Mixed Health Systems

There is growing global consensus that achieving UHC and the Sustainable Development Goals (SDGs) will require strengthening “mixed health systems” — to optimize engagement between public and private sectors to equitably deliver quality products and services to consumers. Specifically, there is recognition that public sector delivery systems and supply chains alone lack the capacity to meet the demand in the system created by UHC commitments. However, by effectively stewarding mixed health systems, countries can level the playing field for both public and private sectors and innovators, increasing equity in access and quality of services and products across both sectors. Despite a greater understanding and commitment to strengthening mixed health systems and public-private engagement, the challenge of how to do so successfully remains.

R4D’s work to strengthen mixed health systems is rooted in several principles including that:

• Mixed health systems and public-private engagement should be fit-for purpose and responsive to a set of shared, validated population health needs, demands, and challenges as expressed by the health system actors;
• The public health sector should provide strong stewardship of mixed health systems, including: mobilizing, engaging, incentivizing, regulating, and monitoring public and private actors to optimize the health market;
• The private health sector can be engaged, organized, and shaped to provide high-quality, affordable health services that help countries move toward UHC through government incentives and targeted social investment;
• Sustainable private sector-initiated innovations should be shared throughout the marketplace; and
• Both “hard” (technical and system-level) and “soft” (engagement and interpersonal) factors must be considered to achieve effective, efficient and resilient mixed health systems.

Employing these principles, R4D’s approach to strengthening mixed health systems includes work in 5 areas:

1. Support national and sub-national governments to become better system stewards. Work with country governments including national ministries of health and health financing agencies to create policies and practices to more effectively engage and steward private providers of services and products.
2. Strengthen capacity and self-reliance of private providers, entrepreneurs and innovators. Support defragmentation of the private sector, build capacity of intermediary organizations and networks, while also strengthening the capacity and scalability of providers, entrepreneurs and innovators, including their ability to engage with the public sector.
3. Act as neutral brokers and incubate platforms and processes for dialogue. Facilitate deliberative dialogue processes to foster trust and mutual understanding among public and private sector, and incubate, structure, facilitate and sustain platforms to support public-private engagement.
4. Strengthen country enabling environments and technical assistance ecosystem for mixed health systems. Strengthen system processes and institutions to regulate and provide quality oversight, develop and integrate financing mechanisms, foster political will, and organize service delivery. Collaborate with local mixed health systems strengthening experts and partners to ensure work is properly tailored to each context and that the evidence used to help inform decision-making processes builds on recent activity and avoids duplication of previous efforts.
5. Facilitate global, regional and local cross-learning on mixed health systems. Enable, structure, facilitate and sustain networks and platforms for joint learning on mixed health systems at the sub-national, national and global levels. Act as a knowledge translator of learning and information on mixed health systems.

• Spearheaded seminal learning on mixed health systems and health market intermediaries that has informed global thinking and is consistently cited by global institutions, funders, and country practitioners alike.
• Pioneered and piloted novel processes for strengthening public-private engagement. This included conceptualizing a Public-Private Engagement Ecosystem that promotes consideration of environmental, structural and “softer” engagement factors when working to strengthen public-private engagement, and development of the Journey Guide for Effective Public-Private Engagement in Health that includes practical tools developed, applied and tested with public and private health system stakeholders in both Kenya and India.
• Designed and piloting strategic health purchasing arrangements for TB and MNH with the goal of incentivizing private provider behavior and shaping service delivery patterns under Indonesia’s national health insurance to increase the number of care-seeking clients in the private sector who are provided with quality, comprehensive care.
• Launched and ran the Center for Health Market Innovations to promote policies and practices that improve privately delivered health care for the poor in low- and middle-income countries. R4D connected donors, impact investors and policymakers to innovators running programs profiled in CHMI’s database.
• Helped improve the financial sustainability of social franchise networks / intermediaries in Cambodia, Nigeria, Tanzania, and Uganda. R4D supported intermediaries to identify pathways to financial sustainability through accessing public funding more effectively, establishing and leveraging the role of the intermediary in facilitating successful PSE, and, ultimately, mitigating the financial barrier to service utilization faced by women and girls.
• Launched and facilitated the Joint Learning for Universal Health Coverage’s Private Sector Engagement Collaborative. Worked with country stakeholders to develop and publish the JLN Engaging the Private Sector in Primary Health Care to Achieve UHC: Advice from Implementers to Implementers, and worked with country stakeholders to conduct and synthesize learning on  Regulation of Private Primary Health Care across 6 countries.