Private sector engagement to deliver maternal, newborn, child health and family planning services during COVID-19 in Uganda
Private sector engagement to deliver maternal, newborn, child health and family planning services during COVID-19 in Uganda Private sector engagement to deliver maternal, newborn, child health and family planning services during COVID-19 in Uganda ISBN 978-92-4-008021-8 (electronic version) ISBN 978-92-4-008022-5 (print version) © World Health Organization 2023 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, pro- vided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Private sector engagement to deliver maternal, newborn, child health and family planning ser- vices during COVID-19 in Uganda. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see https://www.who.int/publications/book-orders. To submit requests for commercial use and queries on rights and licensing, see https://www.who.int/copyright. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned com- ponent in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. How- ever, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Graphic design by Justine Fisher, Impact for Health International. iii Acknowledgments Abbreviations and acronyms Definitions Abstract Introduction Methodology » Design » Ethics and consent » Key informant interviews » Analysis Framework Findings » Align structures » Foster relations » Build understanding » Enable stakeholders » Nurture trust » Deliver strategy Discussion Conclusion References Annex: Interview Guide iv iv v v 1 2 2 2 2 2 3 3 4 5 6 7 8 9 10 11 12 13 Contents The World Health Organization gratefully acknowledges the contributions of those who agreed to be interviewed as key informants for this study. This report was written by: Gabrielle Appleford (World Health Organisation), Anna Cocozza (World Health Organisation), Blerta Maliqi (World Health Organisation), David Clarke (World Health Organisation), Simon Muhumuza (Makerere University School of Public Health), Olive Sentumbwe-Mugisa (World Health Organisation Country Office, Uganda) and Jesca Sabiiti (Department of Reproductive and Child Health, Min- istry of Health, Republic of Uganda). The overall coordination of this document was led by Mr. David Clarke. The data was collected, organized and synthesized by Gabrielle Appleford and Anna Cocozza. The authors express their gratitude to WHO country colleagues in Uganda for the support provided in identifying countries’ key informants. Financial support for the preparation and production of this publication was provided by MSD for Mothers. essential health services family planning low- and middle-income country department of maternal, newborn, child and adolescent health and ageing maternal, newborn and child health Ministry of Health primary health care WHO’s system governance and stewardship unit small and medium-sized enterprises universal health coverage Uganda Healthcare Federation World Health Organization EHS FP LMIC MCA MNCH MoH PHC SGS SME UHC UHF WHO Acknowledgments Abbreviations & Acronyms iv The private sector includes all individuals and organisations that are neither owned nor di- rectly controlled by governments and are involved in the provision of health-related goods and services. These consist of formal and informal healthcare providers ranging from drug shops to specialised hospitals, comprising for-profit and not-for-profit entities, both domestic and foreign. For the purposes of this brief, we focus on domestic private sector entities (1). Health system governance refers to how governments ensure that strategic policy frame- works exist and are combined with effective oversight, coalition-building, regulation, atten- tion to system design and accountability (2). Stewardship refers to how government actors take responsibility for the health system and the well-being of the population, fulfil health system functions, assure equity, and coordinate interaction with government and society, including the private sector (3). This case study documents the experience, benefits, challenges, and lessons learnt of engaging the private sector in health to maintain the delivery and use of essential maternal, newborn and child health (MNCH), including family planning (FP) services during the COVID-19 pandemic in Uganda. A case study methodology was employed, drawing on desk review and key informant interviews, which were conducted between November and December 2021. Sev- eral opportunities were raised by respondents, to seize momentum, to ‘build back’ and nurture trust in the health system eroded by COVID-19 pandemic, harnessing all health sectors. While these were specific to Uganda, they are applicable to a wider audience and contexts. Definitions Abstract v Private sector Health system governance Stewardship © WHO / Esther Ruth Mbabazi
