Models of public-private engagement for health services delivery and financing in Southern Africa: a systematic review

Collaborative governance in a primary health care partnership in Papua New Guinea

INTRODUCTION

Collaboration in primary health care is recommended to achieve global health goals. Public-private partnerships (PPP) are one means of collaboration. Our study examined collaboration in a case study PPP for primary health care in Western Province, Papua New Guinea (PNG).

METHODS

Interviews with key informants involved in the PPP were conducted and key programme documents were reviewed. Data were coded and deductively analysed using the collaborative governance model developed by Emerson, Nabatchi and Balogh.

RESULTS

The key features of the case study PPP that were highlighted by the collaborative governance model were: identification of partners, trust, procedural arrangements, and leadership.

DISCUSSION

We identified four lessons of significance in the practical establishment and implementation of a partnership in a complex and challenging setting such as PNG: the need to (i) prioritise in-person collaboration and communication, (ii) engage dynamic individuals to lead the partnership, (iii) encourage relationships across all sectors and actors, and (iv) remain flexible and adapt to local cultural and context.

CONCLUSION

Collaborative governance offers a practical framework to understand, assess and strengthen collaboration in multi-stakeholder partnerships in the health sector.

Public-Private engagement and health systems resilience in times of health worker strikes: a Ghanaian case study

In low and middle-income countries like Ghana, private providers, particularly the grouping of faith-based non-profit health providers networked by the Christian Health Association of Ghana (CHAG), play a crucial role in maintaining service continuity during health worker strikes. Poor engagement with the private sector during such strikes could compromise care quality and impose financial hardships on populations, especially the impoverished. This study delves into the engagement between CHAG and the Government of Ghana (GoG) during health worker strikes from 2010 to 2016, employing a qualitative descriptive and exploratory case study approach. By analysing evidence from peer-reviewed literature, media archives, grey literature and interview transcripts from a related study using a qualitative thematic analysis approach, this study identifies health worker strikes as a persistent chronic stressor in Ghana. Findings highlight some system-level interactions between CHAG and GoG, fostering adaptive and absorptive resilience strategies, influenced by CHAG's non-striking ethos, unique secondment policy between the two actors and the presence of a National Health Insurance System. However, limited support from the government to CHAG member facilities during strikes and systemic challenges with the National Health Insurance System pose threats to CHAG's ability to provide quality, affordable care. This study underscores private providers' pivotal role in enhancing health system resilience during strikes in Ghana, advocating for proactive governmental partnerships with private providers and joint efforts to address human-resource-related challenges ahead of strikes. It also recommends further research to devise and evaluate effective strategies for nations to respond to strikes, ensuring preparedness and sustained quality healthcare delivery during such crises.

Learning from the End of the Public-Private Partnership for Lesotho's National Referral Hospital Network

Background

Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP.

Objective

We assessed successes and challenges to performance of the QMMH-IN PPP.

Methods

We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis.

Findings

Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility.

Conclusions

The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

Models using private general practitioners to provide caesarean deliveries at five South African district public hospitals: insights for public-private contracting for obstetric care in rural areas

BACKGROUND

Harnessing of private sector resources could play an important role in efforts to promote universal access to safe obstetric care including caesarean delivery in low- and middle-income countries especially in rural contexts but any such attempt would need to ensure that the care provided is appropriate and patterns of inappropriate care, such as high caesarean delivery rates, are not reproduced for the entire population.

OBJECTIVE

To examine the contracting arrangements for using private general practitioners to provide caesarean delivery services in rural district hospitals in South Africa.

METHOD

We utilised a mixed-method study design to examine the contracting models adopted by five rural district hospitals in the Western Cape, South Africa. Between April 2021 and March 2022, we collected routine data from delivery and theatre registers to capture the profile of deliveries and utilisation of contracted private GPs. We also conducted 23 semi-structured qualitative interviews with key stakeholders to explore perceptions of the contracting arrangements.

RESULTS

All five hospitals varied in the level of use of private general practitioners and the contracting models (three private in-sourcing models - via locum agencies, sessional contracts, and tender contracts) used to engage them. Qualitative interviews revealed insights related to the need for flexibility in the use of contractual models to meet local contextual needs, cost implications and administrative burden.

CONCLUSION

Structured appropriately, private public partnerships can fill important gaps in human resources in rural district hospitals. Policy makers should look to developing a 'contracting framework' which requires compliance with a set of underlying principles but allows for flexibility in developing context specific contracting arrangements. These underlying principles should include a 'risk' based delivery model, adherence to public sector- evidence-based protocols, time-based rather than per delivery/type of delivery remuneration models, group liability arrangements, and processes to monitor outcomes.

Facilitators and Barriers in the Implementation of a Digital Surveillance and Outbreak Response System in Ghana Before and During the COVID-19 Pandemic: Qualitative Analysis of Stakeholder Interviews

BACKGROUND

In the past 2 decades, many countries have recognized the use of electronic systems for disease surveillance and outbreak response as an important strategy for disease control and prevention. In low- and middle-income countries, the adoption of these electronic systems remains a priority and has attracted the support of global health players. However, the successful implementation and institutionalization of electronic systems in low- and middle-income countries have been challenged by the local capacity to absorb technologies, decisiveness and strength of leadership, implementation costs, workforce attitudes toward innovation, and organizational factors. In November 2019, Ghana piloted the Surveillance Outbreak Response Management and Analysis System (SORMAS) for routine surveillance and subsequently used it for the national COVID-19 response.

