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This study investigates the contributions of private-sector innovations to strengthening primary health care (PHC) in South Africa through a systematic literature review. Grounded in the health systems strengthening framework and the primary health care approach, the review critically analyses key private initiatives, including nurse-led Unjani Clinics, retail pharmacy-based health services, and public-private partnerships (PPPs). These models demonstrate significant potential in improving accessibility, scalability, and efficient resource use within the PHC system, particularly in underserved urban and rural communities. The findings highlight how private-sector involvement can complement public health efforts by extending service reach, empowering frontline health workers, and optimising limited health resources. Despite these positive contributions, the study identifies equity, policy coherence, and long-term sustainability challenges. Private-sector models sometimes risk exacerbating health disparities if not fully aligned with universal health coverage goals and national health strategies. Moreover, the sustainability of PPPs and retail services depends heavily on regulatory oversight, clear quality standards, and robust governance frameworks. To maximise the impact of private-sector participation, the study recommends enhanced policy integration, strengthened collaboration between public and private actors, and rigorous monitoring to ensure alignment with South Africa’s national health priorities and the overarching principles of equity and social justice in PHC delivery.
Council for Medical Schemes, Pretoria, South Africa
Samantha Iyaloo
Council for Medical Schemes, Pretoria, South Africa
Kgothatso Nkoana
Council for Medical Schemes, Pretoria, South Africa
Phakamile Nkomo
Council for Medical Schemes, Pretoria, South Africa
Selby Masekela
Council for Medical Schemes, Pretoria, South Africa
Percy Daames
Council for Medical Schemes, Pretoria, South Africa
Musa Gumede
Council for Medical Schemes, Pretoria, South Africa
*Address all correspondence to: m.willie@medicalschemes.co.za
1. Introduction
Stark inequities between the public and private sectors mark South Africa’s healthcare system. While the private sector serves just under 15% of the population, it consumes a disproportionately high share of national health expenditure and possesses significantly more resources and healthcare professionals [1, 2]. South Africa’s health system reforms have advanced towards universal health coverage, yet persistent inequalities and human resource shortages demand coordinated, rights-based, and community-driven interventions to ensure quality, equity, and resilience [3]. Most of the population depends on the overstretched public health system, where access to quality primary health care (PHC) is often compromised by staffing shortages, infrastructure challenges, and limited service availability [4, 5]. Strengthening PHC is critical to achieving universal health coverage (UHC) and reducing the burden on higher levels of care [4, 6].
Globally, PHC is recognised as a key driver of equitable and cost-effective health systems. The World Health Organisation (WHO) underscores PHC as the cornerstone for strengthening health systems, particularly in low- and middle-income countries. It emphasises its centrality in achieving universal health coverage and advancing the Sustainable Development Goals (SDGs) [7]. Strengthening primary health care is the most cost-effective way for low- and middle-income countries to achieve universal health coverage and improve health outcomes, particularly for marginalised populations [8]. A key finding from the WHO [9] states that scaling up PHC interventions in low- and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030. In South Africa, primary health care re-engineering is a central focus of the National Health Insurance policy reform, highlighting the need for strengthened partnerships between the public and private sectors to address workforce shortages and improve the equitable distribution of healthcare professionals, supported by aligned Human Resources for Health strategies to enhance implementation success [10]. This chapter explores the gaps in PHC provision in South Africa and examines the contributions and lessons from the private health sector in addressing these gaps. Drawing on case studies and emerging models of care, it highlights how private initiatives have improved access, quality, and efficiency in PHC delivery.
The foundational role of PHC in achieving UHC is well-documented globally [11]. PHC improves population health outcomes by delivering integrated, accessible, and person-centred services near where people live and work [12]. In South Africa, the public sector has historically borne the primary responsibility for PHC delivery. Numerous studies have underscored persistent systemic challenges across both public and private healthcare systems. Within the public sector, issues such as chronic underfunding, inadequate infrastructure, human resource constraints, and fragmented service delivery have significantly impeded the effectiveness of PHC [13, 14]. In contrast, the private sector’s limited benefit coverage for PHC further restricts its accessibility and effectiveness, with allocations declining to less than 6% of total benefits paid [2]. These parallel challenges across the public and private sectors highlight the urgency for coordinated reform, aligning with the objectives of PHC re-engineering under the National Health Insurance (NHI), which aims to transform service delivery by fostering greater collaboration, innovation, and integration across the health system.
