Mind the gap: what we’ve learned from our search of the literature on governance of the private sector in health during the COVID-19 response

Blog article
Mind the gap: what we’ve learned from our search of the literature on governance of the private sector in health during the COVID-19 response

With successive waves of COVID-19 battering low- and middle-income countries (LMICs), increasing attention has been directed to market and governance failures during the emergency response (1). These are most visible in LMICs, where shortages of COVID-19 tools have been acutely felt. These include vaccines, diagnostics, and therapeutics, oxygen and personal protective equipment (PPE). In most LMICs, demand for COVID-19 tools has far outstripped available supply, reflective of a highly inequitable global therapeutic context and a failure to meet the promise to “leave no one behind” (2-4).  In some countries, during COVID-19 surges, “trauma was on vivid display”[1] with media attention directed to opportunistic behaviors and adverse practices within private healthcare service delivery compromising efforts to reach the right to health for all.

Search strategy

To explore this topic, we sought to understand why and where there has been swift and proactive co-operative action between the public and the private sectors, to build better and more effective governance of national COVID-19 response and more resilient health systems. Within national COVID-19 response, we were specifically interested in looking at the governance of the health system as a whole and how and where a lack of governance allowed for adverse practices and opportunistic behaviours during emergency peaks in demand as a result of COVID-19.

We searched the WHO COVID-19 Database and Google Scholar for articles published between January 2020 and June 2021. Since our interest was in national response, we excluded articles that focused on the global COVID-19 response including global governance, global private/commercial sector, and global supply chains. We also excluded global and country level business philanthropy.

What we found

Our search strategy identified 2,201 citations. We used Rayyan as support software to screen the articles, which included a combination of original research, reviews and commentaries. Through screening, 60 full text articles were selected and screened in a second phase. After the first full-text screen, 37 articles were extracted in total.

Key words from the extracted articles have been categorised by concept in Table 1 to demonstrate the diversity in approach to our topic area.

Table 1


Key words

Emergency, preparedness, and response

Disaster science, Disaster resilience, Crisis theory, Disaster management, Public health emergency management, Pandemic preparedness, Infectious disease

Health systems

Health system resilience, Health system approach, Health systems strengthening, Public-private-mix

Health service delivery

Delivery of health care, Private healthcare sector, Public health, Private acute healthcare market, Digital technologies, Primary health care, Pharmacies, Pharmacy professional, Guidelines


Public-private partnerships, Reform, Public policy, Public management theory, Human resources in health, Universal health care, Policy evolution, Health policy and systems research, Delphi process, Policy instrument, Crisis policymaking


Agilities, Regulatory science, Compliance, Public procurement, Informal payments, Unfair Price Evaluation Board, Competition Authority, Advertising Board


Cooperative governance, Hierarchical governance, Network governance of crisis response, Regulation and governance, Institutional infrastructure, Comprehensive, Multi-sectoral

Public/civic/societal engagement

Public voice, Social media, Social determinants, Community engagement, Digital divide, Culture, Social equity, Health inequality, Agency, Social class

Commercial/private sector

Private sector, Biotech industry, Product innovation, Test kit

Political science

Politics of service coverage, Neoliberalism, Laissez-faire, Sustainability, Collaboration


Ethics, Fraud, Corruption, Trust, Price gouging


Learning, organizational learning, quadruple-loop learning


The articles were published in a variety of journals, covering a range of high income and LMIC contexts; often a comparative lens was used, looking at multiple countries or regional groupings (e.g., Arab states, East Asian states) while an almost equal number were country specific. The journals represent a multi-disciplinary, multi-agency and multi-cultural authorship.

  • Health system: Health Systems and Reform, Journal of the American College of Surgeons, International Journal of Health Services, Clinical therapeutics, Journal of Community Health Research, Research in Social and Administrative Pharmacy.
  • Health policy: Public Management Review, American Review of Public Administration, Health Policy, Health Policy and Planning, Korean Journal of Policy Studies, International Journal of Sociology and Social Policy.
  • Global health: Global Public Health, Global Health Action, BMJ Global Health, The Lancet, The Pan African Medical Journal, Frontiers in Public Health, International Journal of Environmental Research and Public Health.
  • Political science: World Development, Policy and Society, Sustainability.

There was a concentration in focus geographically, with more articles published on Asian countries than sub-Saharan Africa countries, for example. This may have been due to the period covered by the review, and the evolution of the pandemic. There was also a mutable shift in focus over time. Many of the articles that addressed the early phases of the pandemic covered concepts such as preparedness and service delivery. Those that were published in later phases of the pandemic were more reflective, addressing concepts such as learning, inequities and ethics.

There was less literature that specifically addressed adverse practices and opportunistic behaviours of the private sector in health during COVID-19. We found that more was documented on governance failures than market failures, with the latter largely documented in the media and referenced in the literature. Governance failures were described as “hierarchical” and “multi-agency” in addition to “multi-sectoral”, suggesting significant challenges with a whole of society and whole of government response to COVID-19 in many contexts. There were recognised theories offered for analysing COVID-19 from a disaster and crisis perspective, but less recognition or use of theory for analysing health governance and systems resiliency.


In closing, there is need to “mind the gap”, to look at governance of the whole sector, the relationship of emergency response to national public health objectives and resilient health systems. In this regard, there is a major gap in documented experiences and knowledge, in terms of how governments have intervened in health markets and with what effects. This needs to be corrected if we are to strengthen the response to COVID-19 across whole health systems in an evidence-informed way. We plan to develop a research framework for governance of the private sector in health during the COVID-19 response to address this gap.

The Country Connector offers a platform where local researchers can express interest in collaborating with WHO and the other Connector members to mind the gap identified in the scientific literature and develop resources, tools and guidance needed for stronger health system governance and better public policy towards the private sector in health.

For more information email us at: contact@ccpsh.com


  1. Owen DW, Yung KC, Grépin KA. The failure of private health services: COVID-19 induced crises in low- and middle-income country (LMIC) health systems. Glob Public Health. 2021;16:1320-33. doi: 10.1080/17441692.2021.1874470.
  2. Lal A, Erondu NA, Heymann DL, Gitahi G, Yates R. Fragmented health systems in COVID-19: rectifying the misalignment between global health security and universal health coverage. Lancet. 2021;397:61-7.
  3. Binagwaho A, Mathewos K, Davis S. Equitable and Effective Distribution of the COVID-19 Vaccines - A Scientific and Moral Obligation. Int j health policy manag. 2021.
  4. Urgent needs of low-income and middle-income countries for COVID-19 vaccines and therapeutics. Lancet. 2021;397:562-4. doi: 10.1016/s0140-6736(21)00242-7.