Article Text

Original research
Evaluation of frameworks demonstrating the role of private sector in non-communicable disease management and control: a systematic review and thematic synthesis
  1. Nadia Amin Somani1,
  2. Keiko Marshall2,
  3. Hammad Durrani3,4,
  4. Kun Tang5,
  5. Roman Mogilevskii6,
  6. Zulfiqar Bhutta4,7
  1. 1School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
  2. 2Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
  3. 3Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
  4. 4Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
  5. 5Vanke School of Public Health, Tsinghua University, Beijing, China
  6. 6Institute of Public Policy and Administration, University of Central Asia, Bishkek, Kyrgyzstan
  7. 7Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan
  1. Correspondence to Professor Zulfiqar Bhutta; zulfiqar.bhutta{at}sickkids.ca

Abstract

Objectives Conduct a systematic review of existing frameworks to understand the for-profit private sector’s roles in non-communicable disease (NCD) control and management. Control includes population-level control measures that prevent NCDs and mitigate the magnitude of the NCD pandemic, and management includes treatment and management of NCDs. The for-profit private sector was defined as any private entities that make profit from their activities (ie, pharmaceutical companies, unhealthy commodity industries, distinct from not-for-profit trusts or charitable organisations).

Design A systematic review and inductive thematic synthesis was performed. Comprehensive searches of PubMed, EMBASE, Cochrane Library, Web of Science, Business Source Premier and Proquest/ABI Inform were conducted on 15 January 2021. Grey literature searches were conducted on 2 February 2021 using the websites of 24 relevant organisations. Searches were filtered to only include articles published from the year 2000 onwards, in English. Articles that included frameworks, models or theories and the for-profit private sector’s role in NCD control and management were included. Two reviewers performed the screening, data extraction and quality assessment. Quality was assessed using the tool developed by Hawker et al for qualitative studies.

Setting The for-profit private sector.

Results There were 2148 articles initially identified. Following removal of duplicates, 1383 articles remained, and 174 articles underwent full-text screening. Thirty-one articles were included and used to develop a framework including six themes that outlined the roles that the for-profit private sector plays in NCD management and control. The themes that emerged included healthcare provision, innovation, knowledge educator, investment and financing, public–private partnerships, and governance and policy.

Conclusion This study provides an updated insight on literature that explores the role of the private sector in controlling and monitoring NCDs. The findings suggest that the private sector could contribute, through various functions, to effectively manage and control NCDs globally.

  • Health policy
  • International health services
  • PREVENTIVE MEDICINE
  • PUBLIC HEALTH

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Strengths and limitations of this study

  • A diverse search was performed that encompassed sources from a variety of disciplines (ie, medical science, business), allowing for a multisectoral approach to the development of our framework.

  • The systematic review was thorough, using a well-developed methodology, and quality assurance was in place.

  • Our search was limited to articles published in English, which may have introduced language bias by restricting the number and diversity of articles available for inclusion, potentially shifting the direction and nature of our results.

  • This study is prone to publication bias, as our decision to only include published studies may have reduced the evidence available, as unpublished articles and opinions could have provided additional perspectives.

  • The protocol for this review was not registered, thus increasing the risk of bias and reducing transparency.

Introduction

Non-communicable diseases (NCDs) are the leading cause of death globally, but disproportionately impact low/middle-income countries (LMICs).1 In 2019, NCDs caused over 42 million deaths (74.4% of deaths globally).2 The four major NCDs were cardiovascular diseases, cancers, chronic respiratory diseases and diabetes.2 Addressing NCDs is prioritised in the Sustainable Development Goals (target 3.4) which calls for measures to reduce NCD-related mortality.3 Prevention mechanisms alongside the provision of early or timely treatment are required to effectively address the NCD pandemic, however, many countries lack adequate resources to do so.4 5 A holistic approach working across health systems is required to effectively tackle NCDs.6 Because the private sector plays an integral role in health systems globally and is a significant driver of the NCD pandemic, substantial support from private sector stakeholders is essential to prevent, manage and control NCDs.7 8

Private sector stakeholders involved in health systems can be categorised into the following categories: not-for-profit and for-profit, formal and informal, domestic and international.7 This review is focused on the for-profit private sector. Given the diversity of the private health sector, it may occupy numerous roles in the health system and provide different services or functions. These may include manufacturing, distributing and providing health-related goods and services, informing or lobbying for policy development, managing healthcare institutions, financing health services, training healthcare workers and providing information technology.7 Due to these large and complex roles in health systems, many countries use a mixed-model approach where both private and public stakeholders deliver health-related goods and services to meet population needs.7 In countries with low private sector capacity, this mixed-model approach may not meet health goals and targets.7 To address this issue, it is important to investigate the role of the for-profit private sector in expanding, strengthening and building the capacity of these countries to meet health goals, and whether they provide a net positive or negative impact.