OBJECTIVE

This study aims to identify the facilitators of and barriers to the sustainable implementation and operation of SORMAS in Ghana.

METHODS

Between November 2021 and March 2022, we conducted a qualitative study among 22 resource persons representing different stakeholders involved in the implementation of SORMAS in Ghana. We interviewed study participants via telephone using in-depth interview guides developed consistent with the model of diffusion of innovations in health service organizations. We transcribed the interviews verbatim and performed independent validation of transcripts and pseudonymization. We performed deductive coding using 7 a priori categories: innovation, adopting health system, adoption and assimilation, diffusion and dissemination, outer context, institutionalization, and linkages among the aspects of implementation. We used MAXQDA Analytics Pro for transcription, coding, and analysis.

RESULTS

The facilitators of SORMAS implementation included its coherent design consistent with the Integrated Disease Surveillance and Response system, adaptability to evolving local needs, relative advantages for task performance (eg, real-time reporting, generation of case-base data, improved data quality, mobile offline capability, and integration of laboratory procedures), intrinsic motivation of users, and a smartphone-savvy workforce. Other facilitators were its alignment with health system goals, dedicated national leadership, political endorsement, availability of in-country IT capacities, and financial and technical support from inventors and international development partners. The main barriers were unstable technical interoperability between SORMAS and existing health information systems, reliance on a private IT company for data hosting, unreliable internet connectivity, unstable national power supply, inadequate numbers and poor quality of data collection devices, and substantial dependence on external funding.

CONCLUSIONS

The facilitators of and barriers to SORMAS implementation are multiple and interdependent. Important success conditions for implementation include enhanced scope and efficiency of task performance, strong technical and political stewardship, and a self-motivated workforce. Inadequate funding, limited IT infrastructure, and lack of software development expertise are mutually reinforcing barriers to implementation and progress to country ownership. Some barriers are external, relate to the overall national infrastructural development, and are not amenable even to unlimited project funding.

Financing health system elements in Africa: A scoping review

Countries that are reforming their health systems to progress towards Universal Health Coverage (UHC) need to consider total resource requirements over the long term to plan for the implementation and sustainable financing of UHC. However, there is a lack of detailed conceptualization as to how the current health financing mechanisms interplay across health system elements. Thus, we aimed to generate evidence on how to utilize resources from different sources of funds in Africa. We conducted a scoping review of empirical research following the six-stage methodological framework for Scoping Review by Arksey & O'Malley and Levac, Colquhoun & O'Brien. We searched for published and grey literature in Medline, Cochrane Library, PubMed, WHO database, World bank and Google Scholar search engines databases and summarized data using a narrative approach, involving thematic syntheses and descriptive statistics. We included 156 studies out of 1,168 studies among which 13% were conceptual studies while 87% were empirical studies. These selected studies focused on the financing of the 13 health system elements. About 45% focused on service delivery, 13% on human resources, 5% on medical products, and 3% on infrastructure and governance. Studies reporting multiple health system elements were 8%, while health financing assessment frameworks was 23%. The publication years ranged from 1975 to 2021. While public sources were the most dominant form of financing, global documentation of health expenditure does not track funding on all the health system dimensions that informed the conceptual framework of this scoping review. There is a need to advocate for expenditure tracking for health systems, including intangibles. Further analysis would inform the development of a framework for assessing financing sources for health system elements based on efficiency, feasibility, sustainability, equity, and displacement.

Public-private partnership models for rehabilitation service delivery: A scoping review

Background

Public-private partnership (PPP) for the delivery of health services is known to improve access to healthcare, yet little is known about its utilisation for rehabilitation services, particularly in sub-Saharan Africa (SSA).

Objectives

As a first step to generating evidence to develop a PPP model for physiotherapy service delivery in South Africa, our study mapped and described available research evidence on PPP models for rehabilitation services in the global literature.

Method

The Arksey and O'Malley framework guided our scoping review. Published research on rehabilitation and PPP was searched in five databases from 2000 to August 2022 using keywords, Medical Subject Headings (MeSH) and Boolean terms. Two reviewers independently completed the titles, abstracts and full-text screening of the articles and data extraction from the included articles. A narrative synthesis was conducted, and summaries of the findings are reported.

Results

Nine articles were included from a total of 137 obtained from the evidence searches. Of these, five were from Australia and the others from Hong Kong, Denmark, Bangladesh and the Netherlands. All the included articles showed evidence of PPP models for physiotherapy service delivery.

Conclusion

Our study suggests that PPP models for physiotherapy service delivery exist, particularly in high-income countries (HICs). It also highlights limited research in low- and middle-income countries (LMICs).

Clinical implications

There is a need for primary studies to generate further evidence and develop innovative PPP models for rehabilitation services for the populations who need them most as part of efforts towards improving access to healthcare in LMICs.

Mapping global evidence on public-private partnership for medical rehabilitation services delivery: a scoping review protocol

INTRODUCTION

Access to medical rehabilitation remains poor in Sub-Saharan Africa. This is partly due to inadequate service delivery emanating from ill-defined public health policies. Developed countries have adopted public-private partnership (PPP) agreements between the government and private sectors, thus presenting superior quality and access to rehabilitation services. To help develop a PPP model for physiotherapy service delivery in South Africa, this scoping review will map research linked to PPP for medical rehabilitation services delivery and outcomes in the global context.

