in a questionnaire survey with data from 83 psychiatrists working in public and private sectors. No insurance coverage of mental health problems, patients' poor compliance of medication, and stigma of seeing psychiatrists were rated as the top barriers in the survey. Some psychiatrists mentioned in focus groups that they might write down the associated physical symptoms of the patients rather than the mental disorder diagnoses on the medical certificate. They observed some patients suspecting that psychiatric drugs were prescribed to control their behavior and make them more muddleheaded. The survey also found that consultation time constraint, long patient waiting list, and difficulty in discharging patients to primary care mostly affected public psychiatrists rather than private ones. However, they perceived similar facilitators, including public campaign to promote positive results of help-seeking, adequate explanation by other health professionals to the patients before referrals, handling severe cases by casework approach, and having a regular primary care physician. The top barriers are related to insufficient public awareness and negative attitudes towards mental illness and its treatment. Major solutions include promoting positive results of help seeking, enhancing collaboration with primary care physicians, and follow-up of severe cases by a casework approach.

Purpose: Bihar is one of the resource-constrained state in India. Health systems in Bihar is mixed and complex. Majority of people access health care from the private sector, although the cost is much higher. State government is trying to regulate the private sector by bringing policies aimed mainly at administrative control and barely at market harnessing methods. First regulatory policy was enacted in the year 2010 but couldn’t be implemented. Later, state government adopted the central act “The Clinical Establishment Act (CEA) in the year 2013. But, no private health facility could be registered, hence they continue to be unregulated. We adopted case study approach to understand successful regulatory framework and make recommendations for the Government of Bihar. Focus/Contents: Constitutional provisions in India mandates improvement in public health, nutritional status and right to life for all citizen as a responsibility of government. The health issue is under the jurisdiction of state government. Due to unregulated proliferation of mixed health systems, high inequity in access and low quality of care is most important challenge. Many factors contribute to this challenge, these are; limited role of government as steward, insufficient institutional arrangements, lack of motivation, the dominant role of doctors and professional associations in the overall political economy. All other countries, where regulation is successful have robust institutions, which is decentralized. All other states of India, where regulation is successfully used innovative approaches and harnessed technology to advance the implementation of legislation. Based on this review, we recommended the possible approach towards larger stewardship role of government in Bihar. The approach can be: a). The government must continue to focus on strengthening public health systems and b). Government must start regulating the private sector. Identified next steps were: Policy analysis of CEA, mapping of the private sector in health care, engaging the stakeholders, and policy mapping to explore options to constructively engage the private sector. Significance for sub-theme area /field building dimensions: We adopted this unique strategy for motivating and developing the capacity of local government for ensuring effective regulation. Co-planning with state-level policymakers was done by rounds of meeting to identify steps for future research and policy action. Co-designing of research focus with policymakers turned out to be suitable health policy and systems research approach for complex issues. Target audience: The target audience for this study was the department of health in the state of Bihar. Approach to build stewardship capacity can be replicated in other similar settings.

We designed a model for hospital selection and patient transport in the emergency medical system. The model integrates the criterium of insurance coverage, seldom used in the literature and the usual criteria such as care capacities, congestion and proximity, typical of countries with mixed health systems (public-private). In addition, the model considered the travel and waiting times in emergency departments as performance measures in different time slots and days of the week. We developed and implemented a prototype in the Python programming language connecting to web services from Google Maps API (Directions, Maps JavaScript) to support the decision-making process in real-time and tested its performance. This research study validated the model with actual data from events managed by the emergency medical system in a Colombian city. We used Monte Carlo simulation to predict the current and proposed models’ travel and transfer time (travel time + waiting time). The simulation results indicate that the proposed model, which considers insurance coverage, emergency departments capacities, congestion and proximity, has a lower probability of putting at risk the lives of critically ill patients. In addition, non-critical patient satisfaction increases as wait times decrease.

Can Cyprus overcome its health-care challenges?

