"Caught In Each Other's Traps": Factors Perpetuating Incentive-Linked Prescribing Deals Between Physicians and the Pharmaceutical Industry.

BACKGROUND: Despite known adverse impacts on patients and health systems, 'incentive-linked prescribing', which describes the prescribing of medicines that result in personal benefits for the prescriber, remains a widespread and hidden impediment to quality of healthcare. We investigated factors perpetuating incentive-linked prescribing among primary care physicians in for-profit practices (referred to as private doctors), using Pakistan as a case study. METHODS: Our mixed-methods study synthesised insights from a survey of 419 systematically samples private doctors and 68 semi-structured interviews with private doctors (n=28), pharmaceutical sales representatives (n=12), and provincial and national policy actors (n=28). For the survey, we built a verified database of all registered private doctors within Karachi, Pakistan's most populous city, administered an electronic questionnaire in-person and descriptively analysed the data. Semi-structured interviews incorporated a vignette-based exercise and data was analysed using an interpretive approach. RESULTS: Our survey showed that 90% of private doctors met pharmaceutical sales representatives weekly. Three interlinked factors perpetuating incentive-linked prescribing we identified were: gaps in understanding of conflicts of interest and loss of values among doctors; financial pressures on doctors operating in a (largely) privately financed health-system, exacerbated by competition with unqualified healthcare providers; and aggressive incentivisation by pharmaceutical companies, linked to low political will to regulate and an over-saturated pharmaceutical market. CONCLUSION: Regular interactions between pharmaceutical companies and private doctors are normalised in our study setting, and progress on regulating these is hindered by the substantial role of incentive-linked prescribing in the financial success of physicians and the pharmaceutical industry employees. A first step towards addressing the entrenchment of incentive-linked prescribing may be to reduce opposition to restrictions on incentivisation of physicians from stakeholders within the pharmaceutical industry, physicians themselves, and policymakers concerned about curtailing growth of the pharmaceutical industry.

Pakistan's Progress on Universal Health Coverage: Lessons Learned in Priority Setting and Challenges Ahead in Reinforcing Primary Healthcare.

Pakistan developed an essential package of health services at the primary health care level as a key component of health reforms aiming to achieve universal health coverage. This supplement describes the methods and processes adopted for evidence-informed prioritization of services, policy decisions adopted, and the lessons learned in package design as well as in the transition to effective rollout. The papers conclude that evidenceinformed deliberative processes can be effectively applied to design affordable packages of services that represent good value for money and address a major part of the disease burden. Transition to implementation requires a comprehensive assessment of health system gaps, strong engagement of the planning and financing sectors, serious involvement of key national stakeholders and the private health sector, capacity building, and institutionalization of technical and managerial skills. Pakistan's experience highlights the need for updating the evidence and model packages of the Disease Control Priorities 3 initiative and reinforcing international collaboration to support technical guidance to countries in priority setting and UHC reforms.

The Use of Evidence to Design an Essential Package of Health Services in Pakistan: A Review and Analysis of Prioritisation Decisions at Different Stages of the Appraisal Process.

BACKGROUND: Pakistan embarked on a process of designing an essential package of health services (EPHS) as a pathway towards universal health coverage (UHC). The EPHS design followed an evidence-informed deliberative process; evidence on 170 interventions was introduced along multiple stages of appraisal engaging different stakeholders tasked with prioritising interventions for inclusion. We report on the composition of the package at different stages, analyse trends of prioritised and deprioritised interventions and reflect on the trade-offs made. METHODS: Quantitative evidence on cost-effectiveness, budget impact, and avoidable burden of disease was presented to stakeholders in stages. We recorded which interventions were prioritised and deprioritised at each stage and carried out three analyses: (1) a review of total number of interventions prioritised at each stage, along with associated costs per capita and disability-adjusted life years (DALYs) averted, to understand changes in affordability and efficiency in the package, (2) an analysis of interventions broken down by decision criteria and intervention characteristics to analyse prioritisation trends across different stages, and (3) a description of the trajectory of interventions broken down by current coverage and cost-effectiveness. RESULTS: Value for money generally increased throughout the process, although not uniformly. Stakeholders largely prioritised interventions with low budget impact and those preventing a high burden of disease. Highly cost-effective interventions were also prioritised, but less consistently throughout the stages of the process. Interventions with high current coverage were overwhelmingly prioritised for inclusion. CONCLUSION: Evidence-informed deliberative processes can produce actionable and affordable health benefit packages. While cost-effective interventions are generally preferred, other factors play a role and limit efficiency.