Increased globalisation in recent years has reinforced the importance of the for-profit private sector’s role in preventing and controlling the NCD pandemic.8 Private for-profit stakeholders have many advantages when working towards controlling and managing NCDs.6 Private businesses have credibility, convening power and geographical presence within local communities, enabling them to influence lifestyle choices that control and manage the development of NCDs and their risk factors.6 Private for-profit businesses are often committed to involvements spanning longer than political cycles, which is essential for success, due to the long timelines required to address NCDs.6 Lastly, private for-profit stakeholders generally have the human capacity, financial resources and ability to penetrate markets, which are vital in mixed-model approaches with private and public stakeholders to control and manage NCDs.6

Despite the significant roles that the private sector plays in NCD management and control, previous literature does not comprehensively evaluate the private sector’s involvement in these roles. The aim of this study is to conduct a systematic review of existing frameworks to understand the for-profit private sector’s roles across various sectors and systems.

Methods

This systematic review is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses. No protocol was prepared.

Search strategy

Comprehensive searches of PubMed, EMBASE, Cochrane Library, Web of Science, Business Source Premier and Proquest/ABI Inform were performed in 15 January 2021. A search strategy using terms related to: (1) NCDs; (2) private sector; (3) framework/model/theory was formulated and administered, which is available in online supplemental appendix A. Results were filtered to only include those published from the year 2000 onwards, in English.

A search plan template was adapted to develop an organised approach to find relevant grey literature.9 Grey literature searches were conducted on 2 February 2021 using the websites of the following relevant organisations: WHO, Organization for Economic Co-operation and Development, World Bank, American Cancer Society, NCD Alliance, Union for International Cancer Control, Center for Strategic and International Studies, World Economic Forum, UNICEF, Center for Disease Control and Prevention, Global Alliance for Chronic Disease, Wellcome Trust NCD, National Institute of Health, United Nations Development Programme, Council on Foreign Relations, FHI360, Research Triangle Institute International, NCD Child, Pan American Health Organization, Save the Children, and World Vision. Search terms again included (1) NCDs; (2) private sector; (3) framework/model/theory were formulated and administered, and searches were limited to articles published in English from the year 2000 onwards.

Study selection

The BeHEMoTH (behaviour of interest, health context, exclusions, models and theories) technique was used to develop a clear set of inclusion criteria.10 The behaviour of interest was management and control of NCDs, and the health context was the for-profit private sector. The final component was models, theories or frameworks that assessed the private sector’s role in NCD management and control. Articles were excluded if they only focused on the public or non-profit private sector, lacked descriptions of private sector roles or frameworks, models or theories, did not mention NCDs, or had an empirical study design. Presentations, interviews, press releases, newspaper/magazine articles, abstracts and articles that were unavailable online were additionally excluded. Efforts were made using library resources to attempt to gain access to articles that were not available online. Two reviewers (NAS, KM) used Covidence Software (2021) to independently conduct screening. Any discrepancies between reviewer decisions were addressed through discussion or by a third reviewer (HD) when necessary. Reference lists of included studies were also screened for relevant articles.

Data extraction

Two reviewers (NAS, KM) used Covidence Software (2021) to extract relevant information from the selected academic articles. A pre-piloted data extraction form was used, which is available in online supplemental appendix B.

Quality assessment

The same two reviewers (NAS, KM) independently assessed the quality of the each included study using the tool developed by Hawker et al,10 which is available in online supplemental appendix C. The quality assessment was conducted to understand the validity of the selected articles, and the specified tool10 was used as it was identified to be an effective way to systematically evaluate qualitative health research. The tool assesses nine areas for quality: abstract and titles; introduction and aims; method and data; sampling; data analysis; ethics and bias; results; transferability and generalisability; implication and usefulness. For this review, the questions on ethics and bias, and sampling were excluded as they were not relevant to the included studies and would skew the quality assessment outcomes. Each section was ranked as 4=good, 3=fair, 2=poor or 1=very poor. Values for each study were added up to provide a total score, which corresponds to a letter grade indicating study quality: A (22–28)=high quality; B (16–21)=medium quality; C (7–16)=low quality. Any discrepancies in quality assessment between reviewers were resolved via discussion. The quality scores did not inform analysis in any other way and are presented here for reference only.

