Governance of the private sector in health systems

With rising demand for modern and high-quality health services and severe fiscal constraints on public financing for health services, the private sector has expanded its presence in the health care sector across geographies. The increased involvement has also led to an increased need to better govern the sector and in 2016, the World Health Assembly (WHA A63.27) resolved to improve countries' effective engagement, oversight, and regulation of private healthcare providers. In 2019, WHO issued a call to action on private sector engagement (PSE), calling for a more central role for domestic actors (especially governments but also private and civic actors) in brokering PSE as part of work on the Sustainable Development Goals (SDGs) agenda. The same year, WHO established a Technical Advisory Group (TAG) on the Governance of the Private Sector for Universal Health Coverage (UHC) to provide advice on how WHO should approach PSE. The TAG developed a practice-based approach to governance with six governance behaviours, Deliver Strategy, Enable Stakeholders, Foster Relations, Build Understanding, Align Structures, and Nurture Trust. 

However, the understanding of the evidence base relating to private sector governance remains inadequate, and we were commissioned by WHO Geneva to conduct a scoping review looking at the evidence of private sector governance approaches, effectiveness and enablers. It also identified important areas for future evidence generation. The scoping review was then used to inform the development of a governance progression pathway, or maturity model, to assist countries in assessing their governance capacities to work effectively with the private sector, prioritising actions to improve governance, and tracking progress over time.

Challenges

The private sector’s role is growing across many settings, especially in low- and middle-income countries (LMICs), where the sector constitutes 50% of health service delivery. However, the sector remains under-governed in many contexts. With ambitious SDGs the combined resources of the public and private sectors will need to be effectively and efficiently harnessed to meet this demand. This will not only require formal governance mechanisms but also new ways of working, interacting with each other and sharing of information. However, the understanding of the governance behaviours and the evidence base relating to them remains inadequate. There is, yet no understanding of how governments can move / have moved towards strengthened governance of the private sector. This necessitates efforts that are grounded in both a rigorous review of theory and practice and take account of the contextual nuances of various settings, and that these contexts are in themselves dynamic and adaptive. 

Our approach

We partnered with leading academics in a scoping review synthesising the available literature on governance of private health care financing and delivery, incorporating narrative synthesis of 108 identified articles across both published and grey literature. The team then developed a progression pathway intended to provide national governments with a standardised qualitative approach for assessing, planning, and facilitating work to reform a country's current governance arrangements about the private sector in health. The progression pathway helps by informing policies and prioritisation, helping to build institutional capacity and scaling up existing examples of effective governance practice. 

Outcomes

The primary areas of work and outcomes include: 

1. A scoping review synthesising the available literature on governance of private health care financing and delivery in LMICs.
2. The development of the Progression Pathway for the Governance of Mixed Health Systems. This will be published by WHO as a technical normative product.
3. Two publications in a BMJ Special Edition, a separate stand-alone publication on the Regulation component of the scoping review and a practice paper on the development of the progression pathway.
4. A joint OPM - WHO satellite session at Health Systems Global (HSG) 2024 in Nagasaki, Japan.
    

This assessment was carried out by Oxford Policy Management. The Technical Team Lead was Catherine Goodman; the Technical Experts were Sophie Witter and Mark Hellowell. We are also thankful to Debrupa Bhattacharjee, Munmun Biswas, and Agrima Sahore for their support.

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