METHODOLOGY

The Arksey and O'Malley (2005) framework (identify the research question, identify relevant research, select studies, chart the data, collate, summarize, and report findings) will be used to guide this review. Peer-reviewed literature will be searched in PubMed, EBSCOhost, Cochrane library, SCOPUS, and Google Scholar from 2000-2022 using a combination of keywords, Medical Subject Headings, and Boolean terms. Screening of the articles at all stages will be conducted independently by two reviewers using the eligibility criteria as a guide. The reference lists of retrieved articles will be manually searched for relevant studies. Emerging themes and sub-themes will be collated, summarized, and the results reported in the narrative form.

DISCUSSION

We anticipate identifying literature gaps for future research to inform policy on PPP for rehabilitation services delivery in Sub-Saharan Africa and actual practice. The results of this review will contribute to building a model that will enable the provision of equitable rehabilitation services at the district health level using PPP.

Experiences of public-private contracting for caesarean delivery in rural district public hospitals: A qualitative interview study

Governments in sub-Saharan Africa are exploring public-private-engagements for the delivery of health services. While there is existing empirical literature on public-private-engagements in high-income countries, we know much less about their operation in low and middle-income countries. Obstetric services are a priority area where the private sector can make an important contribution in terms of skilled providers. The objective of this study was to describe the experiences of managers and generalist medical officers, of private general practitioner (GP) contracting for caesarean deliveries in five rural district hospitals in the Western Cape, South Africa. A regional hospital was also included to explore perceptions of public-private contracting needs amongst obstetric specialists. Between April 2021 and March 2022, we conducted 26 semi-structured interviews with district managers (n = 4), public sector medical officers (n = 8), an obstetrician in a regional hospital (1), a regional hospital manager (1) and private GPs (n = 12) with public service contracts. Thematic content analysis using an inductive, iterative approach was applied. Interviews with medical officers and managers revealed justifications for entering into these partnerships, including retention of medical practitioners with anaesthetic and surgical skills and economic considerations in staffing small rural hospitals. The arrangements held benefits for the public sector in terms of bringing in required skills and having after hours cover; and for the contracted private GPs who could supplement their income, maintain their surgical and anaesthetic skills and keep up to date with clinical protocols from visiting specialists. The arrangements held benefits for both the public sector and the contracted private GPs and were deemed to be an example of how national health insurance could be operationalised for rural contexts. Perspectives of a specialist and manager from a regional hospital provided insight into the need for different public-private solutions for this level of care in which contracting out of elective obstetric services should be considered. The sustainability of any GP contracting arrangement, such as described in this paper, will require ensuring that medical education programmes include basic surgical and anaesthetic skills training so that GPs opening practice in rural areas have the required skills to provide these services for district hospitals where needed.

Strategies to strengthen non-governmental organizations' participation in the Iranian health system

Background

Non-governmental organizations (NGOs) added a new dimension to intersectoral action for health. Involving the NGOs in health system strengthening could lead to a more efficient, equitable, and better-governed healthcare system. This qualitative study explored effective strategies for NGO participation in the Iranian health system to achieve broader health system goals.

Method

We conducted 33 semi-structured interviews with health policymakers and planners, NGO actors at the national and provincial levels, and other key informants. The qualitative data were analyzed through a thematic analysis approach. Trustworthiness in the study was observed at all stages of the study.

Result

Four main themes- were identified: empowerment for learning leadership and management skills, creating active participation in policy-making, capacity building for participation, clarifying participation process, falling into 17 sub-themes. Along with the government and health sector policymakers, NGOs may have a significant role in improving health system goals and increasing equity, social responsiveness, financial risk protection, and efficiency.

Conclusion

The participation of NGOs in the Iranian health system is a complex process. All elements and dimensions of this process need to be considered when developing a platform for the appropriate participation of NGOs in the health system functions. Evidence-informed strategies for strengthening the participation of NGOs in the health system should be used to utilize NGOs potential to the fullest.

Hospital services under public-private partnerships, outcomes and, challenges: A literature review

Public-private partnerships (PPP) is used to advance health service access and quality. PPP implementation in hospitals is vital to shorten the service and quality gap. Hospitals are the most significant health budget spender, and this study aimed to identify the PPP effect on hospital performance indicators and its implementation challenges. Thirty-three inclusive articles were filtered and collected from Pubmed, ScienceDirect, Medline, and Sage Publication databases. Results showed that various articles succeeded in implementing PPP and improving the access and quality of health services. Several hospital performance indicators such as diagnosis, therapy, service waiting time, length of stay, referral rate, mortality rate, and patient satisfaction were reported to show better results. However, there was insufficient evidence to say the same on related financial indicators. Policy, resource, communication and trust, risk, and evaluation monitoring were considered challenges in PPP implementation. Its success was not only influenced by major factors such as governance model, finance, politics, and social but also was influenced by the medical practice model applied within the organization. This study contributed to whether PPP affects the hospital performance indicators.

The Evolution of Trust Within a Global Health Partnership With the Private Sector: An Inductive Framework

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.