Data synthesis

An inductive thematic analysis approach was used for data synthesis, to enable the analysis to be data-driven as the data were complex and specific to certain health-related contexts.11 First, similarities and differences between frameworks, models or theories were identified, grouped, named and organised into a table of themes and subthemes.11 This first step was an iterative process as the authors switched between re-analysing the selected articles and categorising the frameworks, models or theories selected. These themes were identified as factors that explain the private sector’s role in managing and controlling NCDs. Next, each theme was defined based on content from included papers in order to clearly establish which topics and areas were encompassed under each theme.11 Finally, these themes were organised into a framework to visually display the dynamic relationship between various factors that influence the role of the for-profit private sector’s management and control of NCDs.

Patient and public involvement

Neither patients nor the public were involved in the design, conduct, reporting or dissemination plans of our research.

Results

Following the removal of duplicates, 1383 unique records were screened for inclusion. Of these, 174 articles underwent full-text screening, and 31 articles were included (figure 1). Key characteristics of each included article are presented in online supplemental appendix D.

Figure 1

PRISMA flow diagram. NCDs, non-communicable diseases; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Using thematic synthesis, six themes were identified as key pillars describing the private sector’s role in NCD control and management (online supplemental appendix E). These included public–private partnerships (PPPs),8 12–21 knowledge educator,19 22–30 direct investment and finance,12 19 22 27 29–36 healthcare provision,15 26 27 31 32 35 37 innovation,6 14 18 23 31 36 37 and governance and policy.12 16 21 23 38 39

The framework developed (figure 2) demonstrates the relationship between themes, elucidating roles played by the private sector within greater health systems to control and manage NCDs. Through these roles, the private sector works independently, or in conjunction with other sectors, to improve NCD control and management efforts. The governance and policy and PPP pillars were considered overarching themes in the framework. Both serve as facilitators between the private sector, the other four pillars, and NCD management and control. They often dictate how and where the private sector fits into health systems in terms of levels of engagement. In contrast, the other four themes were roles where the private sector has a direct impact on NCD management and control. The arrow circling the figure demonstrates the interconnectedness of all themes regarding NCD control and management.

Figure 2

Framework of private sector roles in NCD management and control. NCD, non-communicable disease; PPPs, public–private partnerships.

Key themes

Healthcare provision

The private sector is a major healthcare provider for people with NCDs.31 The provision of private healthcare generally includes the following components of NCD prevention and management: diagnoses, treatments and delivery of quality supplies and products.

The private sector offers diagnostic and specialist services that are not readily available in the public sector.35 These services have been provided through private polyclinics, which act like small hospitals and house a variety of general and specialist examinations and treatments for health conditions including NCDs.35 Another type of private healthcare provider includes small private practices providing individualised, patient-centred chronic care.35 Private stakeholders have also introduced patient-centred pharmacies, where traditional medicine dispensing responsibilities shift from pharmacists to pharmaceutical technologists and other healthcare professionals.26 These changes enabled pharmacists to build capacity by providing direct care in outpatient and inpatient contexts, including chronic care provision.26

The private sector plays roles in the indirect provision of healthcare which are critical in providing quality chronic care. These roles include providing and maintaining health facilities, equipment, cleaning services and utilities including power, waste and water management.27 One example is providing transportation services to health facilities, which increases access to chronic care and healthcare for populations in remote areas.27 Without private sector support in healthcare provision, burdens fall on public sector, which has limited financial and human resources to meet population health needs. Absence of the private sector would result in weaker health systems, unable to provide adequate care to chronic patients and thus control and manage NCDs. Private sector involvement in the evaluation, marketing, manufacturing and distribution of health products contributes to improvements of entire health systems and indirectly NCD healthcare provision.37