In many low- and middle-income countries (LMICs), health systems comprise both public and private enti- ties, with the private sector in health playing a large and expanding role in healthcare service delivery (4). This represents a mixture of both opportunities and threats for the provision of essential health services (EHS) and for health system governance. The way the private sec- tor is organised and operates is significantly influenced by the organisation and behaviour of the public sector, with a well governed and competent public health sys- tem generating complementary private healthcare ser- vice delivery (1). In contrast, countries with weak gover- nance and an unregulated private sector in health may also have an inefficient and inequitable public health system (1). In sub-Saharan Africa, 35% of outpatient care is deliv- ered by the private-for-profit sector and an addition- al 17% is delivered by informal private providers (4). Consequently, national health policies increasingly rec- ognize the importance of engaging the private sector in health. The impacts of these contributions however depend on appropriate governance prerequisites, in- cluding institutions, management capacities, a culture to collaborate, amongst others to allow effective part- nerships and delivery designs that target the needy and underprivileged (5). A change in mindset across the healthcare value chain is thus needed to position the Introduction private sector as a co-investor and partner in healthcare systems (6). This has been particularly emphasised by the outbreak of the COVID-19 pandemic. Putting all health systems under constraints, the emergency partic- ularly exacerbated the need for governments to deploy whole-of-government and whole-of-society approaches to respond to health crises. This has been seen in many LMICs, where the private sector played a crucial role in supporting governments in the fight against the pan- demic, bringing resources, skills and capacities to maxi- mize the national response, and filling the public sector needs in maintaining essential health services (7). Building on the existing work of the WHO Health Sys- tems Governance and Stewardship unit and the de- partment of Maternal, Newborn, Child and Adolescent Health and Ageing (MCA), this case study documents the experience, benefits, challenges and lessons learnt of engaging with the private sector in health to main- tain the delivery and use of essential maternal, newborn and child health (MNCH), including family planning (FP) services1, to protect universal health care (UHC) out- comes (quality, access, financial protection) during the COVID-19 pandemic in Uganda. Uganda has been se- lected as a case study as the private sector in health has long played an important role in the healthcare system, particularly for MNCH services (8). 1: the case study we refer to MNCH services as inclusive of FP. 1 © WHO / Esther Ruth Mbabazi Design A case study methodology was employed using key in- formant interviews, as it allows exploration of the “rich- ness of actual cases” (9) and reinforces adaptive and shared learning. A literature review was not conducted as part of the case study however background articles relevant to the context have been referenced in the pa- per. A specific focus of the case studies was on the de- livery and use of EHS with a specific focus on MNCH and FP services during the COVID-19 pandemic. Ethics and consent Written consent was sought for the interviews. Respon- dents’ information was anonymised as part of data analysis and presentation of findings. Quotations are referenced as international, private sector, academic, government and umbrella organisation respondent. Be- cause the case study involved data collection only from persons working in their official capacity on issues in the public domain, the protocol [ID: CERC.0147] was ex- empted from further WHO ethical review. Ethical clear- ance was provided by Makerere School of Public Health Ethics Committee [SPH-2021-133]. Key informant interviews Semi-structured, in-depth interviews were conducted with 18 respondents from international (3), private sector (3), academia (3); government (5) and umbrella organisations (5).2 Some respondents worked across re- spondent categories, for example, respondents working Methodology both in the public and the private sectors. Designation is therefore based on how respondents self-identified and were recruited into the study. Interviews were con- ducted over the period of November and December 2021. Targeted sampling was employed where respon- dents were selected by the Ministry of Health and WHO Uganda Country Office. Interviews were conducted in English and led by the primary and second authors. All interviews were conducted remotely using an online meeting application. Interviews were audio recorded to facilitate note taking and transcription. Analysis A coding frame was developed for data extraction, based on the semi-structured interview guides. A frame- work matrix was developed by the primary author for the analysis using Microsoft Excel 2016. The matrix was constructed horizontally with the key themes and ver- tically by respondent. Interview notes were condensed, with information arising from data sources inserted into the matrix. Quotes from the transcripts were inserted as part of data extraction. Where needed, the authors compared notes and understandings to ensure com- pleteness of information and consistency of interpreta- tion. The completed framework matrix was reviewed by the primary and secondary authors. The primary author drafted the paper, and the other authors reviewed the drafts and final manuscripts. 2: Umbrella organisations were professional in nature. 