Governments in low- and middle-income countries increasingly recognize their role as stewards of mixed health systems comprising both public and private actors, but policy often lacks a nuanced understanding of how individuals switch between these two sectors for their healthcare needs, especially for family planning (FP) and maternal, newborn and child health (MNCH). In this cross-sectional study, we used data collected by The Demographic and Health Surveys Program between 2014-2021 from eight countries (Afghanistan, India, Indonesia, Kenya, Malawi, Nigeria, Pakistan, and Uganda) to describe service and sector use among women with a recent birth, a need for FP, and a child under five years old experiencing an illness (N = 53,014). We applied multivariable logistic regressions in each country to test the associations first between sector for birth and missed opportunities for contraceptives or sick child care, and next, between sector use dynamics between birth and contraceptive use (sector fidelity, sector switching, or nonuse of services) and nonuse of sick child care. Sector at facility for birth and sector switching between services was common, but neither were generally associated with missed opportunities for care for sick children. However, private sector use at birth predicted nonuse of contraceptives in four countries, though the directionality varied. Consistently, women who did not access care at birth and contraception had significantly greater odds of missing care for sick children. Notably, in Malawi, the adjusted odds ratio of missed sick child care among those with nonuse of care for birth or contraceptives was 2.5 times that of those with sector fidelity (95% Confidence Interval: 1.43-4.22). These findings underscore the need for health system stewards to closely consider both the public and private sectors in health governance. Greater cross-sectoral cooperation and continuity of care is paramount to improving health outcomes.

Background: Public-private partnerships (PPPs) in global health are increasingly common to support sustainable development and strengthen health systems in low- and middle-income countries. Since the release of the Sustainable Development Goals (SDGs) in 2015 culminating in a discrete goal "to revitalize the global partnership for sustainable development," public health scholars have sought to understand what makes PPPs successful in different contexts. While trust has long been identified as a key component of successful strategic alliances in the private sector, less is known about how trust emerges between public- and private- sector partners, particularly in global health. Therefore, we investigated how trust between partners evolved in the context of Project Last Mile (PLM), a global health partnership that translates the business acumen of The Coca-Cola Company to strengthen public health systems across Africa.Methods: This study draws upon secondary analysis of qualitative data generated as part of the longitudinal, mixed-methods evaluation of PLM across country settings. Seventy-seven interviews with a purposeful sample of key stakeholders were conducted in Mozambique, South Africa and eSwatini between August 2016 and July 2018. Trained qualitative interviewers followed a standard discussion guide, and audio-recorded interviews with participants’ consent. In this secondary analysis, we analyzed qualitative data to understand how trust between partners was cultivated across settings.Results: We drew upon stakeholder experiences to inform an inductive framework for how trust develops over time. Our analysis revealed five domains that were foundational to building trust: (1) reputational context, (2) team composition, (3) tangible outputs, (4) shared values, and (5) effective communication. Conclusion: The framework may be useful for private and public sector entities seeking to establish and sustain trust within their global health partnerships.

Partnership and fragmentation in international health: threat or opportunity?

Despite recent efforts in Ethiopia to increase health coverage, underutilization of both public and private sectors—the two main sources of formal healthcare—continues. This study gathered ethnographic interviews from 50 patients and 25 healthcare providers and observations of 7 public and private sector hospitals in Addis Ababa, Ethiopia, to identify causes of public and private healthcare underutilization. Analysis of patient and provider narratives revealed patterned itineraries of underutilization, and clear differences in service delivery and quality between the private and public sectors. Both sectors face accessibility issues that negatively affect patient and provider experiences. Public hospitals are congested and underfunded, private hospitals are understaffed and expensive, and both sectors experience constant shortages of medical equipment and drug stocks. The complexity and gaps in the current healthcare system leave healthcare providers overburdened and patients feeling neglected, uncertain, and frustrated. Health-seeker trajectories in Ethiopia’s medically-plural system are characterized by prolonged searches and costly treatment dead ends without any healing or end to suffering; ultimately, this results in complete hopelessness. A conceptual framework is proposed to explain why the quest for healing generates hopelessness for both health seekers and providers. While providers combat hopelessness with referrals to other sites of care, health seekers navigate the precarity of the health system through an economy of affection - a wide range of community relationships of mutuality, and collectivity. This labor has fostered development of third spaces for community organizing and spiritual enlightenment, where suffering is addressed, healing occurs and lost hope is regenerated.

BackgroundGlobally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.MethodsA systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).ResultsWe identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.ConclusionGiven the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.Trial registrationPROSPERO registration number CRD42022340059.

