The governance of private sector engagement in health in the African Region: a descriptive case study

Given the large role the private sector plays in health systems, it is crucial for the public sector to meaningfully engage the private sector for service delivery in mixed health systems—termed private sector engagement (PSE).¹ PSE in health governance entails that governments focus on the whole system (i.e., govern both the public and private sectors).¹ The Sustainable Development Goals—specifically Sustainable Development Goal 17, “partnerships for the goals”—call for effective public-private partnerships.² To reach the health-related Sustainable Development Goal targets and the Universal Health Coverage (UHC) 2030 agenda, commitment and resources from all actors involved in health is needed. A resolution to engage the private sector in providing essential health services was adopted in the sixty-third World Health Assembly. Since then, the World Health Organization (WHO) has made progress towards recognizing and engaging the private health sector, but a larger system-wide shift is necessary to catalyze action for UHC.¹

Recognizing the importance of PSE, several policy and governance frameworks and declarations have been adopted at the global level.¹ Within the African Region, 17 countries outlined PSE as a priority in their 2022/2023 work plans, given the prominent role the private sector plays. It is estimated that the private sector accounts for a large proportion of service delivery^3,4 and training³ in African health systems. For example, in urban areas, the private sector delivered 55.9% of services, providing more care than the public sector or traditional health practitioners.³ The private sector’s involvement in the health system includes the provision of health-related services, medicines and medical products, financial products, training for the health workforce, information technology, infrastructure, and support services. However, the current status of PSE in health within the African Region is unknown.

METHODS

This study utilized a descriptive case study approach to answer the research question: what is the status of PSE in health in the African Region, as defined by the WHO? Case study methodology can help investigate “a phenomenon (…) in a specific context (…) with boundaries that can be unclear and changing (…)”,⁵ and is thought to be well-suited for such investigations with these parameters [^6–8 as cited by ⁵]. In the case of this study, the phenomenon of interest is PSE, the context is the African Region, and the nature of the boundaries are ever-evolving given the differing ways the private sector is engaged in health, that is particularly notable during the COVID-19 pandemic. More specifically, a descriptive case study approach was selected given the focus on this individual case, as opposed to drawing comparisons between multiple cases, as is the case in a comparative case study approach.⁵

Data sources

The case study was based on (i) a survey of stakeholders from the public sector, private sector, and development partners,⁹ as well as (ii) presentations and deliberations at a WHO-hosted multi-country consultation in the African Region on PSE to advance progress towards UHC. Both the survey and multi-country consultation focused on 17 countries of interest because these countries included PSE in their 2022/2023 work plans and requested technical support on PSE from the WHO. In other words, the survey was distributed to participants from these countries and the meeting convened participants from these countries. These countries are: Angola, Botswana, Burkina Faso, Burundi, Cabo Verde, Chad, Comoros, Congo, Cote d’Ivoire, Kenya, Mauritania, Nigeria, Senegal, Sierra Leone, South Sudan, Uganda, and Zambia. Each of these data sources is described in detail below.

Stakeholder survey

The survey—for which results have been published⁹—was conducted using a purposive sampling strategy, with public sector, private sector, and development partner participants from these aforementioned 17 countries. The survey was administered in English, French, and Portuguese online using Qualtrics and data was collected in October and November of 2022.⁹ Responses in French and Portuguese were translated into English using computer software to facilitate analysis by M.A.⁹ In total, the survey collected responses from 81 respondents including those from development partners (44.44%), the public sector (43.21%), and the private sector (12.35%) from across 13 countries.⁹

The survey questionnaire was developed based on the WHO’s governance behaviours for PSE. In other words, the survey was reviewed to ensure an appropriate number of questions were presented on each governance behaviour to capture relevant data. The WHO Advisory Group on the Governance of the Private Sector for UHC conceptualized governance behaviours that are designed to foster more resilient and responsive health systems. These behaviours were established as part of the WHO strategy, Engaging the private health service delivery sector through governance in mixed health systems,¹ launched in 2020. The strategy contributes a specific focus on the role of the private sector as a part of health system governance and health system strengthening. The governance behaviours use simple descriptors and statements to convey behavioural intent. Thus, this strategy enables stakeholders to focus on broader institutional arrangements for health system performance, which include priorities, strategic direction, articulation of principles and values of the health systems, and the underlying policy and regulatory framework.