Delineating natural catchment health districts with routinely collected health data from women's travel to give birth in Ghana

Background

Health service areas are essential for planning, policy and managing public health interventions. In this study, we delineate health service areas from routinely collected health data as a robust geographic basis for presenting access to maternal care indicators.

Methods

A zone design algorithm was adapted to delineate health service areas through a cross-sectional, ecological study design. Health sub-districts were merged into health service areas such that patient flows across boundaries were minimised. Delineated zones and existing administrative boundaries were used to provide estimates of access to maternal health services. We analysed secondary data comprising routinely collected health records from 32,921 women attending 27 hospitals to give birth, spatial demographic data, a service provision assessment on the quality of maternal healthcare and health sub-district boundaries from Eastern Region, Ghana.

Results

Clear patterns of cross border movement to give birth emerged from the analysis, but more women originated closer to the hospitals. After merging the 250 sub-districts in 33 districts, 11 health service areas were created. The minimum percent of internal flows of women giving birth within any health service area was 97.4%. Because the newly delineated boundaries are more “natural” and sensitive to observed flow patterns, when we calculated areal indicator estimates, they showed a marked improvement over the existing administrative boundaries, with the inclusion of a hospital in every health service area.

Conclusion

Health planning can be improved by using routine health data to delineate natural catchment health districts. In addition, data-driven geographic boundaries derived from public health events will improve areal health indicator estimates, planning and interventions.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

Has Latin America achieved universal health coverage yet? Lessons from four countries

Background

Seven years after the commitment to United Nations’ call for Universal Health Coverage, healthcare services in Argentina, Brazil, Colombia, Mexico are generally accessible and affordable; but they still struggle to meet population health demands and address the rising health care costs. We aim to describe measures taken by these four countries to commit by Universal Health Coverage, addressing their barriers and challenges.

Methods

Scoping literature review, supplemented with targeted stakeholders survey.

Results

The four countries analysed achieved an overall index of essential coverage of 76–77%, and households out of pocket health expenditures fall below 25%. Services coverage was improved by expanding access to primary healthcare systems and coverage for non-communicable diseases, while provided community outreach by the increase in the number of skilled healthcare workers. New pharmaceutical support programs provided access to treatments for chronic conditions at zero cost, while high-costs drugs and cancer treatments were partially guaranteed. However, the countries lack with effective financial protection mechanisms, that continue to increase out of pocket expenditure as noted by lowest financial protection scores, and lack of effective financial mechanisms besides cash transfers.

Conclusions

Argentina, Brazil, Colombia, and Mexico have made progress towards UHC. Although, better financial protection is urgently required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00793-7.

This review presents the current situation of UHC implementation in Argentina, Brazil, Colombia, and Mexico, using different elements from the WHO in their 13th Program of Work to compare service coverage and financial protection.

During the 1990s, health systems within several Latin American countries, anticipating to Universal Health Coverage increasing the service coverage, but struggling to fulfill financial protection standards. Still the four countries struggle to find mechanisms that could increase pooling mechanisms capable of increasing service coverage, while reducing financial inequities among people.

The decentralization of the primary healthcare system, the development of public-private partnerships, and the implementation of progressive financing mechanisms like conditional cash transfers are potential manners to improve service delivery and financial protection contributing to effective UHC.

Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review

BACKGROUND

Developing essential health services through non-governmental organisations (NGOs) is an important strategy for progressing towards Universal Health Coverage (UHC), especially in low- and middle-income countries. It is crucial to understand NGOs' role in reaching UHC and the best way to engage them.

OBJECTIVE

This study reviewed the role of NGOs and their engagement strategies in progress toward UHC.

METHOD

We systematically reviewed studies from five databases (PubMed, Web of Science (ISI), ProQuest, EMBASE and Scopus) that investigated NGOs interventions in public health-related activities. The quality of the selected studies was assessed using the mixed methods appraisal tool. PRISMA reporting guidelines were followed.

FINDINGS

Seventy-eight studies met the eligibility criteria. NGOs main activities related to service and population coverage and used different strategies to progress towards UHC. To ensure services coverage, NGOs provided adequate and competent human resources, necessary health equipment and facilities, and provided public health and health care services strategies. To achieve population coverage, they provided services to vulnerable groups through community participation. Most studies were conducted in middle-income countries. Overall, the quality of the reported evidence was good. The main funding sources of NGOs were self-financing and grants from the government, international organisations, and donors.

CONCLUSION

NGOs can play a significant role in the country's progress towards UHC along with the government and other key health players. The government should use strategies and interventions in supporting NGOs, accelerating their movement toward UHC.

Equitable Access to State-of-the-Art Medical Technology-a Malaysian Mini-Public-Private Partnership Case Study

BACKGROUND

The provision of equitable and affordable health care has become increasingly challenging as advanced technology is introduced, particularly in developing countries. We explored the hypothesis that focused, small-scale mini-public-private partnerships have a potential role in providing equitable and affordable access to advanced technology for the benefit of all patients in developing nations, particularly middle-income countries.

METHODS

A clinician-led financial plan was developed at the University of Malaya to create the Centre for Image Guidance and Minimally Invasive Therapy (CIGMIT) to provide an integrated platform for high-end care for Malaysian patients of all ages, both public and private, requiring complex neurosurgical and spinal procedures and stereotactic and intensity-modulated radiotherapy. The challenges faced during development of the plan were documented together with an audit of patient throughput and analyses of financial risk and return.