BackgroundThe prevalence of type 2 diabetes is increasing at an alarming rate in developing countries. However, glycaemia control remains suboptimal and insulin use is low. One important barrier is the lack of an efficient and effective insulin initiation delivery approach. This study aimed to document the strategies used and proposed by healthcare professionals to improve insulin initiation in the Malaysian dual-sector (public–private) health system.MethodsIn depth interviews and focus group discussions were conducted in Klang Valley and Seremban, Malaysia in 2010–11. Healthcare professionals consisting of general practitioners (n = 11), medical officers (n = 8), diabetes educators (n = 3), government policy makers (n = 4), family medicine specialists (n = 10) and endocrinologists (n = 2) were interviewed. We used a topic guide to facilitate the interviews, which were audio recorded, transcribed verbatim and analysed using a thematic approach.ResultsThree main themes emerged from the interviews. Firstly, there was a lack of collaboration between the private and public sectors in diabetes care. The general practitioners in the private sector proposed an integrated system for them to refer patients to the public health services for insulin initiation programmes. There could be shared care between the two sectors and this would reduce the disproportionately heavy workload at the public sector. Secondly, besides the support from the government health authority, the healthcare professionals wanted greater involvement of non-government organisations, media and pharmaceutical industry in facilitating insulin initiation in both the public and private sectors. The support included: training of healthcare professionals; developing and disseminating patient education materials; service provision by diabetes education teams; organising programmes for patients’ peer group sessions; increasing awareness and demystifying insulin via public campaigns; and subsidising glucose monitoring equipment. Finally, the healthcare professionals proposed the establishment of multidisciplinary teams as a strategy to increase the rate of insulin initiation. Having team members from different ethnic backgrounds would help to overcome language and cultural differences when communicating with patients.ConclusionThe challenges faced by a dual-sector health system in delivering insulin initiation may be addressed by greater collaborations between the private and public sectors and governmental and non-government organisations, and among different healthcare professionals.

The private provision of health services in Vietnam was legalized in 1989 as one of the country's means to mobilize resources and improve efficiency in the health system. Ten years after its legalization, the private sector has widely expanded its activities and become an important provider of health services for the Vietnamese people. However, little is known about its contribution to the overall objectives of the health system in Vietnam. This paper assesses the role of the private health care provider by examining utilization patterns and financial burden for households of private, as compared with public, services. We found that the private sector provided 60% of all outpatient contacts in Vietnam. There was no difference by education, sex or place of residence in the use of private ambulatory health care. Although there was evidence suggesting that rich people use private care more than the poor, this finding was not consistent across all income groups. The private sector served young children in particular. Also, people in households with several sick members at the same time relied more on private than public care, while those with severe illnesses tended to use less private care than public. The financial burden for households from private health care services was roughly a half of that imposed by the public providers. Expenditure on drugs accounted for a substantial percentage of household expenditure in general and health care expenditure in particular. These findings call for a prompt recognition of the private sector as a key player in Vietnam's health system. Health system policies should mobilize positive private sector contributions to health system goals where possible and reduce the negative effects of private provision development.

Background and Objectives: Public-private partnerships (PPPs) are among the interesting topics for scholars, policymakers and managers in various fields, including health. The purpose of this study is to design a model for the development of PPP in the health system of Iran. Methods: This is a qualitative study using a Meta-Synthesis approach. The data were collected by reviewing articles related to the literature which were searched in valid national and international databases. Then, using the opinions of a panel of experts, the qualitative findings extracted from the articles were synthesized to finally discover new concepts. Results: Out of 217 articles extracted, 27 final articles were selected and 66 initial codes were extracted. According to experts, the final results include 3 main dimensions and 12 Components: public sector with Components (organizational and institutional, Administrative and social, legal and regulatory, structural and contextual), private sector with Components (economic and financial, Banking and inflation, technical and specialized, Technology and equipment, legal and contractual) and the charity sector with Components (acceptability and effectiveness, awareness and confidence building, communication and interaction). Conclusion: The present study provides a new model and perspective on how to develop PPP in the health system of Iran. Based on this model, the managers of public, private and charity sectors can improve the health system of the country by using the huge economic, social and cultural capacities of society.