These governance behaviours are believed to be “critical to private sector health service delivery governance” and are: (i) deliver strategy, “agreed sense of direction and articulation of roles and responsibilities”; (ii) align structures, “organizational structures to align with policy objectives”; (iii) enable stakeholders, “institutional framework that empowers actors”; (iv) build understanding, “collection and analysis of data to align priorities for action”; (v) foster relations, “working together to achieve shared objectives in a new way of doing business”; and (vi) nurture trust, “mutual trust amongst all actors as reliable participants”.¹

WHO-hosted multi-country consultation in the African Region on PSE

The UHC & Life Course cluster at the WHO Regional Office for Africa, in collaboration with colleagues from WHO headquarters and the Eastern Mediterranean Regional Office, organized a multi-country consultation on PSE for UHC to build awareness and foster leadership, hereinafter “meeting”. This meeting convened country teams from the 17 countries of interest and country teams included: senior staff from ministries of health working with the private sector, private sector representatives, WHO Country Office staff, and other relevant country partners. The meeting spanned two days, averaging an estimated 60 participants in attendance per day, and was hosted fully online with simultaneous translation into English, French, and Portuguese. The meeting was interactive with open discussion stemming from the collection of participant views to probing questions that were presented after each session through an online tool, menti-meter. Participants were also encouraged to use the online chat box for questions and suggestions. The meeting led to both engaged and fruitful discussion, leading to renewed enthusiasm for ongoing and future efforts on PSE. Meeting notes were taken to produce an internal meeting report.

Data analysis

The raw data from this survey, the article detailing the overarching survey findings with respect to the governance behaviours, and the meeting report were used for this case study. A synthesis of major themes was sought, as opposed to undertaking thematic coding. This approach was selected given that the lead author, MA, carefully reviewed and thematically coded the survey responses included in the analysis, attended the meeting, and drafted the meeting report, all of which contributed to the development of this case study journal article. Overall, a comprehensive analysis of the data was undertaken, including analysis of both quantitative and qualitative data sources, with the aim of presenting a fulsome picture of the case at hand.

By design, this case study is not meant to be generalizable to other regions or all the contents applicable to every country within the African Region. Instead, it is meant to illustrate cross-country experiences and perspectives held in select countries of interest. Ultimately, it is up to the discretion of the reader to assess how the information presented may or may not be applicable to their respective setting.

RESULTS

The results of this case study are outlined in the following two sections: (i) status of the private sector’s role in health in the African Region and (ii) push for greater dialogue on PSE in health, including an in-depth look into Nigeria, Senegal, and Sierra Leone.

Status of the private sector’s role in health in the African Region

The private sector plays a large role in health in the African Region. For example, in sub-Saharan Africa, 35% of outpatient care is delivered by the private-for-profit sector and in some countries, an additional 17% is delivered by informal private providers.¹⁰ Overall, the private sector’s role in health in the African Region can be categorized into four main buckets: (i) formal arrangements for providing direct health services (e.g., health facilities registered under national regulations, both for-profit and non-profit); (ii) informal arrangements for providing direct health services (e.g., informal providers without certifications or accreditations, such as traditional practitioners and unregistered providers); (iii) undertaking activities that support health service provision but fall outside of the direct health care umbrella (e.g., marketing of healthy products, training, cleaning and catering services, drug manufacturing, and infrastructure development); and (iv) approaches that support government policies and programmes (e.g., contractual agreements, strategic partnerships, sector-wide approaches, and voucher programmes). These roles demonstrate how the private sector contributes to the broader health system and how the government engages with private providers to deliver health services.

Private sector players also supported COVID-19 response efforts in various ways. These engagements were outlined as relating to: infrastructure (e.g., building of Isolation Centres in Nigeria, renovated isolation center in The Gambia); treatment of COVID-19 cases (e.g., Nigeria, South Africa, and Rwanda); local production (e.g., face masks, gloves, gowns, personal protective equipment, ventilators, disinfectants); in-kind contributions (e.g., provision of various supplies); and financial contributions (e.g., response plans in Benin, Ghana, Nigeria, and Uganda). In the Democratic Republic of Congo, Nigeria, Senegal, and Uganda, the private sector played a role in strengthening laboratory, case management, risk communication, and health service continuity systems.¹¹ In all four countries, the private sector also supported increased access to COVID-19 testing services through partnerships with the public health sector.¹¹ In the Democratic Republic of Congo and Nigeria, private facilities supported contact tracing and surveillance activities.¹¹ In Senegal and Uganda, governments partnered with the private sector to manufacture COVID-19 rapid diagnostic tests.¹¹ The private sector has also contributed to the treatment and management of COVID-19 cases and private entities have provided personal protective equipment.¹¹ In Kenya, the private health sector supported COVID-19 response activities through public awareness campaigns, laboratory testing, and other response measures, and these efforts were guided by the government’s rapid response and preparedness plan, which the private sector was a part of.¹² And in Rwanda, private sector pharmacists and nurses were considered essential workers, were authorized to operate their facilities, and supported the national awareness campaign initiated by the Ministry of Health.¹³ Private sector facilities, including Polyclinique du Plateau which is one of the largest private clinics in Kigali, were instructed to increase capacity to receive and manage suspected COVID-19 patients.¹³