2 Findings have been structured using the WHO governance behaviours, a framework adopted in the WHO strat- egy report, “Engaging the private health service delivery sector through governance in mixed health systems”. Behaviours have been operationalized for essential MNCH services as follows: Framework Figure 1. Analytical Framework 3 Align structures: alignment of public and private structures for the continuation of essential MNCH services during the COVID-19 emergency. Foster relations: coordination arrangements and sectoral en- gagement for the continuation of essential MNCH services during the COVID-19 emergency. Build understanding: private sec- tor data captured and information exchange for the continuation of essential MNCH services during the COVID-19 emergency. Enable stakeholders: the de- velopment and implementation of financing mechanisms and regulations, to authorize and incentivize health system stake- holders for the continuation of essential MNCH services during the COVID-19 emergency. Nurture trust: recognition and management of competing and conflictive interests for continu- ation of essential MNCH services during the COVID-19 emergency. Deliver strategy: organisational learning to improve engagement of the private sector for the deliv- ery of essential MNCH services to support the COVID-19 response. Key findings have been framed for consideration by a Ugandan audience and for wider cross-coun- try learning. Findings Most respondents felt that there was inadequate at- tention given to essential MNCH services within the national response structure, particularly during the initial phase and lockdown periods of the pandem- ic, “there was disruption, and the coordination was not well done for the continuation of the essential services...the focus was basically on security” (aca- demic respondent). In part this was due to emphasis on curtailing the pandemic from entering the coun- try and isolating the disease once it gained entry. “A containment mindset detracted from preparing the whole health system” (umbrella organisation). It was surmised by a government respondent that the engagement with the private sector was geared to- wards the business community to fund the response rather than private health entities as part of the re- sponse structure. Within the national response structure “surge capaci- ty” mainly focused on the public sector and specialised COVID-19 care. This was not questioned by some re- spondents, “of course, government prioritized the public institutions but along the way, private sector had to be engaged” (in- ternational organisation respondent). Training of private health entities was funded through intermediaries, such as non-governmental and umbrella organisations. This allowed for some cascade of capac- Align Structures ity to the private sector in health and towards primary care and enabled the continuation of essential MNCH services. Social franchising networks were also able to cascade essential MNCH supplies and operational sup- port to private health providers and offered similar surge capacity to the public sector. This conduit and the role of non-governmental partners more generally al- lowed donor resources to be channelled to the continu- ation of essential MNCH services. Despite these efforts, there were gaps in the pro- vision of essential MNCH services as clinics were closed and wards devoted to emergency care, particularly during waves of COVID-19 transmis- sion. Emergency wards became overwhelmed, “as eventually the [routine] patients found a way of getting to hospitals” (private sector respondent). Private health facilities took the necessary precautions to provide essential MNCH services, but this came at a financial cost which was passed on to patients. Gaps in MNCH service provision also came at a human cost, “especially for the second wave, preg- nancy and COVID-19 didn’t move well together” (private sector respondent). 4 The national response structure included the private sector in health; however, representation was limited, “each of those pillars had like a task force…there were more or less the same players that are representing the private sector” (umbrella organisation respondent). Coordination platforms pre-existed the pandemic and were co-opted for the COVID-19 response with the Uganda Healthcare Federation (UHF) widely recognised by government and non-governmental respondents as the nodal entity for the engagement with the private sector in health. UHF membership is voluntary, making it “not the voice of all the private sector” (umbrella or- ganisation respondent); its membership and footprint are comprised of larger private health entities mainly in Kampala and the metropolitan areas. Given this, there were concerns raised amongst respondents on how or if there was any “trickle down” of information and guid- ance “to the people on the ground, that are implementing all the different services” (international organisation respon- dent). Several respondents further suggested that the private sector in health needed to better organise itself to be effectively engaged. Government respondents viewed this task as the responsibility of UHF. There was no explicit role defined for private health providers in the COVID-19 response, “the private sector continued to pro- vide their services anyway, as they have always been providing” (interna- tional organisation respondent). Continuation of essential MNCH services through the private sector was not formalised, “it wasn’t like an official message to go out, provide essential health services, it was just the space that was left” (um- brella organisation respondent). However, in the context of Kampala, there was greater attention to the role of the private sector in health and the development of a coordination and referral system, given that most of the health facilities in the capital are privately-owned and operated. Base assumptions about organisation and profit orien- tation dictated government support for the private sec- tor in health during the COVID-19 response. In general, this was minimal, “regularly people would say, but the private sector is being neglected. It needs to be there” (umbrella organisa- tion respondent). In contrast, faith-based organisations retained a more privileged status with the public sector based on shared “not-for-profit” values. While