The provision of healthcare services by the private sector, however, can at times introduce inequities in health systems due to the higher costs associated with these services.31 Relatively higher income individuals may be better able to overcome shortcomings within public health systems and obtain high-quality private healthcare. Lower income individuals, however, must either settle for available public healthcare services or use lower-quality, unregulated private healthcare.31 Furthermore, the potentially more lucrative private sector may result in a shortage of healthcare workers in the public sector, further weakening this system and widening disparities in care.31 Individuals working in the private sector have also been found to be more likely to ignore guidelines proposed by ministries of health and the WHO, which may call into question the actual quality of care in this sector.35 To use the private sector to its highest potential and improve the quality of health systems overall, it is critical that accountability is established for all involved to ensure that the needs of the underserved in the community are met before prioritising any commercial interests.26

Innovation

Innovation plays a key role in identifying or improving health services, delivery methods, products, systems, policies and technologies that improve health and well-being. Health innovation addresses gaps in healthcare, by creating and demonstrating new perspectives, with an emphasis on responding to needs of vulnerable populations, including chronic care patients. Private sector plays a major role in health innovation by providing innovative technologies that improve affordability, safety, sustainability, efficiency, quality and/or effectiveness of healthcare, including chronic care.14 27 37 These innovative products can be applied within private centres and across health systems to control and manage NCDs.

Medical devices, eHealth solutions and assistive devices are examples of health technologies that can be used to control and manage NCDs by improving well-being, quality of life and provision of care.22 31 40 Leveraging the private sector to create effective life-saving products and increase health literacy improves access and enables health systems to provide quality chronic care.22 37 Innovative technologies developed by private stakeholders have also been consolidated to create disease management programmes including patient registries, evidence-based decision support protocols and datamining features to create visuals informing and engaging patients in controlling and managing NCDs.18

Private sector stakeholders enable compatibility between disease management programmes and smartphones, enhancing access and support to NCD care.18 Technologies can also be used to identify and support centres with expertise in NCD control in terms of prevention, and serve as comprehensive extensions of primary care.23 36 Aside from manufacturing technologies, the private sector’s work in NCD control and management includes manufacturing of innovative health medicines that prevent NCDs.6 37 One specific example is the development of polypills, which are pills that combine numerous generic NCD-preventing drugs to better manage the NCD pandemic.6 Polypills reduces risk for stroke and ischaemic heart disease by 80% and 88%, respectively, and have been manufactured by private partners for as little as $1.6

Another example of innovation related to NCD control and management in the private sector is Information and Communications Technology (ICT), which plays a large role in continuous development and dissemination of care, especially for chronic diseases.18 31 Examples of ICTs in healthcare include telecare, electronic health records and communication systems. ICTs have been used to improve quality of care, foster patient-centred care and educate patients and healthcare workers in remote communities facing challenges delivering NCD care.18 31 To tackle challenges, improve NCD-related outcomes and inform healthcare providers, private sector stakeholders have leveraged ICTs including augmented reality and artificial intelligence.18 Despite the importance of ICTs and information sharing, introducing new venues for knowledge dissemination can lead to private providers not adequately sharing information with other private centres nor public health systems.31 This can impede the monitoring of disease burdens and public health initiatives to prevent controllable situations from becoming epidemics.31

The private sector’s innovative work in NCD control and management also includes incentivising healthy lifestyles through health insurance companies.6 Innovative, incentivised private health insurance programmes provide benefits including discounts on healthy products, with further reductions for individuals who have completed health checks.6 These programmes have lowered hospital admission rates for NCDs and reduced risks of developing NCDs.6

Knowledge educator

The pillar of ‘knowledge educator’ further describes private sector involvement in NCD control and management by demonstrating the significant impact health education has on how people manage their health behaviours and ultimately NCD risk.

A foundational component of this theme is capacity building through educating healthcare workers. Many LMICs have a shortage of doctors and specialists, and lack capacity to hire and train more staff to provide timely NCD care.22 A resourceful and efficient way to tackle this capacity issue is through private sector provision of training to nurses, pharmacists and other health personnel to provide appropriate chronic care.19 24 26 30 Private stakeholders have trained healthcare workers to detect, screen and manage NCDs (ie, appropriate delivery of medicines, perform basic consultations and provide appropriate educational materials).22 26 28 Some training has additionally been developed through private stakeholders establishing postgraduate training programmes focusing on local health priorities, especially chronic care.26 A common example of private sector education to address NCDs through is training pharmacists and other healthcare workers to provide chronic care in both public and private clinics and hospitals.26 Private educational programmes, when integrated into local contexts, have improved the capacity of healthcare systems through shifting dependency from private donors, to being locally sustained with government support.26 Other advantages of these educational programmes include a reduction of burdens on hospitals and doctors and increased chronic care provision by maximising pharmacists’ impact through the creation of new learning opportunities.26 It was of concern that private partners may prioritise their own teaching interests over the needs of local communities, thus collaborating with local workers and scientists was critical to ensure the teaching of contextually relevant concepts.26 Overall, these initiatives improve the abilities of populations to manage NCDs, as well as control NCD burdens and severity.