BackgroundThe role for the private sector in health remains subject to much debate, especially within the context of achieving universal health coverage.This roundtable discussion offers diverse perspectives from a range of stakeholders – a health funder, a representative from an implementing organization, a national-level policy-maker, and an expert working in a large multi-national company – on what the future may hold for the private sector in health.DiscussionThe first perspective comes from a health funder, who argues that the discussion about the future role of the private sector has been bogged down in language. He argues for a ‘both/and’ approach rather than an ‘either/or’ when it comes to talking about health service provision in low- and middle-income countries.The second perspective is offered by an implementer of health insurance in sub-Saharan Africa. The piece examines the comparative roles of public sector actors, private sector actors and funding agencies, suggesting that they must work together to mobilize domestic resources to fund and deliver health services in the longer term.Thirdly, a special advisor working in the federal government of Nigeria considers the situation in that country. He notes that the private sector plays a significant role in funding and delivering health services there, and that the government must engage the private sector or forever be left behind.Finally, a representative from a multi-national pharmaceutical corporation gives an overview of global shifts that are creating opportunities for the private sector in health markets.SummaryOverall, the roundtable discussants agree that the private sector will play an important role in future health systems. But we must agree a common language, work together, and identify key issues and gaps that might be more effectively filled by the private sector.

BackgroundSupporting service delivery through the private sector is a policy priority for improving maternal and child health service delivery for UHC. Despite the increased attention, it is not clear how pay-for-performance interventions within the private sector perform post-donor transition. This study aimed to examine the impact of donor transition on private service providers’ ability to deliver maternal and newborn health in Uganda.MethodsAn exploratory qualitative study was conducted in Uganda’s Rwenzori and Lango sub-regions, which benefited from a USAID project to reduce maternal and newborn deaths from 2012 to 2016 in Rwenzori and 2015–2020 in the Lango sub-region. A purposive sample of 52 respondents (Rwenzori = 26, Lango = 16, National = 10) took part in the study. A thematic analysis technique was followed, guided by the components of the health systems dynamics framework, with data management supported by Atlas. ti a qualitative data management software.ResultsOverall, results reflect a mix of progress and setbacks following the cessation of donor funding to the participating private health service providers. The subnational governance to provide oversight to the private sector was strengthened, which extended into the post-transition period. Despite setbacks in the provision of a comprehensive MNCH package, such as a drastic reduction in patient volumes, reduced scope of services offered and inconsistent supply of emergency medicines, the popularisation of MNCH services among the private sector players created awareness of the same post-transition. The information systems built with donor support contributed to improved data reporting from the private sector, which was sustained post-transition. Human resources for health among private sector players were greatly affected post-transition, although the same benefited the public sector with an experienced pool of health workers from which they recruited into public service. Despite the continued use of equipment procured during donor support, the medicines and supplies were greatly affected by funding cessation. Equally affected was the financing following donor cessation to the private sector players post-transition.ConclusionDespite the mixed results following donor cessation of funding to the private sector, these results have important implications for supporting private sector players to improve MNCH services in low-resource settings. The governance, health information systems, and service delivery experiences are critical aspects worth emulating for better engagement of the private sector in strengthening MNCH service delivery.Clinical trial numberNot applicable.

Objective: To map and quantify dental schools in 20 countries in Latin America and the Caribbean (LAC) and characterize them according to their public or private nature. Methodology: This was a cross-sectional descriptive study with a quantitative approach based on documentary analysis of 20 LAC countries. The unit of analysis consisted of officially recognized dental faculties, schools, or programs. The data were collected between March and August 2025. Results: A total of 795 dental education institutions were identified in LAC. The average number of faculty members per country was 39.75 (SD = 119.55), ranging from one to 543. The private sector was clearly predominant, with 638 (80.3%) private institutions and 157 (19.7%) public institutions. Brazil has 543 institutions (68.3% of the regional total), of which 88.0% (478) are private. Countries such as the Dominican Republic (92.3% private), Colombia (87.5% private), and Guatemala (83.3% private) have also demonstrated a strong inclination toward private education. In contrast, Cuba (six institutions) and Haiti (one institution) had only public faculties, and Venezuela had the lowest proportion of private institutions (28.6%) among the countries with mixed systems. Conclusions: The dental education ecosystem in Latin America and the Caribbean is characterized by a high number of institutions and a marked predominance of the private sector, with great regional heterogeneity. This scenario highlights the need for regulation and integrated policies to balance educational supply and quality.