Public–private dialogue: an essential approach to engage non-state actors in a mixed health system

Abstract

Evidence shows that low-income and middle-income country (LMIC) governments are still facing challenges to systematically engage the private sector in health. Barriers to greater interactions between public and private health partners include mistrust of the private health sector’s motives and misunderstanding of the profit motive, based on deep-rooted philosophical beliefs and personal experiences.

This paper examines the implementation of public–private dialogue (PPD) as a means for addressing the aforementioned barriers facing the engagement of the private sector in health in LMICs. The paper responds to a research gap surrounding the process of conducting PPD in health by defining PPD, describing the associated risks and benefits learnt from country examples and providing tactics for leveraging the benefits while addressing the potential risks of PPD. The paper also emphasises the similarities between the process to conduct PPDs in health compared with other social and economic sectors, with the exception of one additional risk, namely ‘institutional misalignment’. This additional risk observed in the health sector can be attributed to the limited capacity of Ministries of Health to govern the private sector and the diversity and fragmentation of private health sector entities.

Summary box.

• Public–private dialogue in health is increasingly being sought by policy-makers as a means for building relationships with the private health sector and for accessing private sector capacity and resources.

• In low-income and middle-income countries, the process is rarely institutionalised and happens on an ad hoc basis with limited evidence on its outcomes.

• Despite the widely available guidance on the process and its implementation in social and economic sectors, there is very limited guidance on its application in the health sector and the key considerations for its successful implementation.

• Explains the observed similarities and differences in the risks and benefits of conducting public–private dialogue in health compared with other social and economic sectors.

• Documents what is known about the experience of implementing public–private dialogue in health in resource-constrained settings.

• Provides practical considerations for conducting public–private dialogue in health that are grounded in country experiences.

• The paper addresses a research gap on necessary conditions and actions that yield successful public–private dialogue in health and particularly in resource constraint settings.

• The paper provides a synthesis of lessons learnt on mitigation tactics grounded in country experiences that support policy-makers to anticipate potential challenges and on factors enabling reaping the benefits of an inclusive process without compromising national health policy goals and objectives.

Introduction

Public–private engagement in health has become increasingly accepted and supported by low-income and middle-income country (LMIC) health ministries and the international global health community. The private health sector is bringing significant capacity, resources and valuable expertise that governments can leverage to improve their population health outcomes.¹ Private sector engagement (PSE) in health is defined as ‘the meaningful inclusion of private providers for service delivery in mixed health systems’.^{2 3} Examples of PSE include private sector collaboration in strengthening public supply chain, expanding access to essential health services, providing ancillary services, leveraging expertise in health and information technologies and building infrastructure, to name a few.^{4 5} There are different modalities to engage the private sector in these areas of collaboration, such as policy dialogue, information sharing, participatory governance, capacity building, technical assistance and public–private partnerships.⁶

The COVID-19 pandemic has underscored the need to strengthen PSE, with the pandemic’s direct impact on service delivery, supply chains for essential health commodities, medical equipment availability—all areas where the private sector plays an active role. COVID-19 demonstrated that countries with existing mechanisms for PSE and dialogue platforms were better able to quickly mobilise and align private sector capacity and resources with those of the public sector to implement a cohesive national emergency response.⁷ The pandemic has also created an opportunity for forging new forms of collaboration and partnerships for both COVID-19 diagnosis and treatment, maintaining essential health services and building resilient and equitable health systems.⁷

Yet, evidence shows that LMIC governments are still not well positioned to systematically engage the private sector in health.^{8 9} Barriers to greater interactions between public and private health partners include mistrust of the private health sector’s motives and misunderstanding of the profit motive, based on deep-rooted philosophical beliefs and personal experiences.^{10 11} Token and infrequent interactions between the two sectors perpetuate mistrust, often to the disadvantage of the population groups who need the services most.⁸ Interactions with the private health sector may also be largely punitive, with health regulations and guidelines implemented more strictly in the private sector.¹²