Civil society organizations also played a critical role in COVID-19 response efforts, particularly at the community-level with key interventions in: surveillance, infection prevention and control, and risk communication and community engagement; supporting access to health care by linking the community and the broader health system; promoting the acceptance of public health measures (e.g., immunization, particularly given the context of very low COVID-19 immunization coverage in the African Region); and health promotion in specific populations (e.g., women and girls in Borno State, Nigeria). For example, in Zimbabwe, Dot Youth Zimbabwe worked with people living with disabilities and brought them to the health facility to get vaccinated for COVID-19, while in Kenya, the Organization of African Youth organized infection prevention and control interventions on public transport.

Push for greater dialogue on PSE in health

We observe a general push for greater dialogue on PSE in health in the African Region with emphasis on PSE being apparent in three select countries: Nigeria, Senegal, and Sierra Leone.

Nigeria

A multi-stakeholder analysis and dialogue was conducted in Nigeria to review and assess mechanisms for PSE in delivering maternal and newborn health services and to propose models for effective engagement. The analysis found that despite the private sector delivering about 60% of health care services in Nigeria that are highly utilized due to ease-of-access, short waiting times, and respect by providers, the private sector is highly fragmented, poorly regulated in terms of service delivery, and is not fully engaged in the development of health policies and strategies.

The analysis determined that the private sector faces several challenges including: stewardship and governance, health policies, regulation, engagement, accountability, quality of services, communication, and market conditions. The analysis also led to several recommendations, which include: the need to adequately involve the private sector (both for-profit and not-for-profit entities) in the development of national health policies and implementation strategies; instituting mechanisms for continuous public-private dialogue and engagement; disseminating health policies, strategies, plans, and the latest guidelines and quality standards to all private sector actors; providing data tools (e.g., health management information system registers, tally sheets) to private sector health service providers; strengthening government capacity to regulate and oversee the private sector; ensuring the provision of adequate financial and human resources to health regulators to effectively monitor the private sector; building the capacity of private sector providers; and providing adequate financial and non-financial incentives for private providers to ensure quality services (e.g., by expanding access to low interest loans and other financial products with less stringent requirements for the private sector).

The private sector is organized under the Healthcare Federation of Nigeria and is proactively engaging the government to provide support and partnership opportunities to address health system issues. Many milestones have been achieved, including advocating for the establishment and implementation of “Pro-Health Taxes” to finance the health sector and strengthen the health ecosystem and for the creation and implementation of a cancer health fund to subsidize the cost of care for select patients.

Senegal

The contribution of the private sector is growing and there is a long history of collaboration between the government and the private sector in Senegal. Senegal’s Ministry of Health and Social Action mapped private health structures and developed a strategy in 2017–2018 to strengthen the health system through the private sector, which has been strongly supported by the United States Agency for International Development and the World Bank. Today, there are over 1436 private health care structures and 60% of these are based in Dakar. A study entitled Strategic Note on Public-Private Partnerships in the Health Sector, conducted by the Ministry of Health and Social Action with support from its partners, focuses on the status of public-private partnerships and identifies four strategic areas of intervention: health service delivery, social protection, strengthening governance of partnerships in the health sector, and health information systems. The results of this report are being used to mobilize additional resources.

In 2019, the Division of Private Medicine and Occupational Medicine was established, which sits within the Directorate of Private Health Establishments within the General Directorate of Health Establishments. This division mobilized political will to ensure the concerns of the private sector are appropriately considered. The directorate’s mission is to: (i) ensure compliance with the regulations governing the practice of private medicine; (ii) promote partnerships between private and public health establishments and to monitor the implementation of agreements; and (iii) secure proper planning of health care officers, on behalf of both public and private sectors.

Senegal’s planned activities are to: (i) update the mapping of private structures to monitor progress and measure contributions; (ii) promote access to inputs for private sector actors for the implementation of priority programs; (iii) revise and popularize the texts that govern the conditions for opening private health facilities to make the sector attractive to investors; (iv) support the signing of agreements with health districts to improve collaboration at the operational level, particularly for the completion of health data; and (v) support the signing of agreements between the Union of Mutual Health Insurance Companies and the Private Health Sector Alliance for tariff arrangements in private health structures in application of the strategies for achieving UHC.