In addition to educating healthcare workers, population-level health promotion strategies are key to increasing NCD control and awareness within communities, through prevention efforts such as providing lifestyle change opportunities, and minimising risk of developing NCDs.24 The private sector has been leveraged in various ways to promote positive change in population health behaviours.23 25 29 One example includes promoting physical activity to reduce risks of developing NCDs, by creating recreational spaces and investing in sports and leisure facilities.27

A priority of knowledge exchange and training is to build health system capacity, which in turn improves NCD control and management. Human and institutional capacity are precursors for the effective function of health systems but are generally overlooked.41 Private sector involvement through educating healthcare workers and providing training programmes has been effective in building capacity of health systems, to enable them to meet local populations’ chronic care needs and manage NCDs.25 26 41

Direct investment and finance

The private sector is involved in the financing of NCD control and management in several ways, including treatment prices, supply chain costs, health insurance and direct investments.19 22 31–33 Investment and financing from the private sector have provided necessary funds to support the provision of financially accessible NCD care, especially in resource-poor communities.32 Limited public sector funds and capacity create barriers to achieving NCD-related and Sustainable Development Goals (SDG)-related goals, emphasising the need for the private sector to address the barriers.12

Economic accessibility and affordability are major barriers to accessing quality healthcare as they determine an individual’s ability to pay for goods and services without financial hardship.33 In the private sector, prices and out of pocket (OOP) expenditures for chronic care are generally higher than the public sector, impeding the accessibility of healthcare services and medications.22 29 34 35 41 These high prices of medications are attributed to manufacturer pricing and add-on costs throughout the supply chain to improve profit.15 22 27 33 One way the private sector increases accessibility is by providing more affordable generic branded medicines.22 Private sector also impacts NCD care financing through private health insurance which improves affordability and accessibility.27 32 Overall, the balance between the private sector providing high quality care and affordability/accessibility of said care may be called into question despite the listed mitigation efforts.

The private sector also directly invests in NCD control and management. Examples include investing in training centres educating health providers on NCD control and management, producing human resources and providing capital to establish accredited educational institutions.27 30 36 The private sector also invests in infrastructure like polyclinics, which are facilities that provide healthcare to manage and control various diseases, including NCDs.35 In areas with minimal health infrastructure and services, private sector investments in cost-effective, NCD-targeted interventions helps ensure equitable and affordable care.30 Direct investments strengthen health systems’ abilities to provide NCD care that meets population needs and prevents continued growth of the NCD pandemic.

Public–private partnerships

PPPs generally involve sharing mutually beneficial support, work, power, finances and/or information between public and private partners, and work towards achieving common goals, including controlling and managing NCDs.13 20 21 Partnerships with diverse private sector stakeholders help public healthcare providers mitigate barriers in addressing NCDs, such as lack of health systems capacity for innovation, and low public sector budgets.14 15 18 19 PPPs also support the use of technology to reduce NCD prevalence, which is key to improving health outcomes.18

Forming PPPs is effective in tackling the NCD pandemic as diverse ranges of partners elicit varied perspectives and resources, especially when private sector objectives support improvement of NCD control and management.8 15 Advantages of partnering with the private sector include reducing financial barriers and challenges associated with NCD treatment.8 14 Additionally, private sector collaboration increases accessibility to NCD-related goods and services and improves the capacity of various healthcare workers who provide NCD-related goods and services through education.8 21 Finally, partnerships with the private sector allow for the provision of innovative technologies used to control and manage NCDs.8 14 21