This paper examines one of the modalities to engage the private sector—public–private dialogue (PPD)—and its importance in addressing many of the barriers that public and private sector stakeholders face to collaborate and partner. As the literature review and country examples demonstrate, there is limited experience in PPD in health and especially in LMICs. Due to the scant resources on PPD in health, the methodology entailed conducting a desk review about policy-making in LMICs and extracting examples in which PPD was implemented during the different stages of the policy cycle. The search strategy included the following keywords ‘health policy’, ‘public-private dialogue’, ‘multistakeholder dialogue’, ‘societal dialogue’ and ‘policy dialogue’. The paper attempts to document what is known about the types of PPD in health in resource-constrained settings, the risks and benefits of PPD and PPD strategies and tactics, as well as what is newly learnt from country examples of PPD.

What is public–private dialogue?

To assist LMIC governments to align different stakeholder groups—such as different government agencies, private health sector groups and civil society organisations—it is important to first understand what PPD is. Definitions of PPD vary greatly with a wide range of terms used: ‘platform’, ‘roundtable’, ‘committee’, ‘partnerships’ and ‘deliberations’.¹³ Box 1 offers a working definition of PPD.¹⁴ A PPD process encourages the public sector to regard stakeholders, like the private health sector and civil society, as equal partners and to become more transparent in their decision-making and interactions with them.¹⁵ PPD can be considered another form of inclusive policy dialogues and/or multistakeholder dialogues but with a focus on genuine involvement of non-state stakeholders.

Box 1. Working definition of public–private dialogue (PPD).

‘PPDs are structured mechanisms—both temporary and permanent—anchored at the highest practical level, coordinated by a secretariat, that facilitates a process involving a balanced range of public, private and civil society actors to identify, filter, prioritise, accelerate, implement and measure policy reforms and actions.’

(Adapted from Herzberg, 2016).

PPD experience in other social and economic sectors demonstrates that PPDs come in many forms: they can be structured or ad hoc, formal or informal, broad-based or issue-specific, permanent or time-bound.¹⁶ Nevertheless, experience suggests that a structured, intentional process often leads to more productive dialogue.¹ A health-related PPD does not necessarily have to be initiated by a government agency like the Ministry of Health; it can be driven by other arms of government, private sector entrepreneurs, civil society leaders or intermediaries such as international donor agencies.^{1 17} Depending on the focus of the PPD, the process involves the government interacting with either a single group in the private health sector or with a wide range of private sector entities through umbrella groups that represent private sector actors and civil society groups.^{1 17} The multiplicity of PPD forms underscores the lessons from country examples of PPDs in health: one type of PPD does not fit all countries and needs to be designed to fit the local context and actors.

Experience in other social and economic sectors demonstrates that a PPD process typically undergoes three separate phases in its lifecycle: Discovery, High-impact results, Future directions (see figure 1).^{15 18} In the first phase—Discovery—the PPD process focuses on building trust, educating the different partners about one another and discovering what works and does not work to facilitate collaboration. During this phase, the public and private PPD partners put in place a structure, set the ‘rules’, and define the focus of the PPD process. This phase may yield limited results but can generate quick wins. The discovery process may last from 6 months to 3 years.

Figure 1. PPD life cycle. PPD, public–private dialogue.

Phase 2—Highimpactresults—is the most productive phase. The PPD partners are motivated by early results and become more experienced in working together. During this phase, the PPD partners understand the PPD process and are comfortable with the PPD structure. Many of the partners have also gained new collaboration competencies and skills during the first phase that they now use in the day-to-day management of the PPD process. The PPD partners begin to realise not only results but also policy and programme successes. This phase may last from one to three years, depending on how successful the PPD partners are in resolving conflict, sustaining momentum and achieving results.

As the PPD process takes on a life of its own, it is appropriate for the PPD partners to question its future direction. In phase 3—Future directions—PPD partners ask: Should the dialogue process be maintained in its current structure? Should it take on new challenges? Should it be transferred to a more appropriate organisation such as a government, non-partisan institution and/or advocacy group? Or, perhaps, the PPD process has run its course and should be disbanded.

