Opinion: Advancing access to care through public-private collaboration

Despite decades of efforts and focus on improving maternal health, we continue to see huge disparities in outcomes. The COVID-19 pandemic exacerbated geographic disparities and put a spotlight on the fragility of health systems everywhere, particularly in low- and middle-income countries, or LMICs.

Harnessing the power of private sector health providers is key to helping close an estimated $33.3 billion annual funding gap for reproductive, maternal, newborn, child, and adolescent health services globally. The United Nation’s Sustainable Development Goals, specifically SDG 17, calls for greater private sector participation as an important vehicle for mobilizing and sharing knowledge, expertise, technologies, and financial resources to support the achievement of the SDGs in all countries, particularly LMICs.

But what does this really mean in practice? And how can we operate differently to help improve maternal health through private sector engagement, while highlighting those who are already operating in a way that is improving health outcomes?

Amid ongoing challenges, collaboration becomes increasingly critical

There are several challenges faced by the public sector. One major roadblock I’ve observed is the ability of governments to integrate the outlook of health economics and the social determinants of health into their thinking. Often, the public sector must prioritize what to do with limited available resources at their disposal and find the best way to allocate resources for public sector health infrastructure.

When working to improve the quality of care and experiences for patients, it’s important to reframe health as a social and economic development concept, rather than only as a public good. This shift can help create more open conversations and opportunities for strategic collaboration with key stakeholders to help augment government capacity in response to public health goals.

Another hurdle has been the ability to help capacitate the public sector in terms of understanding the benefits, value, efficiencies, and impact of engaging private sector service providers, both for clinical and support services. Without the means to properly evaluate and strategically leverage health economic data within countries, there will continue to be limitations in how the public sector can prioritize and improve decision making around the utilization of public funds.

This can clearly be seen in the ongoing struggle to provide adequate, sustainable health solutions for women around the world. Despite significant shifts in the numbers of women giving birth in health care facilities, we haven’t seen a commensurate improvement in maternal death rates globally. This is partially due to the training levels of birth attendants and the resources at their disposal in providing care for women in these facilities and in the delays in seeking care, detecting risk, and escalating to higher levels of care. Integration of private providers at all levels — of prenatal care, intrapartum care, and even transport services — have been shown to significantly benefit outcomes.

Private sector support to help instill solutions for improved care

For private sector service providers, finding innovative models of capital deployment is highly influenced by fluctuations in currency exchange rates, with funders wanting to lend in dollars and borrowers earning income in local currency.

To expand services and access, private service providers need access to capital without punitive interest expectations or dollar-denominated values for financing that is appropriate for the community where we’re trying to expand access to health. On the patient side, innovative models of capital deployment will encourage the development of low-cost opportunities for primary care.

A proven case

A great example of a program that has worked to bridge the public-private divide is Unjani Clinics. MSD for Mothers is among private sector funders who are supporting Unjani Clinics with the goal of reaching underserved women in sub-Saharan Africa. Unjani Clinics is a network of nurse-led clinics that has developed a sustainable clinic model for providing primary health care in South Africa. The network is structured on social franchising principles, where Unjani “nursepreneurs” are both providers of affordable health care and maternal health services for those unable to access private health insurance, as well as entrepreneurs who lead their respective primary health care clinics.

In collaboration with the local authority, Unjani Clinics help to augment the capacity of the public sector by decanting patient volumes to accessible, affordable, community-based clinical services. In South Africa, almost 85% of the population relies on governmental services. The Unjani Clinic network provides a solution to reengineer and strengthen the sub-Saharan health system by providing community-based primary care facilities, providing patients a choice to self-fund their primary care and thus alleviating some of the burden that the public sector faces. Today, Unjani’s over 180 clinics are seeing thousands of patients each month, most of whom would previously have been seen in the public sector.

By combining entrepreneurial autonomy at the clinic level, with systems, standards, and controls at the central nonprofit company to safeguard the social mission, Unjani Clinic strives to strike the right balance between social and financial value creation that often prevents social enterprises from scaling successfully. The network aims to expand at a rate of 50-80 clinics per year, with a strategic plan to open over 600 clinics by December 2030.

In 2024, in partnership with major banks and development finance institutions, Unjani Clinics hopes to deploy an innovative financing model to provide affordable, long-term loans to new clinic owners to accelerate the expansion of the network across all nine provinces of South Africa.

Overcoming barriers for more seamless public-private collaboration

A significant barrier to achieving improvements in health care through the private sector often comes down to bias. We have all observed hesitancy to engage with the private sector due to a common misconception that the private sector is only focused on making profits. This notion has led to skepticism and lack of trust across the public sector, and it is critical we clearly demonstrate the private sector’s ongoing commitment to putting the needs of patients above all.

Additionally, governments are often resistant to private sector integration due to the long-standing legacy in ways of working and providing services for people. Many places have been providing health care through the same system for years and may be resistant to implementing new and different models of delivery of financing and care.

It is important for all of us to move past preconceived ideas of what is right and wrong and work together to adopt and adapt to every method we can find to provide the highest-quality care for the patients we all serve. By raising awareness around the private sector’s positive impact on community health, decision making for the greater good, and putting emphasis on targeted training and skills for individuals across the entire health care system, we can achieve better health outcomes together.

Expanding and improving

The public sector health system must be maintained and further developed. This is where top-end research happens, where bottom-end access happens, and where teaching happens.

But for those evaluating the development of capacity in public health service with solutions centered on adding a doctor or nurse or building a new clinic, I’d pose the following question: What if we were able to reduce public sector patient numbers by one and a half million engagements per year? That creates capacity within the existing system and that is what Unjani Clinic is doing right now in South Africa.

Strides toward a more capacitated public health service have been made in the most incredible way by arming patients with alternative options to receive high-quality care, helping to decongest the public systems and reduce the burden of the public sector. I am confident this can continue to expand and improve in the future.

For more commentary on the ways countries can engage with the private sector and thereby advance equitable access to high-quality, respectful maternal health care check out a recent panel discussing, How the Private Sector can Advance Equitable Access to Care.

The Funding the Future series is supported by funding from MSD, through its MSD for Mothers program, and is the sole responsibility of the authors. MSD for Mothers is an initiative of Merck & Co. Inc., in Rahway, N.J., U.S.

Join the conversation on finding private sector solutions to improve health service delivery for reproductive, maternal, newborn, child, and adolescent health (RMNCAH).