this distinction was chal- lenged, “as all providers need to cover their costs and make some profit” (umbrella organisation respondent), there was a recognised profit-driven element within the private sector in health, particularly those owned by business investors, “they are employing the profes- sionals, making money “ (umbrella organisation re- spondent). Within this milieu, owner-operated large and small and medium-sized enterprises (SMEs) and informal providers, mainly drug shops, continued the delivery of essential MNCH products and services, in an often-uncoordinated way. 4 Foster Relations Prior to COVID-19, the role of the private sector in health service delivery, including MNCH, was considered large but speculative; no definitive estimate or contribu- tion was cited, “the private sector probably provides not less than 40% of the health ser- vices in Uganda…they are a key part of the puzzle” (government respondent). The lack of information and data on the private sector in health was considered a big gap by government re- spondents as it was estimated that only about 30% of private healthcare providers were reporting into the na- tional health information system. There were concerns that private sector contribution to key outputs, such as MNCH, were “missed out”, and that health information was incomplete. There were concerns voiced by most respondents about the secondary effects of COVID-19 on MNCH. All re- spondents indicated that there was a drop in utilisation of essential MNCH services, particularly in the initial phase and lockdown periods. This was attributed to supply and demand side factors, but principally access constraints, given Uganda’s response to COVID-19 en- forced some of the strictest lockdown measures on the continent. Utilisation of essential MNCH services was reported to have subsequently ‘rebounded’ as adapta- tion mechanisms were introduced, and lockdowns lift- ed. However, the impacts on some women and children were not reversed. “When we lock down, it means that people can’t move, not only the patient but also the health workers…I had a midwife who was living at her facili- ty and she said, ‘in the morning, the things that you see people are birth- ing babies at home because they can’t get to the facility and then the cord is caught badly...you just look at the baby…oh, my God, just go to the near- est hospital, I can’t help you.’ It was literally heart-breaking when you see what people were doing to babies and mothers while they were trying to help them in the night before they could ac- cess a facility.” (umbrella organisation respondent) Weekly MoH-led MNCH meetings took place and a monthly update generated from the national health in- formation system disseminated. However, trickle down of information to private health facilities was consid- ered an issue as frontline workers often relied upon the same information that the general public had. This was not disaggregated or specific to vulnerable groups, such as mothers and children, “they will just say these were the number of cases, these are the number of deaths and those were acceptable” (private sector respondent). Several studies were commissioned during the period, however, it was unclear how or if they were used to inform the response and the continuation of essential MNCH services. A government respondent indicated that academic studies were not used as they took a long time to publish. An academic respondent indicated that “there was limited, to no opportunity to share our thoughts” with the notion that published papers might find their way into decision making echelons, “and then maybe [they would] reach out to us and listen to us, and proba- bly see if our opinions had any merits whatsoever” (academic respondent). The most referenced study by respondents was a cost- ing study for COVID-19 treatment; no comparative study was done to understand the additional cost of delivering essential MNCH services and effects on utili- sation patterns. 6 Build Understanding Adverse practices were displayed in the health sector (both public and private) but with little intervention by government. This included cost of essential medicines and equipment, sourced through the open market, “with increased demand, and a limited supply, certain- ly the prices went up…we do not have a law on price regulation, and therefore, even the monitoring was not done” (umbrella organisation respondent). Supply and cost constraints affected the availability and af- fordability of essential health products and services in the private sector, including for MNCH. Quality was ra- tioned, for example, routine tests as part of antenatal care were not done because women could not afford them. This situation did not prompt government inter- vention. However, government did respond to pricing of COVID-19 treatment services when this gained me- dia attention and resulted in public interest litigation. “It was hot, and the bills were going up in the sky, but the public sector were also constrained so they couldn’t put the blame on the private sector. Calls for reform came from the consumers, including some parliamentarians, some of the women activists. Parliamentar- ians wanted to table a bill, regulating the pricing of the private sector in the wake of COVID-19.” (private sector respondent) While there is a Uganda public-private-partnership for health policy, there is no regulatory framework for the private health sector nor were reforms introduced to improve access to care. Formal debate ensued on regu- lation as a result of media attention and litigation, dom- inated by larger healthcare actors. Amongst