While public-private sector engagement in health has become increasingly de-jour — accepted and supported widely by global institutions, initiatives, some country change agents and funders alike — there remains a dearth of evidence on the factors associated with successful and unsuccessful public-private sector engagements in health. You can read more about this lack of evidence in our previous blog.
As part of an evidence review conducted through R4D’s Strengthening Mixed Health Systems (SMHS) project, supported by Merck for Mothers, we found (unsurprisingly) plenty of references to the importance of the “hard” or “nuts and bolts” factors of public-private engagement, such as contracting and regulation. But the literature also pointed to the importance of the dynamics and interactions between stakeholders — the “soft” factors that sometimes go overlooked.
Our lived experience of working in the space of strengthening mixed health systems and public-private engagement validated these findings. Together, then, experience and evidence alike suggest that while the technical elements of public-private engagement and system integration, such as regulatory and financing landscapes, are important and often challenging — equally challenging and impactful are the relationships, dialogue, understanding and collaboration between the public-private engagement actors.
Figure 1: Navigating major factors for effective private sector engagement
Building on these findings, our own tacit knowledge, previous work (demonstrated in in Figure 1) and input from global experts and local partners, we began to bring these “hard” and “soft” factors together to understand and propose a more holistic framework that describes a comprehensive public-private engagement ecosystem (Figure 2). This ecosystem recognizes that public-private engagements exist as part of a complex network of helping or hindering factors and multiple health system actors operating at various points in an engagement cycle.
Figure 2. Public-private sector ecosystem: factors for effective engagement
The ecosystem consists of three factor “sets”
1. Environmental factors that shape the operating environment for a given public-private engagement.
Individual actors in an engagement likely have indirect (if any) influence on these factors but the factors may impact the engagement’s effectiveness and should be considered. These include political, economic, legal, and organizational factors described in detail in work by Blanchet, Ishtiaq and Thomas (2019).
2. Structural factors that define the architecture of a given public-private engagement.
This includes the type of partnership model (e.g. bi-lateral, inclusive of a neutral broker and others), formalities of the model arrangement (e.g. existence of a formal memorandum of understanding) and available resources (both financial and non-financial) to implement the engagement.
3. Engagement factors that relate to the actors implicated in the engagement.
Generally, engagement actors have some control over these factors. Further, we categorized engagement factors into foundational and operational dimensions, which include both factors related to the relationship dynamics between engagement actors as well as their capacities and existing mechanisms that help shape an engagement. We posit that engagements must meet a minimum threshold of foundational factors — trust, mutual understanding, and willingness to engage – to be effective. That is to say that we think it is unlikely for an engagement to either get off the ground, operate effectively, or sustain itself at all without some combination of these three factors. Operational factors include managerial and technical capacities, communication, engagement rationale, and accountability, which are also critical to the successful operations of the engagement.
In addition to the factor sets, the framework references the validated health system gap. This gap refers to the health system problem or challenge identified by stakeholder(s), which the engagement is seeking to solve. This gap should be based on evidence, aligned with beneficiary demand, and validated by a critical mass of stakeholder(s) within the health system. We believe that public-private engagements that ensure they are responding to a validated health system gap will be more likely to succeed.
But why do we need another framework?
Good question! We hypothesize that IF engagement actors consider environmental, structural and engagement factors and design their engagement solution to fill a validated gap or challenge in the health system, THEN the engagement may be more likely to achieve its outcomes and effective, sustained system integration. To put it simply, we believe a more holistic approach to public-private sector engagement in health is needed. This framework helps to identify and map the ecosystem of factors that should be considered in a public-private engagement. It may also help assess some of the critical barriers to successful implementation.
While there has been much interest in public-private sector partnership, engagement and collaboration in global health, approaches have often been unilateral – focusing on the environmental, and to some extent structural factors, of the engagement — leaving aside the softer engagement factors. For example, focusing on ensuring effective contracting and procurement mechanisms without considering issues of mistrust between engagement actors may prevent a public-private engagement from even getting off the ground. We hypothesize that an approach that takes into consideration the complex ecosystem of factors together, and specifically considers the significance of engagement factors, will lead to more effective engagements.
To help engagement actors consider and analyze the different factors identified in the ecosystem we are currently mapping existing health system strengthening tools to this ecosystem, and where relevant tools don’t exist, we are developing additional tools. For example, we have identified several health sector specific tools that can support analysis of environmental factors but have not identified many tools that get at engagement factors. We are developing an engagement factor assessment tool and will be piloting this tool in India to support the Strengthening Mixed Health Systems project. Relatedly we are designing an engagement factor maturity model. Together these tools will allow health system actors to identify engagement related challenges and prioritize areas for strengthening.
Please watch this space, as we’ll be sharing more in the coming weeks and months. We’ll share greater detail about the engagement factor assessment and the maturity model we’re developing and applying in India. We’ll also share results from our review and mapping of existing tools and guidance. Additionally, we will explore why tools that already exist have or have not been used and what, if anything, is needed to help ensure health system stakeholders have the tools they need to mount successful public-private engagements.
The Strengthening Mixed Health Systems project is supported by funding from Merck, through Merck for Mothers, the company’s $500 million initiative to help create a world where no woman dies giving life. Merck for Mothers is known as MSD for Mothers outside the United States and Canada.
Photo © Geoffrey Mwangi/USAID