Global Public–Private Partnerships in Primary Care: Navigating Equity Tradeoffs

Public–private partnerships (PPPs) have become a defining feature of the global health landscape, especially as governments seek to mobilize diverse resources to meet the ambitious goals of Universal Health Coverage (UHC). Their increasing incorporation into Primary Health Care (PHC) systems, particularly in Low- and Middle-Income Countries (LMICs), represents a major departure from their historical roots in disease-specific vertical programs. This transition demands a more critical and nuanced appraisal of how PPPs interact with health equity imperatives. While PPPs may offer avenues for innovation, efficiency, accessibility, and expanded service delivery, they simultaneously risk worsening structural inequities, displacing public investment, and fragmenting care. This commentary explores the core equity trade-offs inherent in PPPs for primary care, highlighting gaps in current governance frameworks, the implications of market-driven approaches, and the need for equity-centred policy design.

PPPs have delivered notable successes in global health, particularly through vertical programs targeting infectious diseases. Flagship initiatives like the Global Fund and Gavi exemplify how strategic alliances between public and private actors can marshal resources and deliver life-saving interventions at scale [1]. However, the horizontal integration of PPPs into PHC, a foundational component of health systems, poses complex challenges. Unlike vertical programs, PHC involves continuous, comprehensive, and community-embedded care. Its delivery is inherently relational and place-based, making it less amenable to commodified or standardized interventions.

The World Health Organization (WHO) acknowledges the potential role of PPPs in achieving Sustainable Development Goal 3, particularly concerning UHC and essential service coverage [2]. Yet, policy frameworks often lack sufficient operational guidance on aligning PPPs with public values such as equity, accountability, and universality. The pivot toward PPPs in PHC, absent clear safeguards, risks importing market logic in a domain where equity must remain paramount.

Empirical evidence from LMICs illustrates how PPPs, if not carefully regulated, can entrench or widen health disparities. Kenya’s Managed Equipment Services (MES) program, designed to modernize diagnostic infrastructure, demonstrates the uneven benefits of PPPs. While well-equipped facilities were established in some counties, poorer regions struggled with recurrent costs and could not maintain equipment, resulting in widened service gaps [3]. Similarly, in India, PPPs in diagnostic services lowered out-of-pocket costs for some urban residents but failed to reach rural populations, reflecting an urban bias and insufficient public oversight [4].

These cases underscore a recurrent theme: PPPs are often structured in ways that favour profit-maximizing behaviours, with private actors naturally drawn to lucrative services or densely populated areas. Hellowell and Pollock [5] argue that this dynamic introduces systematic inequities in service distribution. Moreover, where user fees are introduced either directly or through associated costs such as transportation or digital access, the poorest populations face disproportionate barriers to care [6].

Equity trade-offs are further complicated when PPPs consume a disproportionate share of health budgets. The Lesotho example is particularly instructive. There, a PPP model delivered a high-quality national referral hospital, yet the project absorbed nearly half the national health budget, thereby constraining investment in rural and preventive services [7]. This case raises critical questions about allocative equity: Should we divert scarce public funds to high-cost, high-tech facilities at the expense of broad-based, community-level services?

Even well-intentioned PPPs can fall short without rigorous mechanisms for transparency, accountability, and public engagement. Nigeria’s Saving One Million Lives initiative, which leveraged private sector involvement in maternal and child health, lacked clear accountability structures and equity benchmarks. As a result, disparities in access and quality of care persisted [8]. These experiences highlight the limits of technocratic or efficiency-driven models in addressing the complex social determinants of health.

The digital health frontier introduces a new set of equity considerations. While digital PPPs can increase access to consultations and triage services, as seen in Rwanda and Bangladesh, they can also reinforce existing digital divides [9, 10]. Marginalized populations often lack reliable internet access, digital literacy, or appropriate devices, effectively excluding them from emerging modes of care delivery. Additionally, algorithmic bias and data privacy concerns pose further risks to equity in digitally mediated care.

These developments call for robust governance frameworks that can anticipate and mitigate equity risks. Regulatory capacity is a decisive variable in determining whether PPPs serve public interest goals. Thailand offers a relatively successful model in this regard. There, the government has retained strong stewardship over financing and service provision, using private sector inputs in supportive roles rather than as system drivers [11]. In contrast, weak regulatory environments, as found in many fragile or conflict-affected states, enabled private actors to prioritize donor preferences or market returns over population health needs [12].

A key gap in current discourse is the lack of systematic equity impact assessments embedded within PPP design and evaluation. International donors and development finance institutions, as the principal architects and funders of PPPs, have an ethical obligation to ensure that their investments do not exacerbate health inequities. This requires more than tokenistic stakeholder consultations or retrospective evaluations. Equity considerations must be front-loaded into contracting processes, performance metrics, and long-term sustainability plans. Transparent procurement, independent monitoring, and inclusive governance are essential safeguards.

Furthermore, the global health community must reckon with the implications of expanding PPPs in primary care. The assumption that private sector involvement inherently leads to improved outcomes must be problematized. Innovation and efficiency are not value-neutral; they are shaped by the institutional and political context in which PPPs operate. Without deliberate policy interventions, PPPs may contribute to the gradual privatization and fragmentation of PHC, weakening the role of the state as a guarantor of equitable access.