Benefits of PPD in health

The literature review of the limited examples of PPD in LMIC health systems reveals known benefits to involving the private health sector in policy dialogue. A formal PPD structure and process can have an immediate effect on increasing and improving interactions between public, private and civil society groups, as well as yielding a deeper and more long-term impact. Figure 2 presents the most cited benefits of a PPD process in health while box 2 shares country examples that illustrate the benefits of PPD.^{15 19} It is interesting to note that the country examples align with other social and economic sectors’ stated benefits of PPD.

Figure 2. Benefits of public–private dialogue (PPD) in health.

Box 2. Country examples of public–private dialogue (PPD) supporting effective governance, policy design and implementation in health.

Better diagnosis and policy design:developing a new regulatory framework for private sector engagement in Ivory Coast .

With support from the World Bank Global Financing Facility, Ministere de la Sante Publique (MSP) in Ivory Coast formed a dialogue platform to create a ‘level playing field’ in which multiple stakeholder groups could interact on different policy initiatives, including drafting a policy on private sector engagement. The consultative process revealed several policies and regulations creating barriers to a private role in strategic purchasing of essential health services—a strategic area for the MSP’s universal health coverage plan. The process paused while the MSP hired a local lawyer to review a select number of laws, policies and regulations. The said consultant presented his recommendations to eliminate, harmonise and/or update the target policies and regulations, which were widely discussed once the PPD process resumed. The additional analysis revealed many of the private sector concerns that presented barriers to a greater private sector role and enabled the MSP to include their interests and perspectives leading to concrete actions. Based on the analysis, the MSP not only continued the consultation to finalise a draft of the new PSE Policy but also launched several initiatives to reform key policies and regulations based on the legal review and private sector input.²⁴

Fosters better understanding of the health system’s reform objective:increasing awareness and buy-in for health financing reforms in Morocco.

With support from four international technical agencies, the MSP in Morocco led a consultative process to develop a health financing strategy. Over 250 stakeholders from government, private sector, Non Governmental Organisations, civil society and parliamentarians participated in a year-long process that helped develop a common understanding of the country’s health financing challenges, awareness of the government’s policy objectives and collective ownership of financing actions. This experience also marked a shift from previous top-down approaches in designing health policies to more participation inclusion, buy-in from the private sector for the proposed financing reforms. In the past years, former strategies on health financing were not implemented because of the lack of participation in the process and design and lack of political legitimacy and technical ownership.²⁵

Removes implementation bottlenecks:adapting to changing environment to continuetuberculosis(TB)partnerships in the Philippines .

The United States Agency for International Development assisted TB public and private actors in the Philippines to create a national platform facilitating a PPD process to codesign strategies to increase private TB case notification and reduce prices for patients. The PPD explored market-driven solutions, such as pooled procurement of TB tests and drugs and concessional pricing for private hospitals and laboratories. The TB Consortium developed a plan to have regular promotional activities with physician groups and hospital networks and to advocate for use of the primary diagnostic test—the rapid TB test. But the Philippines went into lockdown due to COVID-19 as the Consortium was launched. Inclusion of private sector stakeholders helped the government design a solution to carry on the TB partnerships. They immediately shifted to a digital platform that included online virtual events for scientific meetings and training for private laboratory staff and a patient portal. Despite the challenges created by COVID-19 lockdowns, the TB Consortium undertook six rounds of pooled procurement in less than 1 year on behalf of its members, comprised large hospital and laboratory networks.²⁶

Mitigates risk:solving problems together through PPD in Tanzania.

