What’s next for strengthening mixed health systems Emily Adams, Jaidev Anand, Dr. Nelson Gitonga, Daniela Gutierrez, Chloe Lanz

Over the past year we have shared many experiences from our work to strengthen mixed health systems (MHS) including the facts about what information is out there and what has been done related to MHS and private sector engagement (PSE), a framework for thinking holistically about MHS, and our team’s approach and experience supporting MHS work at the country-level.

From the outset of the work we aimed to answer three learning questions:

  1. Can approaches to support public-private engagements (PPE) be associated with outcomes like improved quality of engagement between the sectors and improvements in relevant health outcomes?
  2. What factors are associated with helping or hindering to achieve intended outcomes?
  3. What approaches can engagement brokers or supporters take to facilitate factors and ultimately help engagements achieve better health outcomes?

To answer these questions we reviewed over 101 published articles in academic literature, 150 sources in grey literature, conducted two primary case studies to accompany and learn about the technical support we provided in Kenya and India, and conducted six secondary case studies. From this, we have identified several important learnings and good practices that we share here. We’ve also outlined areas that would benefit from further exploration to consider — what’s next for strengthening mixed health systems?

What did we find out about public-private engagements and outcomes?

Evidence confirms that public-private engagements can improve health outcomes; however, not all projects seeking to strengthen MHS are associated with improved health outcomes. This may be in part be because changes in health outcomes take a long time to achieve — years instead of months.

Effectiveness of public-private engagements relies on several interrelated outputs and outcomes being triggered — that is to say that it’s important to think about public-private engagements operating within a complex system and consider the full theory of change. For example, if a public-private engagement doesn’t reduce maternal mortality, do we know whether it increased facility births or decreased patient costs? Do we know whether public-private engagement stakeholders improved their ability to communicate effectively? These are often intermediate steps toward longer-term health outcomes, and it would be useful to understand where along its chain of outputs and outcomes did things break down.

Relatedly, there is a dearth of research on how engagements strengthen system outcomes — like those related to stakeholders improved capacity to structure a public-private engagement or increased trust between the sectors.

What’s next?

Country actors and supporters alike should engage and invest in public-private engagements and invest in learning about these engagements to address evidence gaps. The literature provides strong evidence that public-private engagements can improve health, but more research is needed on how these engagements influence mixed health systems. We suggest that future research look more at the interconnections and recognize the complexity of observing change in mixed health systems as a results of public-private engagements. The first step is recognizing this complexity and making it clear that system-level outcomes are an important step to achieving health outcomes, and thus a critical set of outcomes in and of itself. Further research in this area may hold the key to understanding why some public-private engagements succeed while others do not.

And what about factors that help and hinder public-private engagements?

There are key structural, environmental and engagement factors that show evidence of influencing the success of public-private engagements, and these factors are highly interrelated. Improvements or challenges in one factor area can affect changes in others. In particular, structural factors (such as available resources or model of engagement) and engagement factors (such as will to engage, trust, and mutual understanding) can help or hinder engagement outcomes.

Good practices for tackling the myriad factors that can help or hinder public-private engagements:

  • Assess factors at the start of engagements. Knowing where partners are starting with in terms of engagement, structural and environmental factors is critical for partners and third-party supporters to diagnose which factors to work to address. Consider using the Environmental Factors Spectrum and Engagement Factor Progression Model tools developed as part of this project to improve PPE design and implementation.
  • Public-private engagement stakeholders and third-party brokers should first target and work to strengthen PPE structural and engagement factors given stakeholders’ relatively greater ability to influence these factors (versus broader public-private engagement environmental factors like political will and regulations that they may have less direct influence on).
  • Addressing engagement and structural factors can also help to “set the stage” for an effective launch of new engagements and lead to more successful and impactful engagements down the line.

Recommendations: It is important to understand that public-private engagements operate in complex adaptive systems and supporting these engagements and evolving MHS require a systems approach. Future work and research in the field should investigate whether by working on easier to affect engagement factors, actors can target improvements in trickier to affect other factors.

Finally, what’s the deal with the role of third-party support?

While evidence is limited, research and our own experience as third-party brokers has demonstrated several cases in which third-party brokers can help public and private sector partners identify and overcome obstacles they face in the successful design and implementation of a public-private engagement. Enabling and supporting third party support strengthens the mixed health system ecosystem and is an effective way for donors and funders to support better public-private engagement outcomes

Good practices for third-party support:

  • Celebrate early win Consistently reminding stakeholders of their common goal and sharing early wins of the engagement can help to ensure long-term buy-in from all stakeholders.
  • Ensure facilitation is led by local experts who bring local credibility and contextual familiarity to lead to successful mobilization, engagement, and motivation amongst public-private engagement actors.
  • Remain flexible. Third-party support success hinges on its ability to remain responsive and relevant to emerging needs within the engagement. Remaining flexible allows the third-party support to take advantage of strategic entry points – like adjusting to support public and private stakeholders respond to COVID-19.

Recommendations: There is limited evidence regarding the characteristics of third-party support that are most effective, highlighting three questions that would benefit from additional research: (1) what types of actors are best placed to provide support for different public-private engagements, (2) what types of support (such as technical, financial, or relational) are most critical, and (3) when in their lifecycles are public-private engagements best placed to start and stop third party support?

As countries across the world work toward ensuring universal health coverage (UHC) for their citizens, there is a clear need to optimize the engagement between government and the private sector to achieve population health goals and resilient health systems. This engagement is neither clear-cut nor obvious. Along this journey it will be important for country stakeholders (both public and private) to continue to define and communicate their needs related to strengthening mixed health systems and public-private engagement. It will also be important for the global community to listen and respond to these needs and support efforts to strengthen mixed health systems for UHC.

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