Factors affecting private sector engagement in achieving universal health coverage: a scoping review

Figures & data

Figure 1. Flow diagram of the searches and inclusion process.

Figure 2. Studies in countries evaluating private sector participation in achieving UHC.

Figure 3. The process of identifying, screening, selection, and categorization of factors.

Table 1. Challenges and barriers to private sector engagement in achieving UHC.

Main Themes	Sub-Thems
Quality Challenges	The uneven quality of private health systems compared to each other Concerns about the low-quality of healthcare services provided by private sectors Weak mechanisms for monitoring the quality of health services
Regulations Challenges	Weak regulatory frameworks Weaknesses in implementing regulations Poor at following national guidelines Lack of standardization in the private sector
Resource Barriers	Waste of resources in public and private sectors The private sector Undermines allocative efficiency Unequal distribution resource of health care system
Accreditation and Qualified Challenges	Under-qualified private providers The high cost of licensing and lack of qualifications to apply Longtime Process of Accreditation and licensing requirements for the private sector Poor or limited support in providing occupancy certificates for the private sector
Human resources Challenges	Weakness in attracting and retaining health workers in non-state providers Brain drains from the public sector High staff turnover in non-state providers Overreliance on public sector-trained staff
Ethical Barrier	Corruption in public and private sectors when working together Unresolved conflicts of interest in the public and private sector Unethical practices (induced demand: Over-servicing with private hospitals)
Financial Challenges	Lack of Drawing up healthcare benefit packages and flexibility for the private sector Districts’ financial dependence on donor funds channeled through the central government limited their actual autonomy for establishing contracts directly with NSPs. High administrative costs in the public sector for contracting out with the private sector Delays in reimbursements to the private sector through the public sector High Out-of-pocket payment in the private sector Uneven regional economic development Low levels of government salary for health workers Funding insecurity in public and private sectors when working together Purchasing poor-value care from private sector
Governance Challenges	Weak governance mechanism Inappropriate political interference in key decisions Weakness of government policies in the health sector Weak stewardship health system The role of the private health sector is not well defined in achieving universal health coverage Mistrust between the public and private sectors Limited inter-sectoral collaboration between the public and private sectors
Organizational Barrier	Mismatched organizational styles and differing priorities in public and private sectors Fragile program due to use of donor funding for embarking on public–private partnerships Dual practice between the public and private sectors Poor forecasting and planning for patient load, resulted in NSPS complaining. Weak contract frameworks between the public and private sectors Lack of incentives in public sector A large private sector undermines the integrity and sustainability of the health system overall Imbalance of power between the private and public sectors
Cultural Barriers	Socio-cultural influences such as the need for female health care providers to serve female clients Normative gaps (clear and comprehensive standards and frameworks are lacking to guide a country’s efforts) Little community participation due to large private sector
Services delivery Challenges	Balance tilting towards curative care by private providers Heterogeneity in public and private providers Provides fragmented care in private sector
Market Barriers	Market condition barrier: abuse of market power (market skimming monopolistic behavior and predatory pricing) for profit private sector Limited government control of medicine promotion and advertising Protecting equity
Information Challenges	Private providers do not report to the ministry of health for fear of increased taxation Management information systems were inadequate to monitor the performance of private providers Gaps in evidence (Poorly documented) to decision-making Lack of common understanding Weakness of the health research systems

Table 2. Facilitators for private sector engagement in achieving UHC.