Costing Interventions for Developing an Essential Package of Health Services: Application of a Rapid Method and Results From Pakistan.

BACKGROUND: The Federal Ministry of National Health Services, Regulations and Coordination (MNHSR&C) in Pakistan has committed to progress towards universal health coverage (UHC) by 2030 by providing an Essential Package of Health Services (EPHS). Starting in 2019, the Disease Control Priorities 3rd edition (DCP3) evidence framework was used to guide the development of Pakistan's EPHS. In this paper, we describe the methods and results of a rapid costing approach used to inform the EPHS design process. METHODS: A total of 167 unit costs were calculated through a context-specific, normative, ingredients-based, and bottom-up economic costing approach. Costs were constructed by determining resource use from descriptions provided by MNHSR&C and validated by technical experts. Price data from publicly available sources were used. Deterministic univariate sensitivity analyses were carried out. RESULTS: Unit costs ranged from 2019 US$ 0.27 to 2019 US$ 1478. Interventions in the cancer package of services had the highest average cost (2019 US$ 837) while interventions in the environmental package of services had the lowest (2019 US$ 0.68). Cost drivers varied by platform; the two largest drivers were drug regimens and surgery-related costs. Sensitivity analyses suggest our results are not sensitive to changes in staff salary but are sensitive to changes in medicine pricing. CONCLUSION: We estimated a large number of context-specific unit costs, over a six-month period, demonstrating a rapid costing method suitable for EPHS design.

Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study.

BACKGROUND: The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources. OBJECTIVE: This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting. METHODS: We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility. RESULTS: The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs. CONCLUSIONS: A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50532.

Insight into Private General Physicians' Practices: an Exploratory Qualitative Study in a Rural District of Pakistan.

OBJECTIVE: The study aimed to assess private general physicians'(GPs) healthcare practices, identifying perceived malpractices, the support they receive, and barriers they experience in providing healthcare services. DESIGN: Qualitative exploratory study. SETTING: Rural district, Thatta in Province of Sindh, Pakistan. PARTICIPANTS: 15 GPs. RESULTS: Our results include increased motivation among GPs for continued professional development, the high influence of pharmaceutical companies on providers' prescribing practices, perceived malpractices by GPs, and the prevalence of quackery and ineffective regulatory mechanisms for private GPs in a rural district. CONCLUSION: Our findings have implications for the capacity building of GPs by academic institutions, enforcement of regulatory measures by the authorities, and the introduction of measures to curb practices by unqualified practitioners. Finally, more research will be needed to further understand the perceptions of GPs, their needs and the service delivery interventions that will enhance the quality of care they provide.

What happens when private general practitioners receive incentivisation offers from pharmaceutical sales representatives? A qualitative study in Pakistan.

OBJECTIVES: Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan. METHODS: We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes. RESULTS: We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later. CONCLUSIONS: The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Understanding the Mechanisms of Change in the Supportive and Respectful Maternity Care Intervention in Sindh, Pakistan: Provider Perspectives.

INTRODUCTION: We conducted this qualitative investigation to explore the mechanisms of change in providing respectful care resulting from the supportive and respectful maternity care intervention (S-RMC) in Sindh, Pakistan. METHODS: We applied the principles of realist evaluation methodology with a descriptive explanatory research design. We conducted in-depth interviews with 36 maternity care providers at secondary-level public health facilities where S-RMC was implemented for 6 months. The S-RMC broad components included capacity-building of maternity teams and systemic changes for improvements in governance and accountability within public health facilities. Data were analyzed using a deductive content analysis approach. RESULTS: We identified mechanisms of change, categorized by the S-RMC components: (1) S-RMC training: insight into women's feelings and rights, realization of the value that nonclinical staff can play, understanding of team coordination, orientation in psychosocial components of maternity care; (2) assessment of women's psychosocial vulnerabilities: identification of women's differential needs beyond routine care to provide woman-centered care; (3) psychosocial support: effective engagement with women and within maternity teams and the customization of woman- and companion-focused care; (4) care coordination: improved coordination among clinical and nonclinical staff to provide personalized care and psychosocial support and proper handover to ensure continuity of care; (5) assessment of quality of care: identification of service gaps from women's feedback; and (6) performance review and accountability: monthly performance review meetings to establish team member communication, systematic awareness of the maternity team's performance and challenges, and implementation of collective corrective actions. CONCLUSION: Our findings pointed to S-RMC working along multiple pathways-and concertedly with various health system components-to enable positive processes and behavioral change in maternity teams.

