Abstract
BACKGROUND: Proliferation in government purchase of private healthcare requires stewardship support for impactful alignment to Universal Health Coverage (UHC) goals. This paper provides a synthesis of country purchasing initiatives involving the private sector from the Eastern Mediterranean region (EMR) identifying drivers, stewardship challenges and country aspirations for strengthening purchasing initiatives. METHODS: Findings are drawn from 19 in-depth mixed methods country case studies commissioned by the WHO, guided by a standardised data collection tool for desk review and country stakeholder interviews. Case study synthesis approach was applied to draw on commonalities and emphasising important differences across country contexts. Extraction and analysis into country income groups allowed thematic comparisons. RESULTS: Significant proliferation in the purchase of private healthcare has been driven by contextual opportunities provided by political momentum, local adaptive designs, unlocking of domestic financing and initial operational groundwork particularly in middle-income EMR countries. Common challenges include (1) steering constrained by conflicting ideologies, role dispersion and a focus on UHC schemes rather than the UHC vision; (2) implementation challenges of weak contract management expertise, uncertain quality compliance; and (3) private sector engagement hampered by insufficient communication and trust. Less resourced countries also face challenges of private sector fragmentation impeding purchasing. We found common interest across countries to better integrate the private sector for UHC. Prioritised future needs included (1) national Private Sector Engagement (PSE) planning to inform purchasing arrangements, (2) evidence for better understanding, (3) leadership structures, (4) formal dialogue platforms and (5) social-behavioural incentives for quality and data reporting compliance. Middle-income and high-income countries additionally prioritised payment controls, whereas lesser resourced countries emphasised sustainable fiscal mobilisation. CONCLUSION: The synthesis importantly highlights new directional and relational needs alongside traditional structural, and expertise needs to guide a re-imagined stewardship agenda for strengthening the purchase of private health services in the EMR. Future socio-behavioural research on private sector motivations for partnerships and behaviour under purchasing arrangements will be beneficial for stewarding PSE within local eco-systems.