Main Themes	Sub-Thems
Regulation Facilitators	Pay attention to economic regulation due to regulation of monopoly and competition in the health sector Pay attention to social regulation to achieve and promote social objectives. The improvement of regulatory frameworks through, quality accreditation and standards of care Regulate by the government on how to services delivery in the private sector Effective regulation of competition and management of the private sector contribution Strengthening government capacity to develop, implement, and monitor legislation and other regulations Establishing an appropriate system of incentives and penalties for more private involvement in complementing the government’s responsibility
Financial Facilitators	Increasing the Government’s adequate and sustainable financing for health systems cooperation with health private sector The review of fiscal policy (such as tariffs and import duties) Use of Technical and financial support from donors Develop strategies to limit operational costs in the private-not-for-profit sector Offering standardized service packages and prices that apply to all socioeconomic levels Voucher scheme financing to reduce financial barriers Subsidized to increase access to providers of reasonable quality Attention to Price determination bodies Effective strategic purchasing
Capacity Building	The capacity for management in the public sector to partner with the private sector The awareness and acceptability of structural changes related to responsibility and decisions (power and authority) for initiating commitment in a partnership Active involvement of the private health sector in national health strategic plans and establishment of formal dialogue mechanisms Using of tools of government for indirect governance of the private health sector Governments should take the lead and formulate domestic health goals and priorities The engagement of the private sector, beyond health, in improving access to health services Provision of the framework to guidance to bolster private sector participation International cooperation based on mutual learning across countries Culture shift to collaborate between public and private health sector Create a competitive environment between the big companies and local and small private providers
Policy Facilitators	Time and political commitment in initiating partnerships between the public and private sectors Having the political will to the management of the private sector contribution to ensure that coverage of basic health care There is a strong need for policy modifications to help boost private sector confidence and expand their participation in healthcare National policies to better distribute facilities geographically for better access. Adherence to policy leaving no one behind Develop a policy framework, organizational systems, and financing strategies for engaging the private health sector Minimize political interference in contract implementation
Evidence Base Decision	Adherence to Evidence-based national health strategies and leadership across both public and private sectors Knowledge and evidence on what works for health systems and UHC Public-private-partnerships need to ensure the appropriate use of basic signal functions
Monitoring	Developing comprehensive and elastic frameworks and tools for evaluating public–private partnerships Develop monitoring and reporting mechanisms Effective monitoring to clarify expectations and resolve any misunderstandings among the various stakeholders Assess the readiness of the public and private sectors to work together Independent quality assessment and Health care standardization in the private health sector All partners should be transparency and accountability for results to people and communities
Mobilize Human Resources	Assesses the availability of a properly trained workforce with the requisite numbers of staff Efforts by public private sectors to overcome workforce training. Recognize and leverage the PNFP sector’s extensive network of infrastructure and human resources.
Facilitate Contracts	Properly managing relationships between all actors to contract success Contract flexibility between the public and private sectors
Information Facilitators	Health Research to generates timely and reliable health information Need to be Supported by databases for private-sector mapping Collect and analyze information about how many and which private providers willing to engage

Table 3. The reasons for private sector engagement in achieving UHC.

Main Themes	Sub-Thems
Weak health system	Broken health care system Limit number and Weak public sector The gap in public-sector ambulatory services Fill the gaps in secondary and tertiary care provision Overburdening of public sector hospitals Supplement the public sector which was damaged and weakened during a conflict Need to Quickly scale up vertical health programs Poor quality of services in both sectors
Financial	Weak accessibility and affordability to comprehensive health services in the public sector Rising costs for healthcare services and restricted governments’ financial capacity Higher out-of-pocket spending Lack of investments public sector in the health Dependency on external donors to finance health services Limited mechanisms for pooling risks, resources, and weak enforcement in the tax system Political instability and economic crisis Financial motivations and high profits in the private sector
Recourse Barriers	Infrastructure Challenges	The lack of government capacity to deliver basic health services to marginalized populations and certain populations or geographic areas Lack of capacity to manage the distribution of private health facilities Insufficient number of public health facilities Poor diagnostic capacity facilities in rural areas Inadequate infrastructure and medical supplies
	Workforce Barriers	Shortage of human resources less skilled providers Shortage of qualified healthcare professionals in rural areas
Demographic Changing	Demographic shifts including ageing Population displacement Non-communicable disease burden increase
Community Pressure	Patient demand for better health care The problem of health inequality Excessive use of private sector services by urban and rural populations

Table 4. The goals of private sector engagement in achieving UHC.

Main Themes	Sub-Thems
Health System Strengthening	Investment in both medical education and hospital development Complement and integrated with the local health system Inter-sectoral collaboration to engage in interventions that affect health Enhance health system capacity and sustainability Using private sector health services to Supplement ministry capacity
Financing	Improve the government’s commitment to financing healthcare delivery Designing remuneration packages as per need Purchase of private-sector health services Encouragement by international financial institutions to rely on private actors to decrease the burden on national budgets
Resources Management	Ensure geographic spread of health service providers’ facilities Harnessing resources Better allocate resources to the population Create additional and newer infrastructure Contributions to training health workers
Promoting Access	Expand access to higher-quality health services Expansion of SHI and extend the depth and height of coverage Improved coverage of national health programs
Facilitate Cooperation	Develop a framework for partnerships with the private sector in variable circumstances of the country Implementation of a market-oriented approach through collaborative mechanisms that enhance accountability Implementation of standard treatment guidelines Prioritizing and explicit objectives public–private partnership context and policies
Promotion Health Services	Regulation of the private healthcare sector Improve Patient safety Controlling unnecessary service delivery