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Private Sector Accountability for Service Delivery in the Context of Universal Health Coverage

This is a discussion document commissioned by the World Health Organization and recommended by the Advisory Group on the Governance of the Private Sector to support the development of a WHO strategy. By Gabrielle Appleford

Increasingly, health services are delivered through mixed health systems in lower- and middle-income countries (LMICs). In many LMIC contexts, the private sector is an important source of health-related products and services for many people, including poor people and presents an important partner for universal health care (UHC). However, it will not self-regulate for UHC goals and requires stewardship. How accountable the health system is to citizens and consumers (which may include migrants and undocumented people) depends to a large extent on the degree of accountability between the public and private health sectors. In its place, a culture of mistrust and blame shifting may exist between sectors.

This paper considers accountability and its arrangements for health service delivery in the context of UHC. This work is intended to guide the efforts of the WHO Department for Health Systems Governance and Finance (HGF) and its Advisory Group on the Governance of the Private Sector for UHC. The paper drew on a short literature review, both academic and practice-oriented, on accountability and health service delivery. Primary data was collected through informant interviews with experts working on accountability, health sector governance and/or service delivery. The paper serves as an overview on the topic for WHO staff and member states; and as an input for the roadmap being prepared by the WHO expert committee on the private sector and service delivery.

Based on expert interviews, accountability gaps have been mapped to the following domains at a global level.

More detailed contextual diagnosis is needed at a country level to address accountability systems, and not just the symptoms of poor accountability. Irrespective of context, accountability cultures are needed. These require active entrepreneurs within global health and national health systems as well as the development of soft skills in negotiation, change management and good governance. Change is – or should be - a constant feature in efforts to strengthen accountability.

The following recommendations are put forth to the Advisory Group for consideration as part of the service delivery governance roadmap.

  • Package learning and advice on how to design and implement accountability systems. Develop diagnostic tools for the private sector and accountability environments in mixed health systems.
  • Support member states with the development of transformative accountability agendas, based upon social compacts between sectors, grounded in diagnosis and dialogue.
  • Undertake research to understand the contextual factors that promote or hinder accountability environments in mixed health systems


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