The for-profit private sector is an important provider of health services in most countries, and the sub-Saharan African region is no exception. A recent study puts the percentage of health services sourced from private providers in the World Health Organization’s AFRO region at some 40%.

During the COVID-19 pandemic, the private health sector in this region (and also elsewhere, including South Asia) has experienced a range of financial and operational challenges, which have further aggravated the degree of disruption faced by national health systems.

Now, as new variants of the SARS-CoV-2 virus emerge, some of them more transmissible than the original strain, it is clear that we are still in the foothills of the pandemic. In this context, we conducted a survey of health businesses in nine African countries to understand more about the impact of the pandemic on the private health sector. The full results of this work are outlined here.

The survey paints a grim picture – in which the supply of health care provided in the private sector became squeezed as the pandemic took hold.

The initial impact was financial. Many businesses saw their costs rise sharply (one respondent in Nigeria reported a rise in the prices of Personal Protective Equipment of some 5000%). At the same time, revenues diminished as the ability of patients to seek out and pay for care declined – due to the pandemic itself, and policy responses to it.

The result has been a large reduction in income for health care businesses. Yet the consequences have not been merely financial. Many businesses have been unable to finance their operations – to buy needed equipment and supplies or pay their staff. Some 25% of survey respondents reported that they had chosen to close facilities for at least three months at some point during the pandemic. About half had decided to furlough or lay off some of their employees. Most expected these problems to re-occur in the near future, as the pandemic evolves.

So, given the scale of the private sector in the AFRO region, what consequences have there been from a public health perspective?

According to the survey data, there have been three main effects.

First, in the countries with relatively high rates of infection, the closure of facilities has reduced the population’s access to COVID-related care (e.g. respiratory care, ICU and critical care). Second, a larger group of countries have witnessed reductions in utilisation of other (non-COVID-related) health services. Third, some private providers have responded to these challenges by deploying a range of strategies – such as price gouging, informal payments, and the triaging of patients based on their insurance status – that, as well as being inequitable, are inimical to the goal of minimising the health effects of the pandemic.

Policymakers are seeking to address these effects using a variety of interventions and many of these are, quite properly given the urgency of the situation, focused on short-term solutions (e.g. easing credit constraints). However, there will need to be reflection on longer-term solutions if the ‘root causes’ of these problems are to be addressed.

In many countries, the growth of the private health sector has outpaced the ability of states to put in place an appropriate regulatory architecture for it. In many countries, this imbalance has led to a range of adverse outcomes, including high prices for services of variable quality and limited compliance with clinical, IPC and reporting standards.

And, we now see, a revenue-generating model that can lead to financial and operational disruption at the expense of patients’ access to care.

It has been understood for some time that limited engagement across the sectors, public and private, can inhibit progress towards Universal Health Coverage. The WHO is working on ways to overcome this problem and is developing a Strategy for Strengthening Private Sector Engagement for UHC. The pandemic has reminded us that these limitations stand in the way of other critical health objectives, too – including, perhaps, the establishment of strong, resilient health systems.

Authors: Mark Hellowell (Global Health Policy Unit, University of Edinburgh) and Yvonne Okafor (Africa Healthcare Federation).

Competing interests: None.

Acknowledgements: The authors would like to acknowledge David Clarke, Aurélie Paviza and Bruno Meessen, of the Department of Health Systems Governance and Financing, World Health Organization, for their comments on the blog, and also members of the team who contributed to the research summarised here: Barbara O’Hanlon, Cynthia Eldridge, Anna Cocozza, Claire Gapare and Gabrielle Appleford.

Handling Editor: Neha Faruqui