Scholars increasingly argue for a more integrated approach, where the strengths of both sectors are harnessed to build a resilient health system [15, 16]. Achieving UHC requires effectively integrating targeted health interventions into existing health systems through a systems-thinking approach, supported by a pragmatic balance of public-private participation, and strong government stewardship to ensure sustainability and good governance [15, 17]. Strengthening PHC systems in low- and middle-income countries through standardised performance measurement and shared best practices can enhance care quality, accessibility, and effectiveness [18]. In pursuing a more equitable and inclusive health system, South Africa must move towards a unified approach, transcending public-private divides. Effective collaboration could include shared service delivery models, integrated training platforms, and interoperable health information systems. Achieving this vision requires intentional policy alignment, robust accountability mechanisms, and incentive structures that prioritise quality care and equity over profit-driven imperatives, commonly associated with the private sector [19, 20, 21]. The literature emphasises that meaningful integration requires more than rhetorical commitment: it necessitates deliberate efforts to build trust, establish shared governance structures, and promote active community engagement. In the absence of these measures, South Africa may continue to reinforce a dual health system that disproportionately benefits a minority, while compromising equitable access for the broader population.
2.2 Innovations and partnerships in strengthening PHC delivery
A notable case study illustrating efforts to reprioritise PHC through shared goals is the South African private innovative Unjani Clinic network. This nurse-led initiative, from refurbished shipping containers, has significantly enhanced access to PHC services, especially in underserved and rural communities [22]. These clinics provide low-cost, accessible PHC services to communities that often fall outside the reach of the public health system. With over two hundred operational sites nationwide, Unjani Clinics is a scalable model for community-based care that empowers nurses as frontline providers, while expanding the geographic footprint of healthcare delivery [22]. Retail health services have also played an increasingly significant role in PHC delivery. Chain pharmacies, such as Clicks and Dis-Chem, have incorporated in-store clinics, offering various services, including immunisations, health screenings, and basic consultations [23, 24]. These models are perceived to reduce the burden on public clinics and improve convenience for working individuals and families in urban and peri-urban areas. However, the commercial orientation of such models often raises concerns about affordability and equitable access for low-income groups, especially when these pharmacies are not nearby.
Public–private partnerships (PPPs), collaborative arrangements between government entities and private sector organisations for the delivery of public services have demonstrated substantial potential in closing critical service delivery gaps, particularly in regions experiencing acute shortages of public healthcare personnel [25, 26]. For example, initiatives that deploy private practitioners to rural hospitals to deliver maternal and obstetric care have effectively alleviated human resource constraints while improving service quality. However, the success of such public-private health collaborations hinges on robust government stewardship, enhanced regulatory capacity, and strategic alignment with national health priorities. Furthermore, systematic monitoring and evaluation are essential to scaling up these partnerships sustainably and mitigating potential unintended consequences [25]. Despite these evident benefits, persistent challenges remain regarding regulatory oversight, quality assurance, and coherence with broader national health objectives. This underscores the pressing need for a more integrated and coherent policy framework to ensure private-sector innovations are scalable and contribute equitably and sustainably to the national PHC agenda. Without such integration, PPPs risk fragmenting the health system and undermining efforts towards universal health coverage.
This study is underpinned by the health systems strengthening (HSS) framework and the PHC approach, as articulated by the WHO [27] and Witter et al. [28]. The HSS framework identifies six core building blocks of an effective health system: service delivery, health workforce, information systems, medical products and technologies, health financing, and leadership/governance [29]. These elements ensure equitable, quality, and sustainable health care. This framework helps analyse the private sector’s role in reinforcing public health functions, particularly in under-resourced and underserved communities. The PHC approach, rooted in the Alma-Ata [30] and Astana [31] Declarations, and emphasised by Kraef and Kallestrup [32], promotes comprehensive, community-centred care as essential to UHC. The figure below illustrates how strengthening PHC, reaffirmed as a global priority 40 years later, advances SDG 3 by supporting universal coverage, health security, and related targets, highlighting the need for combined public and private sector contributions, as depicted in Figure 1 below.