Estimating the frequency of inpatient adverse events using a two-step retrospective chart review: a study protocol.

INTRODUCTION: Adverse events are a major cause of patient harm in the hospitalised setting. Low-income and middle-income countries account for a disproportionate share of the global burden of adverse events. However, patient safety research is still centred around high-income countries and high-resource health systems. The methods and data produced from these efforts are ill-suited to low-income and middle-income systems due to the social and technical differences between these settings. We aim to use our pilot-tested, locally developed methodology to estimate the frequency and characteristics of adverse events in hospitalised patients in a lower-middle-income country to inform patient safety policies and initiatives. METHODS AND ANALYSIS: This multi-centre study will employ a two-step chart review methodology to identify adverse events in a representative sample of patients admitted at five hospitals between 1 January 2019 and 31 December 2019. The first step will include assessing patient files against a list of triggers to detect adverse events and the second step will involve an in-depth review of the events to capture pertinent characteristics. The triggers have been adapted from validated tools used in other studies. The reviewing team will be trained on the use of research tools and operational definitions to ensure that data are collected uniformly. The main outcome of interest is the rate at which adverse events occur in hospitalised patients. Further analysis will look to identify and quantify associations between the main outcome of interest and a variety of variables such as patient age and gender using tests of independence and regression techniques. ETHICS AND DISSEMINATION: This study protocol has been approved by the Ethics Review Committee at Aga Khan University (Reference number: 2023-6324-24566). The findings of this study will be published in a peer-reviewed journal and disseminated to the public through national and international conferences, workshops, websites and social media.

The use of cost-effectiveness analysis for health benefit package design - should countries follow a sectoral, incremental or hybrid approach?

BACKGROUND: Countries around the world are increasingly rethinking the design of their health benefit package to achieve universal health coverage. Countries can periodically revise their packages on the basis of sectoral cost-effectiveness analyses, i.e. by evaluating a broad set of services against a 'doing nothing' scenario using a budget constraint. Alternatively, they can use incremental cost-effectiveness analyses, i.e. to evaluate specific services against current practice using a threshold. In addition, countries may employ hybrid approaches which combines elements of sectoral and incremental cost-effectiveness analysis - a country may e.g. not evaluate the comprehensive set of all services but rather relatively small sets of services targeting a certain condition. However, there is little practical guidance for countries as to which kind of approach they should follow. METHODS: The present study was based on expert consultation. We refined the typology of approaches of cost-effectiveness analysis for benefit package design, identified factors that should be considered in the choice of approach, and developed recommendations. We reached consensus among experts over the course of several review rounds. RESULTS: Sectoral cost-effectiveness analysis is especially suited in contexts with large allocative inefficiencies in current service provision and can, in theory, realize large efficiency gains. However, it may be challenging to implement a comprehensive redesign of the package in practice. Incremental cost-effectiveness analysis is especially relevant in contexts where specific new services may impact the sustainability of the health system. It may potentially support efficiency improvement, but its focus has typically been on new services while existing inefficiencies remain unchallenged. The use of hybrid approach may be a way forward to address the strengths and weaknesses of sectoral and incremental analysis areas. Such analysis may be especially useful to target disease areas with suspected high inefficiencies in service provision, and would then make good use of the available research capacity and be politically rewarding. However, disease-specific analyses bear the risk of not addressing resource allocation inefficiencies across disease areas. CONCLUSIONS: Countries should carefully select their approach of cost-effectiveness analyses for benefit package design, based on their decision-making context.

Health data ecosystem in Pakistan: a multisectoral qualitative assessment of needs and opportunities.