RESULTS

CIGMIT opened in 2015. Patient throughput, both public and private, progressively increased in all facilities. In 2015-2019, 37,724 patients used the Centre's facilities. CIGMIT has become progressively more profitable for the University of Malaya, the public and private hospitals, and the investor. CIGMIT has weathered the challenges posed by coronavirus disease 19.

CONCLUSIONS

Focused, small-scale mini-public-private partnerships have a potential role in providing advanced technology for the benefit of patients in developing nations, particularly middle-income countries, subject to an approach that balances equity of access between public and private health care systems with fair reward.

Transitioning health workers from PEPFAR contracts to the Uganda government payroll

Although increasing public spending on health worker (HW) recruitments could reduce workforce shortages in sub-Saharan Africa, effective strategies for achieving this are still unclear. We aimed to understand the process of transitioning HWs from President's Emergency Plan for AIDS Relief (PEPFAR) to Government of Uganda (GoU) payrolls and to explore the facilitators and barriers encountered in increasing domestic financial responsibility for absorbing this expanded workforce. We conducted a multiple case study of 10 (out of 87) districts in Uganda which received PEPFAR support between 2013 and 2015 to expand their health workforce. We purposively selected eight districts with the highest absorption rates ('high absorbers') and two with the lowest absorption rates ('low absorbers'). A total of 66 interviews were conducted with high-level officials in three Ministries of Finance, Health and Public Service (n = 14), representatives of PEPFAR-implementing organizations (n = 16), district health teams (n = 15) and facility managers (n = 22). Twelve focus groups were conducted with 87 HWs absorbed on GoU payrolls. We utilized the Consolidated Framework for Implementation Research to guide thematic analysis. At the sub-national level, facilitators of transition in 'high absorber' districts were identified as the presence of transition 'champions', prioritizing HWs in district wage bill commitments, host facilities providing 'bridge financing' to transition workforce during salary delays and receiving donor technical support in district wage bill analysis-attributes that were absent in 'low absorber' districts. At the national level, multi-sectoral engagements (incorporating the influential Ministry of Finance), developing a joint transition road map, aligning with GoU salary scales and recruitment processes emerged as facilitators of the transition process. Our case studies offer implementation research lessons on effective donor transition and insights into pragmatic strategies for increasing public spending on expanding the health workforce in a low-income setting.

Translating economic evaluations into financing strategies for implementing evidence-based practices

BACKGROUND

Implementation researchers are increasingly using economic evaluation to explore the benefits produced by implementing evidence-based practices (EBPs) in healthcare settings. However, the findings of typical economic evaluations (e.g., based on clinical trials) are rarely sufficient to inform decisions about how health service organizations and policymakers should finance investments in EBPs. This paper describes how economic evaluations can be translated into policy and practice through complementary research on financing strategies that support EBP implementation and sustainment.

MAIN BODY

We provide an overview of EBP implementation financing, which outlines key financing and health service delivery system stakeholders and their points of decision-making. We then illustrate how economic evaluations have informed decisions about EBP implementation and sustainment with three case examples: (1) use of Pay-for-Success financing to implement multisystemic therapy in underserved areas of Colorado, USA, based in part on the strength of evidence from economic evaluations; (2) an alternative payment model to sustain evidence-based oncology care, developed by the US Centers for Medicare and Medicaid Services through simulations of economic impact; and (3) use of a recently developed fiscal mapping process to collaboratively match financing strategies and needs during a pragmatic clinical trial for a newly adapted family support intervention for opioid use disorder.

CONCLUSIONS

EBP financing strategies can help overcome cost-related barriers to implementing and sustaining EBPs by translating economic evaluation results into policy and practice. We present a research agenda to advance understanding of financing strategies in five key areas raised by our case examples: (1) maximize the relevance of economic evaluations for real-world EBP implementation; (2) study ongoing changes in financing systems as part of economic evaluations; (3) identify the conditions under which a given financing strategy is most beneficial; (4) explore the use and impacts of financing strategies across pre-implementation, active implementation, and sustainment phases; and (5) advance research efforts through strong partnerships with stakeholder groups while attending to issues of power imbalance and transparency. Attention to these research areas will develop a robust body of scholarship around EBP financing strategies and, ultimately, enable greater public health impacts of EBPs.

COVID-19: Lockdown and its impact on medical students: A cross sectional study from a medical school in Mauritius

BACKGROUND

The objectives of the study were to identify the psychological impacts of lockdown on medical students due to COVID-19 and to discover the educational perplexities being faced by these students during the lockdown.

METHODS

A cross-sectional study was conducted at Sir Seewoosagur Ramgoolam Medical College (SSRMC), Mauritius. Questions were designed after an extensive review of the literature, so as to ensure relevance to meet the objectives of the study.

RESULTS

Out of 700 undergraduate medical students, 663 participated, which equates to a response rate of 95%. 348 (52.5 %) of the students were stationed in their hometown and the remaining 315 (47.5 %) were stationed in Mauritius. 464(70%) of the students suffered from the psychological impacts of lockdown whereas 634(95.6%) of students suffered from the educational impact thereof. Mauritian students suffered a greater educational impact aOR4.236[1.606-11.173]. Psychological impacts aOR 1.280 [0.917-1.789] and educational impacts aOR 2.464 [1.076-5.647] were more prevalent in hometown-based students. Students pursuing their clinical studies had aOR1.219 [ 0.531-2.798] a greater educational impact as compared to preclinical studies.