Figure 1.
Health Systems Strengthening Framework. Source: Adapted and expanded from WHO [27], Witter et al. [28], and Kraef and Kallestrup [32].
This figure illustrates how HSS, through core pillars, such as infrastructure, workforce, financing, and governance, can advance Sustainable Development Goal 3 (SDG 3) when grounded in PHC principles and a strong public health orientation. PHC foundations emphasise community-based, person-centred, and accessible services, while a public health approach prioritises prevention, promotion, and population-level interventions. Together, these components drive progress towards UHC, enhanced health security, and other health-related targets. This study critically examines how private sector innovations such as Unjani Clinics, retail pharmacies, and public-private partnerships (PPPs) contribute to or deviate from these goals, with specific attention to issues of equity and access [22]. Institutional theory as an analytical lens evaluates how regulatory frameworks, policy environments, and socio-economic forces influence their integration and effectiveness in advancing public health outcomes [32].
This study adopts a literature review methodology to explore the role of private sector innovations in strengthening South Africa’s PHC system. A literature review is appropriate given the study’s objective of synthesising existing knowledge, identifying conceptual gaps, and drawing policy-relevant lessons from diverse private-sector interventions [33]. It enables the critical engagement with empirical findings, policy reports, and theoretical debates across multiple disciplines, including public health, health systems research, and development studies [34, 35].
A structured search was conducted across reputable academic databases. It was supplemented by grey literature from policy institutions such as the Health Systems Trust, the South African Department of Health, and the WHO. Keywords used in the search included primary health care, private sector health, public-private partnerships, Unjani Clinics, retail health services in South Africa, and health systems strengthening. To ensure relevance and currency, the search included peer-reviewed journal articles, government policy documents, and organisational reports published between 2010 and 2024 [34, 35]. Inclusion criteria required that sources be.
focused on South Africa or offered regional or global insights applicable to the South African context,
engaged substantively with PHC or private sector contributions, and
presented empirical findings, policy analysis, or conceptual frameworks. Studies not available in English or lacking sufficient methodological transparency were excluded from the review [33].
The selected literature was subjected to thematic analysis to identify recurring patterns, contradictions, and insights about private-sector contributions to PHC. The study was structured around the WHO HSS framework, enabling a systematic assessment of how private innovations contribute to key health system components such as service delivery, workforce development, and governance. Particular attention was paid to how lessons from models such as Unjani Clinics, retail pharmacy services, and PPPs align with PHC values of accessibility, equity, and community participation [22]. Themes were analysed deductively and inductively using established health systems theory, allowing new insights to emerge from the literature. This approach ensured both conceptual rigour and sensitivity to context-specific dynamics.
A structured search was conducted across multiple academic databases, including MEDLINE, Scopus and Web of Science, covering literature published between 2010 and 2024. The search was complemented by grey literature from key policy and health organisations such as the South African Department of Health (2021), the Health Systems Trust (2023), and the WHO (2020). Keywords included combinations of primary health care, private sector health, public-private partnerships, Unjani Clinics, retail health services in South Africa, and health systems strengthening.
Sources were included if they:
Focused on South Africa or provided regional/global insights relevant to the South African context.
Substantively addressed PHC or private sector contributions.
Presented empirical findings, conceptual frameworks, or policy analyses [25].
Sources were excluded if they:
Were not available in English; or
Lacked sufficient methodological detail or transparency.
A total of 47 sources were included in the review, comprising peer-reviewed journal articles (61.7%), grey literature (12.8%), policy documents (8.5%), working papers (6.4%), books (4.3%), and case studies (6.4%). As summarised in Table 1, this mix of source types ensures academic depth and practical relevance. Notably, 70.2% of the sources were published between 2018 and 2025, reflecting the most recent developments in PHC, private sector engagement, and health system reform.
