Balancing business and accountability: governing equitable primary healthcare partnerships with the private sector

Part 1 of a three part blog series

Reflections from the Symposium on ‘How can the public–private mix advance public healthcare in a transforming world order?’ convened by the Health Systems & Policy Research Cluster at UCL’s Global Business School for Health in collaboration with the Health Systems Global’ s Private Sector & Commercial Determinants of Health Technical Working Group (TWG), May 2026.

Beyond governance as usual

Globally, the governance of primary healthcare (PHC) delivery has followed a government centric approach, over-looking how market dynamics can be better integrated for affordable, equitable care. Health systems are becoming increasingly mixed. Ageing populations, rise of chronic diseases, rapid digitalisation, and tightening public budgets are reshaping how primary healthcare is delivered across the world. Health systems will become increasingly mixed. Outside nationally funded healthcare architecture, the role of high street businesses such as pharmacies as well as online service providers is becoming increasingly salient in the Global North particularly in younger populations. Smaller neighbourhood private providers already provide the major footprint of primary care in the Global South are but are weakly integrated into universal health coverage reforms.

Whether policymakers like it or not, traditional public sector governance approaches no longer reflect reality. The default has been to rely on regulation and purchasing as instruments of control. Or policy neglect allowing market forces to fill the gaps. Both approaches miss a critical opportunity of building partnerships that balance commercial sustainability with public goals. A one-size fits all assumption of commercial motives hinders differentiation between oligarchies, smaller private healthcare providers, digital small and medium enterprises and high-street businesses embedded within neighborhood that are often more familiar with local needs than the public sector.

How can potential private healthcare stakeholders be strategically integrated into cohesive national primary healthcare systems? What mechanisms best align commercial, professional, and public-sector incentives, ensuring that private sector participation strengthens—not weakens—equitable primary healthcare? These questions framed the UCL Symposium’s organized session on Governance: aligning public and private good, drawing on grounded voices from researchers, senior civil servants, technical assistance agencies and development partners from the UK, Latin America, Africa and South Asia.

A strategic shift in conversation is required to address a common gap of partnership-based stewardship to ethically integrate private providers, digital actors and privately held resources to advance primary care for the public good in an increasingly mixed system.

Three Shifts for Converged Governance

Framing the partnership

Partnerships should complement—not compete with—the core national health system. This requires starting with a clearly defined primary healthcare challenge rather than assuming private participation is inherently beneficial. Instances, when it is not well thought out can lead to competition with the national healthcare providers or partnerships being dictated by the market. Private sector participation cannot be taken for granted. Private providers fear bureaucracy over collaboration and support partnerships that strengthen — not replace — their business models. Effective governance depends on establishing mutual benefit. Successful partnerships are co-led rather than government-directed, balancing commercial viability with accountability for equitable PHC outcomes from the outset.

Resourcing not monetising

A partnership approach requires thinking beyond public funding alone. Resources lie in both public and private sectors – these can be infrastructure, staff, supply chains, patient networks, community trust — that can be strategically leveraged to advance national PHC goals. A shift in approach is required from solely relying on public-sector purchasing contracts to mobilising private sector’s complementary assets including non-monetary resources under a coordinated targeted model. Again, defining the PHC challenge is important, then a negotiated equation of who contributes what from a resourcing not financing lens.

Re-thinking stewardship for mixed health systems

Stewardship must evolve beyond the traditional purchaser-provider model towards networked governance. Informal relationships often play an important role in negotiating access to care, particularly where formal systems are fragmented. Networked governance with private provider representatives, professional associations, business networks, and municipalities can strengthen accountability helping exert regulatory oversight, adaptive changes and trust-brokered mediation rather than a sole reliance on top-down enforcement. Equally important are patient-centred social accountability mechanisms. Involvement of municipalities alone is not sufficient but integration of patient centric engagement metrics. Re-shaping the partnership architecture will require re-thinking technical assistance which remains government centric not partnership centric.  

Future research must shift from outcomes measurement to measuring ‘systems integration’. Greater attention is required to exploring the “black box” of an ethical partnership architecture – how dual tensions of commercial viability and public accountability can be converged – under a strategic direction for equitable, efficient and sustainable primary health care.

Authors

By Shehla Zaidi, Victory Olaniyi, Weihao Nie, Priya Balasubramaniam, Gerry Bloom.

1. Global Business School for Health, University College London
2. Private Sector and Commercial Determinants of Health TWG, Health Systems Global

Key Contributors: Marc Donnovan (Boots), Claire Anderson (University of Nottingham), Meenakshi Gautham (LSHTM), Vera Schattan Coelho (CEBRAP), Francis Ayomoh (OPM), Sujata Saunik Ex-Chief Secretary, Arash Rashidian (WHO), David Clarke (WHO), Kabir Sheikh (UCL)

• Read Part 2 of our three-part blog series, now available: Digital innovation for primary health care: aligning public–private partnerships for scale, trust and public good - Health Systems Global (HSG)

• Read Part 3 of our three-part blog series, now available: Rethinking blended financing for primary healthcare - Health Systems Global (HSG)