OBJECTIVE: Data are essential for tracking and monitoring of progress on health-related sustainable development goals (SDGs). But the capacity to analyse subnational and granular data is limited in low and middle-income countries. Although Pakistan lags behind on achieving several health-related SDGs, its health information capacity is nascent. Through an exploratory qualitative approach, we aimed to understand the current landscape and perceptions on data in decision-making among stakeholders of the health data ecosystem in Pakistan. DESIGN: We used an exploratory qualitative study design. SETTING: This study was conducted at the Aga Khan University, Karachi, Pakistan. PARTICIPANTS: We conducted semistructured, in-depth interviews with multidisciplinary and multisectoral stakeholders from academia, hospital management, government, Non-governmental organisations and other relevant private entities till thematic saturation was achieved. Interviews were recorded and transcribed, followed by thematic analysis using NVivo. RESULTS: Thematic analysis of 15 in-depth interviews revealed three major themes: (1) institutions are collecting data but face barriers to its effective utilisation for decision-making. These include lack of collection of needs-responsive data, lack of a gender/equity in data collection efforts, inadequate digitisation, data reliability and limited analytical ability; (2) there is openness and enthusiasm for sharing data for advancing health; however, multiple barriers hinder this including appropriate regulatory frameworks, platforms for sharing data, interoperability and defined win-win scenarios; (3) there is limited capacity in the area of both human capital and infrastructure, for being able to use data to advance health, but there is appetite to improve and invest in capacity in this area. CONCLUSIONS: Our study identified key areas of focus that can contribute to orient a national health data roadmap and ecosystem in Pakistan.

Incentivisation practices and their influence on physicians' prescriptions: A qualitative analysis of practice and policy in Pakistan.

Focus on profit-generating enterprise in healthcare can create conflicts of interest that adversely impact prescribing and pricing of medicines. Although a global challenge, addressing the impacts on quality of care is particularly difficult in countries where the pharmaceutical industry and physician lobby is strong relative to regulatory institutions. Our study characterises the range of incentives exchanged between the pharmaceutical industry and physicians, and investigates the differences between incentivisation practices and policies in Pakistan. In this mixed methods study, we first thematically analysed semi-structured interviews with 28 purposively selected for-profit primary-care physicians and 13 medical sales representatives from pharmaceutical companies working across Pakistan's largest city, Karachi. We then conducted a content analysis of policies on ethical practice issued by two regulatory bodies responsible in Pakistan, and the World Health Organization. This enabled a systematic comparison of incentivisation practices with what is considered 'prohibitive' or 'permissive' in policy. Our findings demonstrate that incentivisation of physicians to meet pharmaceutical sales targets is the norm, and that both parties play in the symbiotic physician-pharma incentivisation dynamics. Further, we were able to categorise the types of incentive exchanged into one of five categories: financial, material, professional or educational, social or recreational, and familial. Our comparison of incentivisation practices with policies revealed three reasons for such widespread incentivisation linked to sales targets: first, some clear policies were being ignored by physicians; second, there are ambiguous or contradictory policies with respect to specific incentive types; and third, numerous incentive types are unaddressed by existing policies, such as pharmaceutical companies paying for private clinic renovations. There is a need for policies to be clarified and updated, and to build buy-in for policy enforcement from pharmaceutical companies and physicians, such that transgressions on target-driven prescribing are seen to be unethical.

Promoting Supportive and Respectful Maternity Care in Public Health Facilities in Sindh, Pakistan: A Theory-Informed Health System Intervention.

BACKGROUND: Disrespect, abuse, discrimination, and lack of emotional support characterize intrapartum care in the health systems of many low- and middle-income countries. Although the World Health Organization (WHO) provides frameworks and guidelines to address this issue, no operational model exists that effectively incorporates WHO intrapartum care guidelines into routine public health services. We aimed to develop and pilot-test a theory-driven, service-delivery intervention package linking dignified care with perinatal mental health to promote psychosocially supportive and respectful maternity care (S-RMC) in public health facilities in Sindh, Pakistan. METHODS: Using a mixed-method, pre-post design, the study was implemented in 6 secondary-level public health facilities in 2 rural districts of Southern Sindh, Pakistan. Its development was guided by the COM-B framework and informed by a literature review, formative research, and consultative sessions with implementers. The intervention was implemented in March-September 2021 and compared women's experiences of S-RMC during childbirth at baseline (n=313) and endline (n=314). We used descriptive statistics and linear regression techniques for analysis. RESULTS: A substantial reduction was observed in the cumulative level of overall mistreatment from baseline to endline, yielding a relative change of 50% (P<.001). Similar change was evident across different types of mistreatment: physical abuse (75%), verbal abuse (72%), ineffective communication (60%), nonconfidential care (78%), health system conditions and constraints (25%), noninclusive care (28%), lack of supportive care (52%), and stigma and discrimination (82%). Furthermore, we observed a significant reduction in the proportion of women experiencing symptoms of anxiety and depression before and after the intervention. CONCLUSION: This intervention built the capacity of maternity teams while improving accountability, health information systems, and governance measures. Given its promise to promote supportive and respectful childbirth in public health facilities, a large-scale effectiveness evaluation across diverse settings is warranted.