The Deutsche Gesellschaft fur Internationalze Zusmmenarbeit supported the Tanzanian Ministry of Health and Social Welfare (MOHSW) to create and facilitate a public–private dialogue platform—Public Private Health Forum—to improve access to quality healthcare, particularly in rural areas. The Forum’s leadership, comprised public and private ‘champions’, held monthly meetings to institutionalise the relationships between public and private stakeholders and identify areas of collaboration. These monthly meetings were critical to coordinate partner activities, share resources and solve problems. The Forum leadership also held quarterly Board meetings to monitor progress on the Forum’s policy agenda, reflect on successes and failures, and make mid-course changes in the Forum strategy as needed. Through the Forum, the public and private leaders identified access to quality maternal health services for rural women as a priority. Using the Forum as a convening mechanism, public and private stakeholders identified a solution to address this problem. MOHSW signed 28 service agreements that secured free access to private hospitals for pregnant women and children under 5 if they do not live near a public hospital. In addition, through the Forum, private enterprises supported the enrolment of more than 30 000 informal sector workers and their families in community health funds and therefore protected them from financial hardship in the event of seeking health services.²⁷

Better diagnosis and policy design

Inclusive policy dialogue in health is increasingly recognised as an important tool for health systems governance by improving and fostering use of evidence in policy design and implementation.²⁰ PPD facilitates interactive knowledge-sharing that allows evidence to be linked to the perspectives, experiences, and knowledge of those who will be involved in, or affected by, future decisions about high-priority issues.²¹

Fosters better understanding of a health system’s reform objective

Including the private sector and civil society in policy or programme design leads to private health sectors and civil society’s better understanding of the government’s intent from the reform and fosters private sector and civil society acceptance and support for the implementation or even ownership of the reform.^{15 19}

Removes implementation bottlenecks

Including the private health sector and civil society through a PPD process in policy design and implementation recognises each stakeholder group’s qualities and competencies and finds ways to harness them for the common good. The PPD process also fosters more realistic and workable implementation plans by incorporating all health actors’ perspectives and constraints^{15 19} as well as increasing the likelihood that both these stakeholder groups will accept and put the policy and regulatory reforms into practice.¹⁹

Mitigates risk

Frequent and consistent communication and sharing information with private sector and civil society groups during design and implementation enables governments to be better prepared for managing conflicts and troubleshooting problems as they arise.^{15 19}

More predictable business environment

Establishing policies, regulations and health plans through a transparent and participatory process enables private health partners to make investments in the health system based on long-term returns and sustainable initiatives rather than temporary measures.¹⁹

Risks of PPD and mitigation measures

As in any political process, there are risks for both the public, private and civil society groups who participate in a PPD. If done poorly, a PPD has the potential of wasting resources and worsening the problem it is intended to solve.¹⁵ Figure 3 describes some of the potential pitfalls in PPD.^{15 18} Nonetheless, recognition of the risks, along with proper planning and dialogue skills, can help PPD public and private actors avoid these shortcomings. There are five primary risks—described below—along with specific tactics to address each one.¹⁵ However, the country examples allow us to infer a sixth and added risk in health PPDs. Box 3 offers country examples of tactics used by governments to overcome risks in an inclusive dialogue process.

Figure 3. Risks of PPD process in health. PPD, public–private dialogue.

Box 3. Country examples of tactics addressing risks in public–private dialogue (PPD).

Reinforced vested interest: employing diverse tactics to ensure multistakeholder participation in Tunisia.

Following the Arab Spring, the Tunisian government organised a large-scale consultation—called the Societal Dialogue for Health System Reform—to address existing governance issues in the health sector. The government formed a steering committee composed of 75 individuals representing different segments of the Tunisian health sector including government, private health sector and civil society. Over the course of 2 years, the Societal Dialogue process consulted a wide range of stakeholders through multiple channels to ensure diverse perspectives: (1) the Technical Committee engaged more than 800 experts to validate the in-depth assessment of the Tunisian health system, (2) the Steering Committee convened two ‘rendez-vous’ in 26 regions with over 32 424 participants and (3) the Steering and Technical Committees involved 92 health professionals and citizen advocates together with 15 national and international experts to integrate the stakeholders’ comments into the assessments and policy recommendations. This PPD process ultimately led to the adoption of the ‘White Book for Better Health in Tunisia’ which was followed by another phase of dialogue (2016–2020) consulting with the adoption of the 2030 National Health Policy.28,30

Over-representation/under-representation:unifying the private sector voice to ensure private sector representation in Ethiopia.