Source type
Number of sources
Year range
Peer-reviewed journal articles
29
2005–2025
Grey literature/reports
6
2021–2024
Books/book chapters
2
2014–2016
Working papers/scoping protocols
3
2023–2025
Policy documents/declarations
4
1978–2018
Case studies/conceptual models
3
2016–2021
Table 1.
Overview of included sources by type and year range.
5.1 Scalable and sustainable service delivery models
The review found compelling evidence that nurse-led innovations, particularly the Unjani Clinics model, provide scalable and sustainable solutions to gaps in PHC coverage. The Unjani Clinics model demonstrates a strategic integration of nurse empowerment, holistic care, innovative financing, and tailored technology, as summarised in Table 2. This multifaceted approach addresses systemic gaps by promoting ownership and sustainability among nurses while enhancing service efficiency and patient outcomes. However, its long-term scalability depends on balancing financial viability with continued quality care delivery [22, 34, 36]. These clinics, supported through a blend of corporate social investment and nurse entrepreneurship, have successfully expanded to over one hundred operational sites nationally. Their decentralised structure enables flexible, localised health service delivery, demonstrating alignment with the WHO’s HSS building blocks of service delivery and workforce development [36, 37]. Furthermore, they reflect key PHC values: community responsiveness, empowerment, and equity. However, the literature cautioned that sustainability depends on ongoing funding, mentorship, and regulatory support, especially in remote areas where health infrastructure is weakest [38, 39].
Key principle/pillar
Description
Owner-operator model
Nurse-owned and operated clinics serving underserved communities; nurses run clinics and handle primary care with referral pathways to doctors/hospitals; empowers nurses with clinic ownership, leading to quality service delivery.
Integrated care model
Patient-centric, holistic approach offering a wide range of primary care services (e.g., diagnosis, treatment, family planning, antenatal care, chronic illness, HIV counselling); reduces siloed care and wasteful expenditure.
Blended finance model
Mix of grant and loan funding; nurses repay loans over 5 years before gaining full ownership; includes impact equity, mezzanine debt, and loans; aims for financial sustainability while keeping care affordable.
Custom-designed software
Proprietary platform (WeCare) tailored for clinic operations: patient management, HR, finance, stock management, patient education, quality assessment, and virtual consultations; enhances clinic efficiency and data management.
Table 2.
Key principles and pillars of the Unjani Clinics model.
Source: Adapted from Szerb et al. [22], Unjani Clinics NPC [34, 35], and Unjani Clinics [36].
5.2 Improved access through retail health integration
Retail pharmacies such as Clicks and Dis-Chem have emerged as important non-traditional entry points into PHC [23, 24]. These outlets offer convenient walk-in services, including immunisations, screenings, and minor consultations, often during extended hours. Their integration with PHC aligns with the PHC principle of accessibility, particularly for employed individuals or those in peri-urban settings who may face barriers to accessing public clinics during standard working hours [40]. However, studies have also raised concerns about exclusionary effects due to affordability and medical scheme limitations, which risk reinforcing health inequities. These findings emphasise the need for policy oversight and inclusive pricing models to ensure retail health services contribute meaningfully to UHC goals [40].
5.3 Strategic resource optimisation via public-private partnerships
PPPs have emerged as a prominent strategy for optimising scarce healthcare resources, particularly in rural and under-resourced provinces with limited government capacity. Collaborations between government entities and private practitioners, such as general practitioners and obstetric and maternal care specialists, have proven instrumental in supplementing the public sector workforce. This augmentation has improved patient outcomes and reduced referral delays, addressing critical service delivery gaps [41].
Despite their growing recognition as essential tools for advancing UHC across Sub-Saharan Africa, PPPs face significant governance, regulatory oversight, and equitable access challenges. Otchere et al. [16] emphasise that, while PPPs hold immense potential for HSS, particularly in workforce development and service delivery pillars, their effectiveness is often hindered by weak policy alignment and insufficient capacity-building efforts. This critique points to systemic weaknesses that limit the scalability and sustainability of PPP initiatives.