Despite the benefits of PPPs in the health sector, the global health community is resistant to collaborating with private entities.12 17 Partnerships with private corporations in alcohol, tobacco and processed food and drink industries, also referred to as unhealthy commodity industries (UCIs), typically raise controversies, as they benefit from health-damaging behaviours that are NCD risk factors.16 UCIs generate profit by undermining efforts to regulate consumption of their products, and from consumers who buy profit-generating products which increase NCDs, like alcohol.16 Collaborations with UCIs thus raise concerns over conflicts of interest where selling products that increase NCD risk is prioritised over addressing NCD-related needs of communities.12 19 20 Therefore, public sector partners have avoided the formation of PPPs with UCIs to address the NCD pandemic due to a lack of clear evidence proving the benefits of these partnerships.16

Governance and policy

There have been significant shifts in global health governance including surges in global health platforms, transnational commercial actions as a determinant of poor health and changes from governance in international organisations and states, to private and hybrid public–private authorities.12 The strengthening and/or establishment of global health platforms involved the development of clear guidelines to address conflicts of interest in governance and policymaking between health platforms and the private sector.12 This enabled the promotion of clear actions to address factors influencing risk and illness, which is critical to achieve NCD-related goals and SDG targets.12 21 Additionally, understanding complexities associated with private sector collaboration requires governing the complex range of interactions and engagements that address NCDs.12

To effectively control and manage NCDs, a critical dimension of governance that needs to be considered is policymaking.21 38 Private stakeholders involved in health and NCD policymaking include corporations and UCIs which generally have interests that conflict with population health and NCD control and management.16 38 UCIs use strategies to undermine effective NCD-related policies and public health programmes (ie, regulations on marketing to children, taxes on unhealthy foods and beverages, traffic light labelling) to generate profit from increased consumption of their products.16 23 38 Due to these discrepancies between UCI interests and addressing NCDs, global and public health stakeholders strongly oppose their participation in NCD-related and health-related policymaking.16 38 This strong opposition arises from evidence that UCI involvement clearly benefits private stakeholders, but not public health goals.12 39 UCIs have been criticised for this role in promulgating environments that favour NCD development, but at the same time they have the power to create environments that positively contribute to NCD control and management.23

There is also a difference in effect observed in terms of how the private sector contributes to NCD-related governance and policies in LMICs versus high-income countries (HICs). The bulk of future growth in profit from sales of UCIs is projected to come from LMICs in part due to saturation of markets in HICs.16 There are also already strict policies in place that limit industries such as tobacco and alcohol in HICs, allowing UCIs to better penetrate policy arenas in LMICs in comparison.16 Overall, the role of the private sector in policymaking is often in opposition with efforts to implement policies promoting NCD control and management as these policies typically impede their profit-driven motives.

Quality assessment

Thirteen studies were awarded a grade of A for high quality,12–16 19 20 23 28 34 35 38 39 15 had a grade of B for medium quality6 17 21 22 24–27 29–33 37 41 and three had a grade of C for low quality8 18 36 (online supplemental appendix F). The three studies deemed to have low quality had poor or incomplete abstracts, descriptions of methodology, disorganised results or a combination of the three.8 18 36 The study by Willis et al20 was awarded the highest rating, and that by Subramaniam18 was awarded the lowest quality rating. Differences between the quality of both articles were observed across all seven assessment criteria.

Discussion

The private sector’s roles in NCD control and management are multifaceted and involve several factors, as demonstrated by our framework. These roles replace or support public sector or non-profit private sector interventions to ultimately improve NCD control and management. The private sector needs to be included as a stakeholder in NCD control and management as it can provide major contributions to healthcare provision, innovation, knowledge education, finance, and governance and policy within greater health systems. Our findings suggest that systems requiring support in these realms can lean on the private sector to provide much-needed in-kind and financial resources. Whether acting alone, or within PPPs, the private sector is an important stakeholder to consider when improving the capacity and quality of health systems to combat NCD burdens.