Sierra Leone

The Private Health Sector Assessment Report, produced in 2020 by the World Bank and the Ministry of Health in Sierra Leone, identified a gap in collaboration and lack of policy dialogues between the public and private sectors in the health care system. Subsequently, the first health summit, held in April 2022 with several hundred participants, produced an aide memoire recommending that the government should increasingly involve the private sector in health service delivery as part of the national effort towards UHC. Following these efforts, the WHO and the Ministry of Health and Sanitation co-facilitated the PSE Forum that brought together 21 stakeholders from the public sector and 20 from the private sector. As part of this forum, a seven-member interim technical working group was created, the terms of reference were adopted, and the workplan will be developed by their next meeting. The three key achievements of the PSE forum are: a jointly identified and agreed upon rapid situation analysis with proposed interventions to improve the situation around the WHO’s six PSE governance behaviours; interventions outlined to act on the recommendations of the Private Health Sector Assessment report; and a roadmap presented by the Ministry of Health and Sanitation that was discussed and agreed on by all participants to ensure that the decisions taken at the workshop are carried out.

DISCUSSION

The results of this study demonstrate that the private sector plays a large role in health in the African Region and that there has been a push for greater dialogue on PSE in health in selected countries. We believe such dialogue around PSE in health can lead to health system strengthening. For instance, with private-public sector agreements in place to collect robust routine health data, health system gaps and weaknesses can be addressed. To support existing PSE efforts, information and tools, such as the WHO Country Connector, can be capitalized on to overcome governance challenges. The WHO Country Connector was established to support governments in managing PSE for national health priorities by fostering country experience sharing and learning. The Connector connects countries to resources, tools, and guidance to improve governance. It also coordinates the efforts of multiple actors, helps with efforts to build strong and resilient health systems, and works to ensure that country-level needs, and demands are focussed on. The primary audience for the platform is member states, particularly Ministries of Health, but also, private sector partners and multilateral and donor agencies within specific countries. The secondary audience the various funding agencies that work in this space and multilateral agencies, civil society, and consumer representatives at the global level.

Limitations

Through utilizing a case study methodology, two limitations to this study are outlined. The first limitation concerns the depth of information presented in this case on PSE in health in the African Region. Although we present an overview of the status of PSE in the African Region alongside examples from three select countries to illustrate how PSE has been focused on in recent years, we are limited in the quantity of information we can provide through this article. Future analyses can entail conducting key informant interviews and/or expanded surveys, not only the African Region, but globally as well. And second, the data sources may have missing information. The information presented is largely based on key stakeholder accounts gleaned through both a survey and the regional meeting. Naturally, there are both limitations to the survey (e.g., computer translations, response rate of 30%) and there may have been key stakeholders who refrained from providing information on their respective countries. However, this limitation is applicable to all research that collects data, given that data may always be unintentionally omitted.

CONCLUSIONS

The significant role the private sector plays in health in the African Region, alongside the growing push for increased dialogue on PSE in health in select countries, presents an opportunity to adopt more multisectoral, whole-of-society approaches. Ultimately, engaging the private sector and placing consumers at the heart of health sector strategies is essential, as emphasized in the recommendations from a WHO landscape analysis.³ We therefore call on relevant stakeholders such as Ministries of Health, the WHO, and private sector actors to take action, as these approaches are crucial for addressing emerging health needs.

Acknowledgements

The authors are grateful to respondents who participated in the study, without whom the research would not have been possible. MA would like to acknowledge the donors to the Mary and Maurice Young Professorship in Applied Ethics.

Ethics statement

This study was undertaken as a part of the work of the World Health Organization (WHO) and received ethical clearance from the World Health Organization Regional Office for Africa’s Ethics Review Committee (protocol ID AFR/ERC/2023/8.11). Respondents were informed that completed surveys will be anonymized and aggregated as part of data analysis and in the presentation of findings. Participants at the meeting were also informed that a meeting report would be produced to detail the events of the meeting. Thus, both processes infer informed consent. All methods were carried out in accordance with relevant guidelines and regulations.

Data availability

The data generated and analyzed during this study is presented in this article or cited appropriately.

Funding

This publication is supported by the World Health Organization.

Authorship contributions

MA1 conducted the analysis and drafted the manuscript. MA1, OS, MA2, ZZ, HK, & JN-O contributed to manuscript development and approved the final manuscript.

Disclosure of interest

All authors are employed by or consulted for the World Health Organization.

Correspondence to:

Michelle Amri
The W. Maurice Young Centre for Applied Ethics,
School of Population and Public Health,
University of British Columbia,
2206 East Mall,
Vancouver,
British Columbia,
Canada, V6T 1Z3
michelle.amri@ubc.ca