CONCLUSION

Lockdown triggered both educational and psychological impacts on medical students. On a psychological basis it was proven that the lockdown induced a feeling of guilt and had a greater psychological impact in pre-clinical students. The COVID-19 situation was simultaneously indicated to be a motivator in the majority of students; however, juxtaposed to this was the fact that various students felt as if they couldn't study at the same level that they were accustomed to due to the uncertainty of the situation.

From paper to practice: an exploratory study of policy making and implementation in alternative forms of healthcare public-private partnership in Ghana

There has been growing advocacy for public-private partnership (PPP) in healthcare in both policy and academic circles over the last 3 decades. However, our understanding of the tensions between the policy cycle and critical organisational trade-offs that characterise alternative forms of healthcare PPPs remains limited. In this paper, we use Walt and Gilson's policy analysis triangle to explore the policy and practice of two alternative models of healthcare PPPs-autonomous and integrative partnerships-at the sub-national level in Ghana, a typical case of a polycentric health management structure. The study is a sequential exploratory qualitative design, consisting of review of four policy documents and in-depth interviews with 13 key informants, comprising health managers from the regional and district health directorates, and medical directors of selected private health facilities. Our findings reveal that in spite of the natural potential of integrative PPP models to present a relatively stronger policy capacity to the private partner than autonomous models, the capacity of sub-national level public-private actors to participate in policy making and implementation remains very limited across both models. We further find that effective policy making and implementation requires significant governance attention to building the policy capacity of actors across vertical and horizontal levels of the partnership, regardless of the model of engagement. We suggest that this is achievable through instrumental multistakeholderism in PPP policy, planning and management. The paper contributes to developing understanding of the policy and practice of healthcare PPP in polycentric institutional settings.

Public-private partnerships in primary health care: a scoping review

Background

The Astana Declaration on Primary Health Care reiterated that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals. It called for governments to give high priority to PHC in partnership with their public and private sector organisations and other stakeholders. Each country has a unique path towards UHC, and different models for public-private partnerships (PPPs) are possible. The goal of this paper is to examine evidence on the use of PPPs in the provision of PHC services, reported challenges and recommendations.

Methods

We systematically reviewed peer-reviewed studies in six databases (ScienceDirect, Ovid Medline, PubMed, Web of Science, Embase, and Scopus) and supplemented it by the search of grey literature. PRISMA reporting guidelines were followed.

Results

Sixty-one studies were included in the final review. Results showed that most PPPs projects were conducted to increase access and to facilitate the provision of prevention and treatment services (i.e., tuberculosis, education and health promotion, malaria, and HIV/AIDS services) for certain target groups. Most projects reported challenges of providing PHC via PPPs in the starting and implementation phases. The reported challenges and recommendations on how to overcome them related to education, management, human resources, financial resources, information, and technology systems aspects.

Conclusion

Despite various challenges, PPPs in PHC can facilitate access to health care services, especially in remote areas. Governments should consider long-term plans and sustainable policies to start PPPs in PHC and should not ignore local needs and context.

Approaches to integrating palliative care into African health systems: a qualitative systematic review

Africa is characterized by a high burden of disease and health system deficits, with an overwhelming and increasing demand for palliative care (PC). Yet only one African country is currently considered to have advanced integration of palliative care into medical services and generalized PC is said to be available in only a handful of others. The integration of PC into all levels of a health system has been called for to increase access to PC and to strengthen health systems. Contextually appropriate evidence to guide integration is vital yet limited. This qualitative systematic review analyses interventions to integrate PC into African health systems to provide insight into the 'how' of PC integration. Forty articles were identified, describing 51 different interventions. This study found that a variety of integration models are being applied, with limited best practices being evaluated and repeated in other contexts. Interventions typically focused on integrating specialized PC services into individual or multiple health facilities, with only a few examples of PC integrated at a population level. Four identified issues could either promote integration (by being present) or block integration (by their absence). These include the provision of PC at all levels of the health system alongside curative care; the development and presence of sustainable partnerships; health systems and workers that can support integration; and lastly, placing the client, their family and community at the centre of integration. These echo the broader literature on integration of health services generally. There is currently a strong suggestion that the integration of PC contributes to health system strengthening; however, this is not well evidenced in the literature and future interventions would benefit from placing health systems strengthening at the forefront, as well as situating their work within the context of integration of health services more generally.

Exploring trust in religious leaders and institutions as a mechanism for improving retention in child malnutrition interventions in the Philippines: a retrospective cohort study

OBJECTIVES

In the context of persistent child malnutrition in the Philippines, the objective of this study was to examine how different dimensions of trust affected programme retention and physiological outcomes when a faith-based organisation (FBO) addressed moderate and severe acute malnutrition among children from households experiencing extreme poverty.

SETTING

We retrospectively analysed survey data collected by International Care Ministries (ICM) in 2012-2013 across 150 communities in eight provinces (Negros Oriental, Negros Occidental, Bohol, Palawan, Sarangani, South Cotabato, Sultan Kudarat and Zamboanga del Norte) of the Philippines.

