Strengthening Mixed Health Systems: Building the Case and Pathways for Quality Private Maternity Care

R4D believes that public-private engagements (PPEs) are a critical part of evolving mixed health systems and that PPEs exist within an “ecosystem” composed of environmental, structural, and engagement factors that impact a PPE’s success. To explore the role of these factors, R4D 1) supported two country-level PPEs in Kenya and India focused on improving maternal health, and 2) conducted associated global learning activities.

The Challenge

Many countries recognize their limitations in achieving the Sustainable Development Goals (SDGs) and universal health coverage (UHC) through public provision of health services alone — and wish to better steward the private sector to do so. However, they often lack information about local private providers and solutions in their countries, do not have a defined stewardship role, and/or are not supported by the appropriate institutional systems and processes to engage private providers in a mixed (public-private) health system. Similarly, the local private sector in many countries wants to engage with the public sector, but they need government direction on how to engage and how to identify strategic opportunities.

In low and middle-income countries around the world, an estimated 40% of women seek maternal and reproductive health care from the private health sector. This makes cooperation between sectors vital to improving maternal health and ultimately achieving the SDG targets to lower maternal mortality.

The Opportunity

Through this project, R4D aimed to:

  • Support governments and local private sector to demonstrate and document practical and actionable processes for integrating quality private maternity care into government-stewarded health systems
  • Produce global knowledge on the practical approaches that countries can adopt to effectively integrate quality private maternity care

Two principles for improving mixed health systems guided the project’s approach to achieving these aims:

  • Mixed health systems and PPEs should be fit-for purpose and responsive to a set of shared, validated country population health needs, demands, and challenges as expressed by the health system actors; and
  • All factors in the PPE Ecosystem should be considered in PPE design and implementation including environmental, structural, foundational, and engagement.

Additionally, both newly created and existing PPEs can benefit from the involvement of a third-party “trusted broker” who can provide technical support to both sectors, facilitate communication, and support the development of joint decision-making and planning.

By working together in a well-stewarded mixed health system, public and private sectors can ensure high-quality services are accessible across facilities, functioning referral systems and linkages between health centers, involvement of multi-sectoral perspectives in health decision-making, and adequate geographic coverage of affordable care.

The resulting evidence on how to successfully integrate quality private maternal care into mixed health systems, including synthesized learnings pulled from past experiences with PPEs around the world, are useful beyond the scope of this project and can help shape effective mixed health systems in a variety of contexts.

Our Work/Progress/Results

Through this project, R4D has led a series of global knowledge generation activities that focused on producing actionable knowledge and learnings on processes for strengthening mixed health systems while simultaneously supporting two country PPEs in Kenya and India. Throughout design and implementation of the work, R4D partnered with two local organizations – Insight Health Advisors in Kenya and Access Health International in India. These organizations ensured that technical support approaches were properly tailored to each country context and that the evidence used to help inform decision-making processes built on recent activity and avoided duplication of previous efforts.

Between November 2019 – April 2021, The SMHS project completed the following activities:

Produced a series of global knowledge products

  • An evidence review of existing scholarship on PPEs in maternal health aimed at understanding important existing evidence about strengthening mixed health systems.
  • The PPE Ecosystem, a framework that recognizes that PPEs exist as part of a complex network of helping or hindering factors and multiple health system actors operating at various points in an engagement. These factors include: environmental, structural, and engagement factors.
  • The Journey Guide for Effective PPE in Health which summarized the SMHS project’s process facilitation approach to support better engagement between public and private health sector actors as well as a compendium of existing publicly available tools and resources on PPE, including tools for facilitating or brokering a PPE. The Compendium also maps each tool to the PPE Ecosystem.
  • The project also produced three tools, discussed in the Journey Guide, that were essential parts of the support provided in Kenya and India. These include::
  • The PPE Resource Compendium, which gathered new SMHS-developed PPE tools (detailed above) along with existing publicly available tools and resources on PPE, including tools for facilitating or brokering a PPE. The Compendium also maps each tool to the PPE Ecosystem.
  • All of the above materials are synthesized together in the Journey Guide for Effective PPE in Health

Supported the development of a new PPE between key multisectoral stakeholders in Kakamega, Kenya

  • A co-creation process with county stakeholders to: 1) more deeply analyze, diagnose and validate challenges in county maternal health and PPE, 2) co-create action plans based on locally relevant solutions, while continuously working to build trust, willingness to engage, communication, and aligning on the engagement rationale.
  • Joint prioritization of a set of action plans focusing on five main challenges related to maternal health and their engagement, including:
    • Ineffective utilization of National Hospital Insurance Fund (NHIF) as a source of financing in both public and private facilities
    • Shortage of human resources for health (HRH)
    • Turnover and shortage of HRH
    • Lack of standardized supervision in public and private hospitals
    • Inadequate funds being channeled back to both public and private health facilities
  • Continuous coaching and mentorship to county and private sector actors.
  • A final workshop with county stakeholders to discuss achievements over the course of the project and how to continue collaborating in the future.

Results from this work include:

  • The creation of a private sector association to organize private providers and facilities.
  • Institutionalization of private sector representation in annual county work planning through the creation of a private sector engagement desk within the county health team, electing a private sector representative on the county monitoring and evaluation technical working group, and the drafting of a memorandum of understanding between the public and private sectors of Kakamega.
  • The creation of formal communication channels, including a multi-sectoral platform, to facilitate regular discussion between government, private, and financial/technical partner stakeholders.

Supported the strengthening of LaQshya-Manyata, an existing PPE designed to assure and improve the quality of maternity services in the private sector in Maharashtra, India

  • Facilitated a series of sector-specific meetings with public, private, and technical partner actors to understand their needs, demands and current perceptions of the PPE.
  • Supported the PPE actors to use the PPE Engagement Factor Self-Assessment tool to anonymously share and better understand individual stakeholder perceptions of the LaQshya-Manyata PPE.
  • Conducted a Rapid Health System Integration Assessment to identify some of the potential opportunities and barriers for continued integration of the LaQshya-Manyata engagement into the existing public system structure.
  • Developed design and material for a multi-stakeholder learning workshop between all parties involved in the LaQshya-Manyata engagement to discuss the results of the assessments and to begin co-creating solutions to further strengthen the partnership.

Generated and documented new evidence for global learning

  • Country Case Studies (Kenya; India case study available upon request). Process evaluations paired with qualitative analysis to answer learning questions for field activities in Kenya and India.
  • Secondary Case Review of PPEs in Health. A crosscutting analysis of six secondary cases aimed at studying and better understanding what factors are associated with successful and unsuccessful PPEs.
  • Learning Report. Brings together lessons and learnings that cut across the primary cases, secondary cases, evidence review, and experiences from the project

About Merck for Mothers

This program 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 US and Canada.

Global & Regional Initiatives

R4D is a globally recognized leader for designing initiatives that connect implementers, experts and funders across countries to build knowledge and get that knowledge into practice.