Policy Brief: Strengthening urban health systems through public-private partnership: Lessons from four countries

Gaps in the public health sector is driving the emergence and growth of a plurality of providers in Bangladesh, Ghana, Nepal and Nigeria. This comes with various challenges and opportunities. 

 

As 2030 draws closer, it is recognised that many of the Sustainable Development Goals (SDGs) targets will remain unmet, including Target 3.8 — to achieve Universal Health Coverage (UHC). 

Achieving UHC means that all people, everywhere, will have access to quality health services whenever needed and without financial burden. Achieving UHC requires that all health providers across the world — regardless of whether they are public, private, informal or non-governmental — work together to ensure quality, affordable health care is available, especially for the poorest. 

The Community-led Responsive and Effective Urban Health Systems (CHORUS) is a research consortium working with communities, health providers and policymakers in Bangladesh, Ghana, Nepal and Nigeria to co-create interventions to improve the health of the poorest urban residents. By working with diverse range of stakeholder groups in four countries in the Global South, CHORUS researchers have identified opportunities to strengthen primary care services in urban health systems with evidence-based policy recommendations. 

 

Key findings on challenges facing the urban poor 

Due to the rapid increase in the urban population, public sector health services in urban settings are under strain. There are limited accessible and available health facilities with insufficient medicines and supplies and not enough health workers with training appropriate to the changing disease burden in the public health system. Over time, these gaps in the public sector have given rise to a burgeoning private, non-governmental, and informal health sector. City governments are often responsible for monitoring and regulating these services, however due to their limited capacity, they struggle to ensure  quality and safety across this complex range of providers. 

While this growth has given new means for people living in cities to access some of the care and medicines they need, in low- and middle-income countries, the wide range of health service providers presents new challenges, including poor health outcomes. For example: 

  • Analysis of Nepal Demographic and Health Survey 2022 found those requiring services for childhood diarrhea predominantly used private providers. This was particularly the case for middle-income and wealthier individuals. Conversely, government facilities were more commonly used by lower-income groups, with 56% in the poorest and 37% in the poorer quintiles. While there is limited urban-specific data, the CHORUS needs assessment highlighted how the poor in the urban context frequently rely on private providers, particularly private pharmacies . However, service user’s data from pharmacies is not currently linked with government system and information about the urban poor is not included.  

 

  • Similarly, in Nigeria, informal care providers such as traditional birth attendants, patent medicine vendors, traditional healers, bone setters, and herbalists, have evolved to fill gaps in in services to the urban poor population (see article on Informal-Formal Healthcare Services Delivery Nexus in Nigeria’s Urban Slums – closed access), who see these providers as viable alternatives, despite a lack of supervision and regulation.
  • In Ghana, our teams systematic review of the Community Health (CHPS) programme found that there were significant challenges in expanding public community health programmes to urban communities . The  need for further health worker training mean that the public health sector often struggles to keep up with the increase in non-communicable diseases and the limitations in seeking support from volunteers within  transient and diverse communities in the urban setting undermine effective programmes. Long working hours for both men and women often prevent them to access public health services due to unmatched opening hours of the heath facilities. It is therefore not surprising that our survey of 3543 urban residents across four communities found that only a quarter had ever used CHPS and only half intended to use CHPS in the future.  
  • The increasing burden of non-communicable diseases is providing greater pressures for primary care. In Bangladesh, the ARK team analysis of the Bangladesh Demographic Health Survey (BDHS) 2017–2018 and 2022 highlighted significant increases in diabetes among urban residents, particularly women. Poor levels of management of hypertension were also found with only approximately 5% of urban residents (5.4% women and 4.6% of men) able to manage their blood pressure through antihypertensive medications. (See the ARK Foundation Policy Brief on the preparedness of urban primary healthcare centres in Managing Diabetes Mellitus and Hypertension)

 

Co-designing solutions to strengthen urban health systems in addressing a plurality of health providers 

CHORUS researchers from Bangladesh, Ghana, Nepal, and Nigeria have been working to support city governments in addressing the challenges of working with this plurality of providers. City governments are keen to find solutions that are from the ground up, equitable and sustainable. This led CHORUS to adopt a co-design approach through which stakeholders worked together as collaborators to address issues with sustainable solutions. However, city governments often require more time, effort, and resources. Despite this, CHORUS worked with urban poor communities, health providers, and policymakers to understand the challenges, identify solutions, and implement them. While the solutions were tailored to each specific context, they had the following in common: 

  • Improved data linkages and information sharing:One way to strengthen linkages between the range of primary care providers in the urban context is to establish data systems that can collect and share patient data. In Bangladesh, the ARK team worked closely with government to introduce a ‘simple app.’ that collects information on patients with hypertension and diabetes from both government and NGO primary care. (See blog for more detail). This is the first time that data from urban primary care has been collected and made available for city corporations and actors to respond to the grown challenges on NCD in the urban context.  Engaging with informal care providers and community is also crucial to understand health seeking behaviours of people and services provided to them.  For instance, in Bangladesh and Ghana, CHORUS researchers formed Community Advisory Groups to explore challenges and identify solutions helping policymakers to make informed decisions about the urban health system. In Nepal, the HERDi team mapped all private pharmacies and primary care facilities that provided Pokhara Metropolitan city with information about the number and location of the providers in their city. This is the first step to strengthening a system that ensures a coherent, safe and effective primary health care system that reaches the urban poor.  
  • Building trust to support the referral system: Strong public-private partnerships that link the public health sector with various private health providers can strengthen the urban health system. This includes building trust, rapport and support between various health providers through regular communication and meetings to exchange ideas and experiences, mutual training opportunities and facilitating collaboration. In Nepal, pharmacy workers were trained by specialists to increase their competencies and skills in the management of hypertension and diabetes, referring cases to public hospitals and providing information on diabetes and hypertension for underserved urban communities. It was done with the reality that pharmacists support the urban poor due to their proximity and trust with this group. 
  • Monitoring, supervision, and support: Private health providers can fill gaps in care provision, however, monitoring, supervision, and support mechanisms are essential to ensure the quality of the services they provide. Regulating the practices and services offered by informal care providers can help to strengthen the urban health system. In Nigeria, CHORUS researchers found that through careful codesign and respect to all parties, adequate governance mechanisms can support the monitoring and supervision of informal health providers. 

Working together to address challenges 

The experience of CHORUS researchers in four countries demonstrates the complexity of the urban context and the necessity of working with a broad range of stakeholders including private, informal health providers, city and national governments and urban poor communities themselves. Carefully and respectful co-design processes supported by research evidence can help to unpack the challenges facing these settings and develop actionable solutions. The next phase of CHORUS is to evaluate the identified health system interventions that link private, public and informal sectors. These evaluations will provide vital information on how to implement these interventions within the routine work of the urban health system and how successful they are in reaching the urban poor and improving health and well-being.  

 

Feature image credit: ARK Foundation