the private health sector, there was resistance, “you cannot regu- late prices, you cannot regulate the private sector…are you going to regulate prices in [countries], where we buy these things from?” (umbrella organisation respon- dent). While discussion focused on pricing, private sector registration and qualification were viewed as more fun- damental. The lack of regulation of the private sector in health was considered a governance failure, with limited appetite for reform, “the government has failed to do its job… it is quite problematic” (academic respondent). In the view of some government respondents, demand dictated supply as part of a “free market environment”. “How can people provide such a ser- vice as health care, and they set up the work, they go home? Nobody’s look- ing?” (umbrella organisation respon- dent). “The ‘hidden sector’ plays according to the market forces, which is detrimental to the users of the services, they get substandard care, depending on how much they can afford. And you can’t measure treatment in kilograms, it is an episode that needs treatment, it shouldn’t be rationed based on ability to pay” (academic respondent). 7 Enable Stakeholders The national COVID-19 response was not guided by the demand side, the needs of the population. Due to the emergency context, the population, particularly the poor in urban areas, “often feel desperate and that’s why they go out and pay for any kind of services” (um- brella organisation respondent). Self-guided navigation of the health system was considered normal, “they’ll vote where to go. Given what they find in the services, they just move” (international organisation respon- dent). In rural areas, the health system was viewed as less chaotic and mainly reliant on the public sector. Within the spectrum of MNCH, some services were more politicised and prioritised than others. Civic and media attention was needed to prompt intervention, “maternal health is political in Uganda and so many civil society organizations were making noise. If there is a prob- lem in reduction of services, they bring it out in the newspapers” (international organisation respondent). Other issues elicited reaction: missed childhood immu- nisation schedules and concerns with re-emergence of disease; a wave of teenage pregnancy in the wake of COVID-19; and greater reliance on self-medication and informal providers, were some that were mentioned by respondents. The secondary effects of COVID-19 on MNCH were reportedly downplayed, “if you talk to a government person, they want to paint a very positive picture” (umbrella organisation respondent), limiting frank discussion and proactive intervention. Conflicting information and the lack of “hard data” may have con- tributed to this. “But when you look at the indicators, did maternal mortality in these districts go up? Did under five mortality go up? ...then we can sit down and have a con- versation…” (government respondent). “So, the population decided to go to the private sector, and the private sector was damn expensive. So many people died. Information is not up to date, but they died” (academic respondent). A blame game emerged; media and civil society blamed government and the private sector in health, national government blamed local government, national gov- ernment blamed civil society and the media for stirring outcries. Effective dialogue was recognised as necessary so that protagonists, including the population, were not “squeezed into corners.” “If we would have listened to each other more, we could have achieved a lot more in the beginning. With practi- cal suggestions, you can make a lot of changes” (umbrella organisation re- spondent). 8 Nurture Trust COVID-19 provided impetus to learn and improve, to deliver essential MNCH services more coherently, to re- think, redesign and regulate the health system. There was recognition that the private sector in health was a key player, “and they should be supported. That capac- ity should be built to complement and supplement gov- ernment service delivery” (government respondent). Equally, there was recognition that the private sector in health was amorphous, “public health is not just how many outlets you have, but what do they do?” (aca- demic respondent). There were comparisons made to the non-health private sector “which everybody loves, because they have a lot of money, they make dona- tions…the health private sector just doesn’t have the elasticity…we’re not actually even making money on a good or bad day on essential health services” (umbrella organisation respondent). There was recognition of the need to rethink base assumptions about the private sec- tor in health, to break down the ‘hidden sector’ into its component parts, to understand capacity and motiva- tion of component entities, and encourage or constrain entities based on this understanding. “People will always tell you, the PPP framework, everybody will talk about public private partnerships, but they’re not there…we’ll talk about it, we’ll laugh about it, we’ll smile about it, but I just don’t see it happening” (umbrella organisation respondent). There was also recognition of the need to redesign the health system, to leverage capacity of the whole sec- tor as a matter of routine, not event, “once the gov- ernment feels that they can’t do it anymore, then yes, maybe we’ll let you [the private sector] try. But, you know, the minute the things stabilize, then you’re out again” (umbrella organisation respondent). While re- sponsibility was seen as sitting with the private sector in health to “clean up its house, to get better mobilized, better organized