Like many health sectors in sub-Saharan Africa, Ethiopia had multiple professional and facility associations claiming to represent the private health sector. In 2016, the Minister of Health expressed the challenges in terms of time and effort for the Federal Ministry of Health (FMOH) to engage the fragmented private sector in policy and programme activities. The Minister encouraged the private sector to unify in an umbrella association, and with support from the World Bank, the multiple private entities came together to the Ethiopian Healthcare Federation (EHF) in 2019. By 2023, EHF became the largest and strongest umbrella organisation of private health actors in the country, comprised 16 member associations representing over 25 000 members associates in all 10 regions and two administrative cities. The FMOH has been able to actively include the private sector through EHF. During COVID-19, EHF served as a dialogue and coordinating platform supporting the FMOH’s response to pandemic and helps the FMOH to rehabilitate health facilities in conflict-affected areas^{31 32}

‘Talk shop’syndrome:Formalisingthe process to ensure momentum ontuberculosis(TB)diagnostics in the Philippines.

In the Philippines, the public and private actors working on procurement, distribution and delivery of TB tests created a PPD process to improve coordination of their activities to increase access to TB diagnostics. The Philippine Coalition Against Tuberculosis, a leader on efforts to stop TB, served as an honest broker by helping the public and private stakeholders to formalise how the two sectors would work together. The Consortium facilitated agreements on roles and responsibilities and processes through ratification of its own charter and the development of memorandum of understanding with Consortium members, suppliers and distributors. Furthermore, the Consortium formalised the process through an elected Governing Council voted by the general assembly. The Council meets quarterly to ensure the mandate and vision of the Consortium. In less than a year, the consortium has reduced the cost of GeneXpert TB by more than 70%.²⁶

‘One person’show:Establishing mechanisms to ensure participation and representation in Tanzania.

Early in the life of the Tanzanian Public Private Health Forum, the leadership put in place several mechanisms to ensure inclusion—both at the leadership and membership level. The Forum established a ‘board’ comprised 23 members representing the public and private sectors (health professionals, service providers and civil society) and development partners. The Board signed a code of conduct with provision to rotate the Board leadership positions to shared leadership between the different actors, set rules on joint decision-making to not give one sector more weight over another, and agree on a firm meeting schedule.^{33 34}

Political capture:Compromise to avoid total opposition to National Pharmaceutical Policy in Cabo Verde.

In 2013, the government in Cabo Verde (GCV) established an inclusive process to develop a National Pharmaceutical Policy. One of the government’s objectives for this new policy would be to restrict the sale of brand pharmaceuticals and replace them with generic drugs. They were immediately met with strong opposition from private pharmaceutical importers and wholesalers as well as private pharmacies who pushed for the inclusion of brand drugs. Eventually, the GCV had to compromise to enable the dialogue process to run its course and fulfil its objectives of putting in place a new National Pharmaceutical Policy.²³ The GCV agreed to allow the private sector to continue selling brand name drugs while at the same time, offer incentives to increase sales of generic products. Although the government was unable to achieve one of its policy objectives—exclusive use of generic drugs—they ultimately achieved their overarching goal of adopting a new National Pharmaceutical Policy.³⁵

Institutional misalignment:Duplication of roles and responsibilities in regulating the pharmaceutical industry in Cabo Verde.

During the same period in the PPD process to develop the National Pharmaceutical Policy, the stakeholders identified an operational issue that created confusion for the private sector stakeholders and tension between different regulatory agencies. The roles and authority between the Direcção General de Farmácia and Agência de Regulação e Supervisão de Produtos Farmacêuticos e Alimentares were unclear. The PPD process was able to clarify the different agencies’ roles and responsibilities under the new National Pharmaceutical Policy.²²

Reinforced vested interests

Selective representation is a common problem in PPD.¹³ Government officials often have long-standing relationships with certain private sector individuals and/or groups in the health sector. Moreover, both public, private and civil society groups may define their roles in relation to their stake in solving a problem.¹³ If poorly planned, PPD can reinforce vested interests and cronyism, give undue influence to certain private sector ‘favourites’, and provide a veneer of legitimacy for bad policies.^{15 19} Similarly, the private sector can also abuse this privilege, especially if private organisations are not representative of the private health sector and promote their own company’s interests.¹⁵

Tactics to address vested interests.