STUDY PARTICIPANTS

Caregivers of 1192 children experiencing moderate acute malnutrition and severe acute malnutrition between the ages of 6 and 60 months.

INTERVENTION

A 16-week child malnutrition treatment programme called Malnourished Child Outreach offered by ICM in partnership with local religious leaders and institutions.

PRIMARY AND SECONDARY OUTCOME MEASURES

Programme dropout and weight-for-height z-score (WHZ) at the end of the programme for enrolled children were the two outcomes of interest. A logistic mixed-effects model was built to assess factors associated with programme dropout and a linear mixed-effects model for factors associated with WHZ at the end of the programme.

RESULTS

Trust in religious leaders or institutions (-0.87 (95% CI: -1.43,-0.26)) was negatively associated with programme dropout, suggesting that with increasing levels of trust, decreasing proportions of children dropped out of treatment. Retention in the programme led to improved WHZ among participating children (-0.38 (95% CI: -1.43, 0.26)). Various measures of social capital, including trust in religious and public institutions, were not associated with WHZ at the end of the programme.

CONCLUSIONS

Leveraging pre-existing trust in religious leaders and institutions among households experiencing extreme poverty is one way that ICM, and potentially other FBOs, can promote retention in child nutrition interventions among vulnerable populations.

Challenges in health service delivery under public-private partnership in Tanzania: stakeholders' views from Dar es Salaam region

BACKGROUND

Public-private partnership in the health sector was introduced to improve the delivery of health services in Tanzania. Contrary, the expected outcomes have not been fully realised. This study aimed at investigating challenges encountered in implementing public-private partnership institutional arrangements in health service delivery in Kinondoni Municipality, Dar es Salaam, Tanzania.

METHODS

A qualitative case study design was employed, where in-depth interviews with stakeholders were held and document reviews conducted. Fourteen (n = 14) participants engaged in this study. Eight (n = 8) and six (n = 6) of the fourteen participants were from the public and private sector respectively. The thematic approach was used to analyse data, and ethical principles in the research process were upheld.

RESULTS

Findings revealed that although public-private partnerships are hailed for supplementing the government's efforts in the provision of health services, institutional arrangements for the smooth provision of these services are lacking. Several challenges encumber smooth provision of health services and these include inadequate resources, ineffective monitoring and evaluation, and insufficient consultations between partners.

CONCLUSION

Inadequate legal and policy framework, or ineffective implementation practices may influence challenges facing institutional arrangements for public-private partnerships. Therefore, strengthening of public-private partnerships is recommended to improve implementation mechanisms and practices such as adherence to partnership agreements and compliance to the policies, laws and regulations.

Insights for the future of health system partnerships in low- and middle-income countries: a systematic literature review

BACKGROUND

Despite growing support for the private sector involvement in the provision of public health services in Low- and Middle-Income Countries (LMICs), a lack of clear information on the future of the provision of such services restricts the ability of managers and policy-makers to assess how feasible integration between public and private actors may be in these countries. This paper presents a systematic literature review which traces the dynamics and boundaries of public-private partnerships for the healthcare sector in LMICs.

METHODS

A total of 723 articles indexed in Scopus were initially submitted to bibliometric analysis. Finally, 148 articles published in several academic journals were selected for independent full-text review by two researchers. Content analysis was made in order to minimise mistakes in interpreting the findings of studies in the sample.

RESULTS

Public-private partnerships identified through the content analysis were categorised into four research areas: 1) Transfer of resources; 2) Co-production of health goods and services; 3) Governance networks; 4) Criteria for successful partnership development.

CONCLUSIONS

The four main research areas supply suggestions for a future research agenda, and managerial and policy implications for partnerships in LMICs.

Introducing rotavirus vaccine to the Palestinian territories: the role of public-private partnerships

BACKGROUND

Introducing childhood immunization poses challenges in environments of societal fragility. The Palestinian territories (Pt) are considered 'fragile' because of their lack of political, economic and territorial sovereignty. Poverty is rife, infant mortality high, and diseases associated with overcrowding widespread. Under these circumstances the Rostropovich Vishneskaya Foundation (RVF) has assembled a network of public and private stakeholders to introduce a country-wide rotavirus immunization program.

METHODS

The incidence of diarrhea was determined for 18 months before and 18 months after the introduction of rotavirus vaccine among all children younger than 5 years presenting to outpatient clinics in Gaza with three or more loose stools per day. Simultaneously the prevalence of rotavirus was established by rotavirus antigen detection in stool samples collected from children younger than 3 years at Caritas Baby Hospital in Bethlehem during the corresponding time periods.

RESULTS

Within 12 months 97.4% immunization coverage was achieved. The incidence of diarrhea dropped by 32.2%, while the prevalence of rotavirus in stool samples decreased by 64.6% throughout the following year.

CONCLUSION

In environments of economic or political instability private-public partnerships for the introduction of comprehensive vaccination programs can work based on close collaboration, shared vision, flexibility and inter-organizational trust.

Emergence of three general practitioner contracting-in models in South Africa: a qualitative multi-case study

BACKGROUND

The general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution.

METHODS

This qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson's health policy analysis triangle and Liu's conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved.

RESULTS

Three models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity.

CONCLUSION

The GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach.