and set up structures” (government respondent), there was recognition of the need for this to be stewarded by government. Equally, there was rec- ognition of the need to get the public sector house in order, to make it more accountable, more responsive, to create an “an osmotic shift” and a realignment of the private sector. It was recognised that this shift needed financing and regulatory reform to drive it. “You may find some of these backstreet clinics, placentas are being dropped into pit latrine, just to give you an ex- ample. But if you have a checklist and a team that comes to inspect and you’re not to fail, for you to be accredited, you’ll have to put things in line” (gov- ernment respondent). COVID-19 prompted a revisit of stalled reforms. Fore- most, it was recognised that this should be guided by population need, irrespective of sector, “I think govern- ment should plan in some skill sets that are available, they don’t have to be in the public sector” (government respondent). Those mentioned focused on alternative financing for the healthcare system, the use of strategic purchasing and the development of an essential health care package, discussions that had been “put aside, but because of the pandemic, were revitalized” (private sector respondent). Immunisation catch up campaigns were seen as a potential focus for reform and strategic engagement with private health providers. The adoles- cent health policy was also reportedly back on the pol- icy table after years of remaining in draft form, “it had stagnated before COVID-19, it is right to ensure that this policy is concluded because I think number of people saw the challenge” (umbrella organisation respondent). The newly created MoH adolescent health division was seen as demonstrating the intent of government to see adolescent policy endorsed and enforced. Momentum for reform and greater public-private engagement was considered an opportunity that needed to be seized. “I think what we are facing right now is not lack of learning opportunities, those are happening…I think the prob- lem is lack of the political will, at the Ministry of Health, but also above it [the high office] to prioritize access of essential healthcare services” (interna- tional organisation respondent). 9 Deliver Strategy The study sought to examine how the private sector was engaged to support the delivery of MNCH services in Uganda during the COVID-19 emergency, using the WHO governance behaviours as an analytical frame- work. The findings of the study suggest that Uganda has an opportunity to ‘build back’ and nurture trust in the health system eroded by COVID-19 pandemic, by harnessing all health sectors to maximize efforts in pro- viding MNCH services for all. Based on the responses of the 18 respondents, the fol- lowing have emerged as key opportunities for Uganda to leverage private sector capacities for public health goals and to strengthen health system’s responsiveness and resilience: • Private sector engagement should be focused on a specific and tangible health problem. There is need to get down to details, “to move beyond the talk, to walk the talk” (private sector respondent). • Problem identification should start from a plan- ning perspective and develop models of engage- ment between the public and the private oriented to population health, “right now, people are look- ing at the provider, but not looking at the popula- tion that they serve. I think we need to go back to the basics of public health” (academic respondent) This should take a primary health care (PHC) ap- proach. • Use policy windows (such as COVID-19) to reframe the role of the private sector in health, accompa- nied by legal, regulatory, and institutional instru- ments, “there is need to work together to say this is what accountability looks like” (umbrella organi- sation respondent). Foundational to this, would be the development of a master facility registry and minimum reporting standards through the national health information system, as a matter of routine. • Establish the fair cost of delivering an essential MNCH service package as a basis for standardi- sation in the private sector to address erratic pa- tient pathways and continuity of care, “trying to Discussion bring standards to the private sector is good for the private sector and it’s good for the communi- ty, it’s good for the government, and it’s good for funders” (academic respondent). • Strategic purchasing could provide opportuni- ty for testing reform and addressing sectoral in- tegration. This could be framed around a specific MNCH ‘problem’, such as immunization catch-up, given that this is seen as a particular issue amongst the urban poor and a current focus of public-private engagement. • In the longer-term, strengthen e-governance and address the “narrow digital footprint”. This would allow for a shift from “trickle down” sectoral com- munications to more efficient and transparent plat- forms, accessible to a range of health entities and healthcare users. • The MoH should steward engagement and ad- dress fragmentation between sectors and part- ner initiatives, “the mandate to provide health to the citizens is with government…this should not be abandoned to the private sector” (umbrella organi- sation respondent). 