• Establish and share widely criteria to select diverse stakeholders to participate in a public–private dialogue (PPD) initiative.

• Establish numerous working groups as an effective strategy to integrate diverse actors.

• Invest time upfront to set the ‘rules’ on how PPD partners will work together—it pays off in the long run. As part of the ‘rules’, establish mechanisms to hold all PPD partners equally accountable.

• Express the ‘rules’ in a code of conduct that all PPD partners sign—preferably in a public forum.

• Ensure that no topics are off-limits for discussion.

Over and under representation

Over-representation/under-representation of public and private sector groups is another risk. Private health sector and civil society groups in most LMICs are not well organised, making it difficult to select truly representative organisations to participate in PPD, therefore, risking under-representation.¹³ Under-representation reinforces the government’s tendency to work with the same private sector individuals/groups and to overlook civil society and smaller, rural private sector actors.¹⁵ Government entities may also feel threatened, so they may invite more public officials, creating a problem of over-representation.

Tactics to ensure balanced representation.

• At the beginning of the process, landscape all stakeholders to identify a diverse range of individuals/groups. Update the landscape exercise periodically to recalibrate the ‘mix’.

• Analyse stakeholders’ interest in and capacity to participate in a public–private dialogue (PPD) process in advance of forming the PPD. Do not think of the private sector as an organised, ‘single’ constituency.

• Civil society organisations (CSOs) are often overlooked in PPD.

• Take care to purposefully involve them from the start, including adding CSO representation in the core leadership group. Invest in building PPD partners, particularly private sector capacity to represent sector-wide interest.

• Seek the support of a neutral party (eg, multilateral development agencies) in the selection of stakeholders and/or the establishment of representative bodies.

‘Talk shop’ syndrome

‘Talk shop’ syndrome with no action is the most common risk in a PPD process. If poorly planned and unfocused, PPD can devolve into a process that does not achieve results or actions. Participants become disillusioned, disengaged. If the process loses focus and credibility, then it can potentially strengthen the position of opponents to the proposed policies and slow down the reform process.^{15 18 22 23} Alternatively, insufficient time for discussion may limit the ability of participants to present their views and endanger the quality of dialogue.²³

Tactics to avoid becoming a ‘talk shop’.

• Codevelop a common understanding of the problem and agree on the objectives of the public–private dialogue (PPD).

• Conduct a survey about time availability among PPD participants before initiating the process and ensure commitment to the indicated slots.

• This would help in planning the dialogue among concomitant commitments that participants will likely have.

• Maintain a strict and regular meeting schedule to review progress (using data) and to hold all partners accountable to their commitments.

• Codevelop meeting agenda, communicate all meeting agendas well in advance, and share meeting notes/action items shortly after the meeting with all PPD partners.

• A well-resourced secretariat can support PPD partners to organise and manage efficient meetings.

• An experienced and resourceful ‘honest broker’ can facilitate meetings and manage PPD partners’ expectations in private conversations beforehand.

‘One person’ show

All PPD processes rely to some degree on the enthusiasm and commitment of a small group of champions. Involvement of top-level government officials and the private sector is one of the determining factors of a PPD’s success. However, building the PPD process too closely around an individual creates significant risk as the individual(s) become less involved or leave the PPD initiative.^{15 18}

Tactics to forestall a ‘one person’ show.

• Manage PPD partners’ time commitment carefully to avoid ‘burn out’.

• Create ‘space’ for others led by delegating and allowing others to assume responsibility for activities

• Rotate and/or plan for succession of leadership. Foster bottom-up support and enthusiasm among a wide range of public–private dialogue (PPD) partners for the initiative.

• Promote the PPD initiative among ‘influential’ (high-level government officials, private sector leaders) to motivate PPD partners to stay involved.