That being said, it is important to remain cognizant of the many conflicts of interest that may arise when working with the private sector due to profit-driven motives that do not align with NCD-related public health goals. When it comes to forming partnerships with the for-profit private sector (ie, through PPPs), it is particularly complicated when UCIs are involved. Thus, there must be sufficient safeguards in place to ensure that public health interests remain prioritised.42 PPPs have been promoted by governments and the UN to combat NCDs, however, there is a lack of evidence of UCI involvement delivering health benefits, and instead partnerships are used as tactics to delay stronger regulation.16 The private sector is able to take on a stronger role in the policymaking field, as PPPs involve shared decision-making powers that permit private partners to participate in setting NCD-related agendas, goals and responsibilities to a greater extent than they could independently.43 Independently, the private sector also influences governance and policy through lobbying efforts, for example. This lobbying frequently aims to fight government efforts to control NCDs.44–55 The effect is even more prevalent in LMICs, as these companies are pushing to continue their expansion in these regions and maximise profits, and thus must prevent the implementation of effective policies that could limit their marketing, over-supply and product affordability.56 Relationships are also built between the private sector and key policymakers through donations to political campaigns, in-kind gifts45 49 52 or a ‘revolving door’ effect where individuals in leadership positions in the private sector take on senior government roles, or vice versa.44 To mitigate any negative influence of commercial determinants of health, governance, accountability mechanisms, contracts, transparency and balance between interests are critical.33 43 57–59

In a similar study, a framework was developed for the prevention and control of NCDs using a primary healthcare approach.60 The critical topics identified in controlling and preventing NCDs included: intersectoral collaboration and private sector involvement, use of technology and community participation (through individual behaviour changes).60 Similar to our findings, they stressed the importance of implementing healthy lifestyle choices and health promotion, as well as use of technology like medical equipment and health records, to manage and reduce risk of developing NCDs.60 Unlike our study, Demaio et al simply stated that the use of technology in terms of NCDs is beneficial, whereas we described in greater detail how innovative technologies can be used to manage NCDs. Another similarity between our findings is the identification of alcohol, tobacco and ultra-processed food and drinks as risk factors for NCDs, which should be addressed across all sectors. More specifically, Demaio et al emphasised the need to enforce policies and legislation for private sector stakeholders to minimise the chronic health impact of alcohol, tobacco and ultra-processed food and drinks. In contrast, our review highlights the complexities associated with partnering with private corporations in the alcohol, tobacco and processed food and drink industries, and underlines the resistance from the public sector to collaborate with these industries to address NCDs. The main difference between the findings of Demaio et al and the current review was in how the private sector was mentioned. Although Demaio et al mentioned how the private sector impacts NCD control and prevention, the review lacked detailed descriptions of the specific roles private sector.60 In comparison, we identified various roles that the private sector plays in managing and controlling NCDs, with respect to each of the six pillars identified. Another difference between the two reviews was that Demaio et al stated the need for a focus on equity across health systems, to address NCDs effectively, especially among poorer populations, whereas the current review focused more on affordability as a barrier to accessing quality healthcare.

Another study developed a framework to improve local, national and international primary healthcare responses to NCDs.61 This framework developed by Maher et al also highlighted the importance of identifying and addressing modifiable risk factors such as smoking and alcohol to effectively manage and control NCDs.61 The importance of financial investments in health systems to enable the appropriate management and control of NCDs was another similarity highlighted in both frameworks.61 The framework by Maher et al highlighted critical topics in controlling and preventing NCDs such as political commitment, and standardised diagnostic treatment protocols. The major difference between both reviews is the lack of mention of the private sector and the roles it can play in controlling and preventing NCDs by Maher et al, which was the central focus of this review. We also emphasised the role of innovation in improving quality, efficiency and effectiveness of chronic care, which was not mentioned by Maher et al. The use of innovative technologies was highlighted in our findings to explain the use of disease management programmes including patient registries to track and manage chronic patients’ records. In contrast, Maher et al suggested the use of record-keeping systems that are either paper-based, paper-based with a computer-based system or entirely computer-based to track and manage patient records. Maher et al further elaborated that despite the method of record keeping used, strategic data could be used to evaluate progress towards NCD management.