10 How accountable a country’s health system is to its population depends to a large extent on the degree of accountability between the public and private sectors. Where there is inadequate accountability, a culture of mistrust and ‘blame shifting’ may exist. This has been the experience in Uganda. Learning from this experi- ence and impetus to reform should be seized. image goes here Conclusion 11 As a follow-up to the study, the authors propose to convene a Ugandan multi-stakeholder workshop to val- idate findings from the case study, to further distil in- sights and policy recommendations. The output of the workshop may result in the formulation of a policy brief to improve engagement of the private sector for the delivery of MNCH services in Uganda. © WHO / Esther Ruth Mbabazi 1. Mackintosh, M., et al., What is the private sector? Understanding private provision in the health sys- tems of low-income and middle-income countries. Lancet, 2016. 388(10044): p. 596-605. 2. World Health Organization, The World Health Re- port : 2000 : Health systems : improving perfor- mance. 2000, Geneva: World Health Organization. 3. Carroll JS, Johnson EJ, 1990 in Yin, R.K. 2008. Case Study Research: Design and Methods, Fourth Edi- tion, Applied Social Research Methods, Volume 5, Sage Publications Incorporated. 4. Montagu D, Chakraborty N. Private Sector Utiliza- tion: Insights from Standard Survey Data. In: Private Sector Landscape in Mixed Health Systems. Geneva: World Health Organization; 2020:10-26. 5. Nabyonga-Orem J, Nabukalu JB, Okuonzi SAPart- nership with private for-profit sector for universal health coverage in sub-Saharan Africa: opportuni- ties and caveatsBMJ Global Health 2019;4:e001193. 6. Towards better engagement of the private sector in health service delivery: a review of approaches to private sector engagement in Africa. Geneva: World Health Organization; 2022. Licence: CC BY- NC-SA 3.0 IGO. 7. Equitable access to COVID-19 tools: aligning the pri- vate sector with national response efforts. Geneva: World Health Organization; 2022. Licence: CC BY- NC-SA 3.0 IGO. 8. Ministry of Health, Health Systems 20/20, and Mak- erere University School of Public Health. April 2012. Uganda Health System Assessment 2011. Kampala, Uganda and Bethesda, MD: Health Systems 20/20 project, Abt Associates Inc. 9. Yin RK. Case Study Research : Design and Methods. 4th ed. Thousand Oaks Calif: Sage Publications; 2009. References 12 13 1. Can you provide a brief summary of your role (op- tional: and that of your organisation)? 2. [foster relations, deliver strategy] How was coor- dination of the COVID-19 response undertaken? -- Was the private sector involved? Were all critical voices represented? Were any left out? [probe: primary health care] -- Did the pillar structure provide for adequate attention to the continuation of essential MNCH services? -- In general, how do you think coordination structures have functioned? Have they facilitated communication and collaboration? 3. [align structures] How has the private health sector been involved in the provision of essential MNCH services as part of the COVID-19 response in your country? -- How has MNCH service capacity been addressed? (In the public and private sectors, including services and supply chains) -- How have MNCH services been adapted? What prompted adaptations? (In the public and private sectors) -- How were service trends affected by new waves of transmission? 4. [nurture trust, enable stakeholders] Were ad- verse practices displayed by some segments of the health sector during the COVID-19 response in relation to essential MNCH services? [probe for specific examples] -- Did these emerge over time, in response to emer- gency peaks in demand? -- What were the root causes? What were the consequences? -- Were there public channels available for report- ing adverse behaviours and opportunistic practic- es? [probe examples] -- How did government act upon such informa- tion? 5. [build understanding] How were essential MNCH service data and trends communicated across sectors and levels of the health system during the COVID-19 response? Annex: Interview Guide -- How did data and information inform decisions in relation to the provision of essential MNCH services? -- What other data and information sources were available/used during COVID-19 to inform the pro- vision of essential MNCH services? [probe: the use of studies and assessments] 6. [enable stakeholders] What measures (regu- lations, financing reforms) were introduced by government to address access to essential MNCH services? [probe: if any inputs or subsidies were directed towards the private sector] -- How was the private sector involved in the de- velopment and implementation of such measures? [probe: role of intermediaries, ability to shape regulation, etc] 7. [nurture trust] How was equity considered as part of the response/access to MNCH essential services? -- How were the needs of specific populations catered for as part of the response? -- How was affordability addressed/monitored? -- How were consumer concerns communicated? -- How did government act upon such information/ concerns? -- Were perspectives of frontline service provid- ers (public and private) considered as part of the COVID-19 response? -- Overall, do you think the response instilled trust in the health system? 8. [deliver strategy] As part of emergency prepared- ness and response, how could the organization of essential MNCH services be improved going forward? -- What learning emerged from the response? -- What policy changes are needed, if any? -- What regulatory and financing changes are needed, if any? -- What role should the academia/the private sec- tor play? -- What role should the public/consumers play? 9. Do you have any other recommendations and lessons for private sector engagement in essential services for other countries/regions? 10. Do you have any final comments or questions? World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland www.who.int