• Establish smaller working groups to create a safe space for less senior participants to voice their opinions without being shadowed by those regarded as experts in the room.

Political capture

Businesspeople may also be leading figures in opposition political groups, making it difficult to persuade governments to engage or to keep a PPD politically neutral. -PPD also risks being monopolised by extremely powerful interest groups that are often in control of key resources and have crucial influence on the government and dialogue process. If not managed carefully, a PPD process can become a façade and screen for collusion, corruption and government/private capture of vested interests.^{15 18 19}

Tactics to prevent ‘political capture’.

• Promote the public–private dialogue (PPD) initiative to the public through an effective outreach programme by emphasising the practical benefits to real people.

• Establish an accountability mechanism between the public and private stakeholders as well as between the PPD initiative and the public.

• Make the PPD process more public.Promote the PPD initiative among ‘influential’ (high-level government officials, private sector leaders) who can facilitate and/or obstruct a PPD process and its proposed reform to help defuse opposition.

• Ensure the PPD mechanism is independent or enjoys some degree of autonomy from government.

Institutional misalignment

When setup as an initiative to fill the existing void created by the inability of institutions to fulfil their roles, the PPD scope and mandate may end up creating competition. Careful thought must be given to whether the scope and mandate of the PPD would overlap with those of existing institutions. All concerned parties may discuss these issues before starting the process to avoid duplication of efforts.^{15 18}

Tactics to align different institutions.

• Establish a public–private dialogue (PPD) steering committee comprised representatives from competing public institutions to ensure alignment within the public sector in its interaction with the private health sector.

• Public and private organisations share their institution’s vision and purpose to find common ground. Take the initiative and set up a meeting to get to know your government/private sector counterparts and/or invite government/private sector groups to public events.

• Share information and data with each other.

• Develop a common understanding of the problem to be addressed through PPD and agree on shared metrics defining success in overcoming the problem.

Conclusions

This paper examines PPD and its importance in addressing many of the barriers that public and private sector stakeholders face to collaborate and partner in achieving national health goals and objectives, such as containing COVID-19 or achieving universal health coverage. Although there have been extensive research and examples of successful PPDs in economic, financial and social sectors, there has been limited experience and research in PPDs in LMIC health systems. The paper, through a limited literature and country examples, shows that there is a growing interest in PPDs to address critical issues in LMIC health systems. Moreover, these PPDs in health are similar to those in other sectors in terms of definitions, types, risks and benefits of PPD and tactics.

LMIC governments and health ministries increasingly accept and support engagement of the private health sector to help them achieve national health goals and objectives. The recent experience during the COVID-19 pandemic underscored the need to strengthen PSE, demonstrating that countries with functional policy dialogue platforms and policy instruments to engage the private sector were better able to quickly mobilise and align private sector capacity and resources.

Indeed, LMIC health ministries are eager to engage the private health sector. Yet, the country examples demonstrated that each country is at a different stage of engagement based on different variables such as how uniform is government support to engage the private sector as well as how well organised is the private sector into associations that represent its diversity. As a result, the PPD process, stakeholder composition, risks faced and tactics used varied from country to country. This article further supports government interests in engaging the private sector and that the PPD approach is a valuable tool to engage non-state actors to address challenges facing mixed health systems.

Facilitating a productive PPD process requires new skills, competencies and resources to better maximise its potential benefits while minimising risks. As challenging as a new way of governing sounds, it is not beyond the reach of LMIC governments and their private and civil society partners. As the country examples demonstrate, participatory processes like PPD are difficult but not impossible to conduct; despite the risks, some have embarked on PPD processes with notable success. To empower more LMIC governments to work with private sector and civil society counterparts to initiate a PPD process that will tackle important public health issues, more research is needed given the limitation of the ad hoc literature review and small number of country examples. Potential areas of future research include (1) what types of PPD mechanisms are most productive in health, (2) what approaches can effectively organise diverse private health sector actors and (3) what tactics and skills are needed to build trust and mitigate a PPD process’ risk in the health sector.

The author is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the World Health Organization.

Data availability statement

Data are available in a public, open access repository.