Recommendations

The findings of this review can guide future policy decisions regarding the role of the private sector in NCD management and control worldwide. While this framework clearly identifies six key pillars that are essential to address the NCD pandemic globally, it is important to note that the policy implications can be broken down into three levels: global, national and local. At the global level, the private sector should be considered as a key player to unite governments and other organisation across countries. The private sector has the power to play a critical role in creating policies and establishing appropriate governance structures to guide decision-making processes when working with stakeholders with similar goals, to address NCDs. This must, however, be accompanied by safeguards and monitoring processes to ensure that this influence is not being complicated by conflicts of interest. The private sector should also be involved in the development of globally sustainable financing mechanisms used to reduce financial barriers in accessing NCD care. At a national level, private sector involvement in financing plays a key role as it can provide funds for countrywide NCD management programmes, training and educational capacity of chronic care providers and infrastructure. Partnerships with multisectoral private sector stakeholders from the agricultural, business and media industries should also be leveraged at the national level to maximise collaborative opportunities, inform evaluations, effectively integrate technological innovations and reach targeted populations. There must also be safeguards and governance structures in place throughout partnerships that outline roles and objectives, however, to ensure that the needs of communities are prioritised above any profit-seeking motives. The private sector can also greatly improve access to critical NCD-related medications and healthcare services; however, equitable access is not always guaranteed due to higher OOP expenditures in the private sector. Thus, initiatives that subsidise costs for lower-income groups or place a cap on fees should be considered so as not to widen disparities in the health of individuals across the socioeconomic status spectrum. Increasing private sector involvements at the global and national levels will help improve provision of chronic care, increase knowledge and awareness of NCDs and ease the process of implementing innovative approaches to address NCDs at the local level as long as it is accompanied by the appropriate governing structures.

Strengths and limitations

This review has several strengths. These included the use of a search strategy including HICs, LMICs and all NCDs. The use of six diverse databases allowed for a multisectoral approach to the development of the framework, that goes beyond the field of medicine. The broad search strategy adapted from well-developed methodology ensured that all relevant articles were captured. A strength of our framework is that it can be generalised and applied to different country and income settings. It additionally provides policymakers and other stakeholders with important pillars that need to be considered when developing strategies to control and manage NCDs. Finally, the review process involved two primary reviewers to screen articles, and a third reviewer to resolve any conflicts, which improves reliability, validity and quality, reducing bias.

This study fills a large gap in existing literature as there are no other recent studies that include frameworks clearly demonstrating the private sector’s role in controlling and managing NCDs. The framework developed based on the extracted themes from this study was carefully constructed to clearly show the role that the private sector and other pillars play in controlling and monitoring NCDs. Each theme was clearly defined and divided into subthemes to make the definitions more holistic, and applicable to other contexts. The clear display of the relationships between the private sector and the themes increases the applicability of the framework, which can be used to influence the development of guidelines to control and monitor NCDs. The framework developed can help identify which factors need to be prioritised to effectively control and monitor specific NCDs, depending on the context.

One limitation of this review is the lack of literature including models, theories and frameworks relevant to the role of the private sector in controlling and managing NCDs. Additionally, the focus of the final 30 articles differed, as NCDs were the primary outcome in some articles, and a secondary or tertiary outcome for other articles. This limitation was evident as some articles only briefly mentioned a theme, whereas other articles provided detailed explanations of the theme and context of the study. It should also be noted that this study was limited to English publications only, introducing language bias, which could have further restricted the results. Finally, the protocol for this review was not registered, thus increasing the risk of bias, and reducing transparency.

Conclusion

This study provides an updated insight on literature that explores the private sector’s role in controlling and monitoring NCDs. This review suggests that as the private sector plays a critical role in the provision of healthcare, it should be leveraged to play a greater role in control and managing NCDs within greater health systems. That being said, appropriate regulatory and governance structures must be in place to ensure the prioritisation of population health over any profit-related motives. Substantial work is needed across sectors for the private sector to improve the ability of health systems to effectively manage and control NCDs. These areas include PPPs, knowledge educator, direct investment and finance, healthcare provision, innovation, and governance and policy. While this review has identified these critical pillars, there is a need for in-depth analysis of each pillar and its relationship with the private sector in the future. In addition, further studies need to focus on the mechanisms and incentive systems, which could facilitate the scaling-up of the private sector engagements. Progress made to advance these areas and build or improve their capacities will enhance the ability to control and monitor NCDs globally.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

Acknowledgments

We are very thankful for the support of the SickKids Centre for Global Child Health and University of Central Asia. The authors thank Gulnara Djunushalieva of the University of Central Asia, who contributed their expertise during the editing phase of this review.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @NadiaSomani

  • NAS and KM contributed equally.

  • Contributors ZB conceptualised the study and secured funding. NAS, KM, HD and KT developed methodology. NAS, KM, HD and KT facilitated data collection and organisation. NAS and KM conducted the analysis. NAS drafted the manuscript, and KM, HD, KT, RM and ZB critically revised it. All authors approved the final version. ZB is the guarantor.

  • Funding This work was supported by MITACS (award/grant number: FR58000 and FR58001) and the Aga Khan Foundation Canada (award/grant number: N/A).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.