Integration of human papillomavirus associated anal cancer screening into HIV care and treatment program in Pakistan: perceptions of policymakers, managers, and care providers.

BACKGROUND: The incidence of anal cancer, largely associated with anal human papillomavirus (HPV) infection, is increasing among men who have sex with men (MSM), and transgender women living with or without HIV. Screening for anal cancer to detect anal precancerous lesions in high-risk groups is an important opportunity for prevention but still lacking in many low-and-middle-income countries. The aim of this study was to explore the readiness of Pakistan's healthcare system to integrate anal cancer and HPV screening into a national HIV program, as perceived by policymakers, health managers, and healthcare providers. DESIGN: This qualitative study using key-informant interviews with participants influence in policy making, implementation and advocacy from public and private sector were conducted between March 2021 to August 2021 in Karachi Pakistan. METHODS: Key informants were purposely selected from different domains of the healthcare system responsible for the target group of interest, MSM and transgender-women in general and people living with HIV in particular. A total of 18 key informants, at different levels of seniority were recruited from governmental and non-governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives. Qualitative content analysis was used to identify the manifest and latent themes, based on socioecological framework. RESULTS: The results were grouped into five major themes; (1) The policy context and priorities, (2) Health systems factors, (3) Community environment, (4) Healthcare setting & providers and (5) Individual-level obstacles. The policy actors expressed their concerns about their limited voice in country's health and health related priority setting. Informants reported a lack of political will and suggested that government should bring a change in the paradigm of healthcare service delivery from reactive to proactive approach. Although, participants unanimously favored integration of HPV preventive services into existing HIV program, they also identified several service delivery barriers including trained workforce shortage, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet key-populations needs. Participants also predicted other implementation challenges such as stigma, social victimization, and systemic discrimination against at-risk groups at healthcare facilities. CONCLUSION: Although policy makers and health providers in Pakistan saw a clear need to scale-up and integrate anal cancer screening for key populations, the feasibility of this is dependent on political will, financing, anti-stigma and discrimination interventions and health system efficiency.

Addition of mental health to the lady health worker curriculum in Pakistan: now or never.

The technical advisory group of the World Health Organization (Geneva, Switzerland) has suggested person-centered and community-based mental health services in response to the long-term and far-reaching mental health impacts of the COVID-19 pandemic. Task shifting is a pragmatic approach to tackle the mental health treatment gap in low- and middle-income countries. Pakistan is dismally resourced to address the mental health challenges. Pakistan's government has established a lady health worker's program (LHW-P) which can be effectively utilized to provide some basic mental health services at community doorsteps. However, lady health workers' current curriculum does not include mental health as a subject. WHO's Mental Health Gap Intervention Guide (mhGAP-IG) Version 2.0 for mental, neurological, and substance use disorders in non-specialist health settings can be adapted and utilized to be included as part of the LHW-P curriculum in Pakistan. Thus, the historical lack of access to mental health support workers, counsellors, and specialists can be addressed. Additionally, this will also help to reduce the stigma associated with seeking mental health care outside the boundaries of home, mostly at a huge cost.

Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries.

This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.

The role of the private sector in delivering essential packages of health services: lessons from country experiences.

Many countries are adopting essential packages of health services (EPHS) to implement universal health coverage (UHC), which are mostly financed and delivered by the public sector, while the potential role of the private health sector (PHS) remains untapped. Currently, many low-income and lower middle-income countries (LLMICs) have devised EPHS; however, guidance on translating these packages into quality, accessible and affordable services is limited. This paper explores the role of PHS in achieving UHC, identifies key concerns and presents the experience of the Diseases Control Priorities 3 Country Translation project in Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar. There are key challenges to engagement of the PHS, which include the complexity and heterogeneity of private providers, their operation in isolation of the health system, limitations of population coverage and equity when left to PHS's own choices, and higher overall cost of care for privately delivered services. Irrespective of the strategies employed to involve the PHS in delivering EPHS, it is necessary to identify private providers in terms of their characteristics and contribution, and their response to regulatory tools and incentives. Strategies for regulating private providers include better statutory control to prevent unlicensed practice, self-regulation by professional bodies to maintain standards of practice and accreditation of large private hospitals and chains. Potentially, purchasing delivery of essential services by engaging private providers can be an effective 'regulatory approach' to modify provider behaviour. Despite existing experience, more research is needed to better explore and operationalise the role of PHS in implementing EPHS in LLMICs.