Moving towards universal health coverage: engaging non-state providers

This editorial provides an overview of the special issue "Moving towards UHC: engaging non-state providers". It begins by describing the rationale underlying the Alliance's choice of a research program addressing issues of non-state providers and briefly discusses the research process this entailed. This is followed by a summary of the findings and key messages of each of the eight articles included in the issue. The editorial concludes with a series of reflections regarding lessons learnt about the engagement of non-state providers, methodological challenges, areas for future research as well as the contribution of the research program towards efforts to build capacity and strengthen health systems towards universal health coverage.

A Partnership Model for Improving Service Delivery in Remote Papua New Guinea: A Mixed Methods Evaluation

Background: The Community Mine Continuation Agreement Middle (CMCA) and South Fly Health Program (the Health Program) is a partnership for improving health service delivery in remote Papua New Guinea (PNG). The Health Program is delivered by a private contractor working in partnership with existing health service providers to improve service delivery using existing government systems, where possible, and aligns with national policies, plans and strategies. A midline evaluation was conducted to determine changes in health service delivery since commencement of the Health Program.

Methods: A mixed methods evaluation was undertaken mid-way through implementation of the Health Program, including a pre/post analysis of health service delivery indicators, semi-structured interviews with health workers and assessment of health facility equipment and infrastructure.

Results: Improvements in many of the long-term expected outcomes of the Health Program were observed when compared to the pre-program period. The number of outpatient visits per person per year and number of outreach clinics per 1000 children under 5 years increased by 15% and 189% respectively (P<.001). Increases in vaccination coverage for infants aged <1 year were observed: 58 % for pentavalent 1st dose (P<.001) and 75% for 1st dose Sabin (P<.001), 30% for 3rd dose pentavalent (P<.001) and 26% for measles vaccination (P<.001). Family planning coverage remained at similar levels (increasing 5%, P=.095) and antenatal care coverage increased by 26% (P<.001). Supervised deliveries coverage declined by 32% (P<.001), a continuation of the pre-Program trend. The proportion of facilities with standard equipment items, transport and lighting increased. Health worker training, in particular obstetric training, was most commonly cited by health workers as leading to improved services.

Conclusion: Following implementation, substantial improvements in health service delivery indicators were observed in the Health Program area as compared with pre-program period and the stagnating or declining national performance. This model could be considered for similar contexts where existing health service providers require external assistance to provide basic health services to the community

Partnerships for Global Child Health

Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.

A means of improving public health in low- and middle-income countries? Benefits and challenges of international public-private partnerships

OBJECTIVE

In the last two decades international public-private partnerships have become increasingly important to improving public health in low- and middle-income countries. Governments realize that involving the private sector in projects for financing, innovation, development, and distribution can make a valuable contribution to overcoming major health challenges. Private-public partnerships for health can generate numerous benefits but may also raise some concerns. To guide best practice for public-private partnerships for health to maximize benefits and minimize risks, the first step is to identify potential benefits, challenges, and motives. We define motives as the reasons why private partners enter partnerships with a public partner.

STUDY DESIGN

We conducted a systematic review of the literature using the PRISMA guidelines.

METHOD

We reviewed the literature on the benefits and challenges of public-private partnerships for health in low- and middle-income countries provided by international pharmaceutical companies and other health-related companies. We provide a description of these benefits, challenges, as well as of motives of private partners to join partnerships. An approach of systematic categorization was used to conduct this research.

RESULT

We identified six potential benefits, seven challenges, and three motives. Our main finding was a significant gap in the available academic literature on this subject. Further empirical research using both qualitative and quantitative approaches is required. From the limited information that is readily available, we conclude that public-private partnerships for health imply several benefits but with some noticeable and crucial limitations.

CONCLUSION

In this article, we provide a description of these benefits and challenges, discuss key themes, and conclude that empirical research is required to determine the full extent of the challenges addressed in the literature.

Health system's barriers hindering implementation of public-private partnership at the district level: a case study of partnership for improved reproductive and child health services provision in Tanzania

Background

Public-private partnership (PPP) has been suggested as a tool to assist governments in lower to middle income countries fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level – which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP.

Methods

This case study was conducted in the Bagamoyo district of Tanzania, and employed in-depth interviews, document reviews, and observations methods. A stakeholder analysis was conducted to understand power distribution and the interests of local actors to engage non-state actors. In total 30 in-depth interviews were conducted with key informants that were identified from a stakeholder mapping activity. The initial data analysis guided further data collection in an iterative process. The provision of Reproductive and Child Health Services was used as a context. This study draws on the decision-space framework.

Results

Study findings reveal several forms of informal partnerships, and the untapped potential of non-state actors. Lack of formal contractual agreements with private providers including facilities that receive subsidies from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. Furthermore, findings highlight weak capacity of governing bodies to exercise oversight and sanctions, which is acerbated by weak accountability linkages and power differences. Disempowered Council Health Services Board, in relation to engaging non-state actors, is shown to impede PPP initiatives.

Conclusion

Effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Orientation towards collaborative efforts that create value and enable its distribution is argued to facilitate healthy partnership, and in return, strengthen a district health system. This study highlights a need for new social contracts that will support integrative collaboration at the local level and bring all non-state actors to the centre of the district health system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1831-6) contains supplementary material, which is available to authorized users.