Moreover, the variability in governance standards and contract terms, often marked by inadequate monitoring and evaluation frameworks, raises concerns about these partnerships’ long-term impact and accountability. The literature suggests that PPPs risk perpetuating fragmentation within health systems without harmonised financing models, and more substantial alignment with national health policies [25, 41].
Further analysis by Ebulue, Ebulue, and Ekesiobi [42] reinforces that successful PPPs in global health innovation depend heavily on robust governance structures, genuine stakeholder collaboration, and clearly defined objectives. Their findings highlight transparency, contextual adaptation to local health environments, and sustained political and financial commitment as critical enablers for improving healthcare outcomes. This underscores the necessity for PPP frameworks that are not only well-designed but also dynamically responsive to evolving health system needs.
The conceptual framework emerging from this study, depicted in Table 3 below, illustrates how private sector models, Unjani Clinics, retail health clinics, and PPPs contribute distinct, yet complementary, approaches to strengthening PHC and advancing UHC through service delivery, workforce development, and enhanced accessibility. While each model aligns with key PHC and HSS principles, their effectiveness and scalability are contingent upon enabling institutional factors, such as regulatory support, financing mechanisms, and governance structures, as well as their ability to overcome systemic challenges related to equity, integration, and sustainability.
Model
Key features
PHC and HSS alignment
Enablers
Challenges
Unjani Clinics
Nurse-led, integrated care, blended finance, custom tech (WeCare)
Equity, workforce, and community-based service
Social investment, mentorship
Funding gaps, rural infrastructure limits
Retail Clinics
Walk-in access, screenings, minor care, and use of commercial spaces
The findings from this literature review underscore the critical role that private sector innovations can play in strengthening South Africa’s PHC system, particularly in addressing persistent gaps in service delivery, workforce capacity, and equitable access. Examining models, such as Unjani Clinics, retail health services, and PPPs, reveals insights into how private sector contributions complement and challenge the public health system’s efforts to achieve UHC.
The success of the Unjani Clinics network in expanding access to primary care services in underserved communities exemplifies a scalable and sustainable model aligned with key PHC and HSS principles. As the literature suggests [22, 34, 36], empowering nurses through ownership and entrepreneurship fosters professional autonomy and service quality, addressing critical workforce shortages documented in the public sector [4, 5]. This aligns with the WHO’s call for decentralised, community-based care that is person-centred and equitable [11]. The blend of social investment and innovative financing in the Unjani model reflects institutional pressures for financial viability balanced with social mission [43].
However, critical analysis indicates that sustainability is contingent on robust regulatory frameworks and continuous support, particularly in rural areas where infrastructure and supervision remain weak [38, 39]. This finding supports broader calls in the literature for deliberate policy alignment and stewardship to avoid fragmentation [15, 17]. It is evident that while nurse-led models advance PHC values, their integration within national health systems must be reinforced by governance mechanisms that safeguard quality and equity.
Retail pharmacy clinics represent an important innovation in enhancing PHC accessibility, particularly for working populations facing temporal and geographic barriers to public clinics [23, 24]. These models leverage existing commercial infrastructure to deliver a range of basic services, embodying the PHC tenet of accessibility and responsiveness [7]. Yet, the literature and this review highlight tensions between commercial motives and equitable service provision [20, 21]. Concerns about affordability and geographic distribution indicate retail clinics may inadvertently exacerbate inequities, reinforcing the dual health system dynamic where wealthier urban populations receive superior care.
This reflects institutional theory’s insight that private actors must navigate competing normative demands between market efficiency and social accountability [43]. Thus, policy frameworks must ensure that retail health integration supports rather than undermines equity goals, through targeted subsidies or incentives for service provision in marginalised areas [44].
The review confirms that PPPs aim to alleviate human resource shortages and enhance quality, particularly in rural and underserved regions [25, 26]. Deploying private practitioners to support public facilities aligns with strengthening strategies for the health workforce within the WHO’s HSS framework. However, the effectiveness of PPPs depends heavily on strong government stewardship, regulatory capacity, and alignment with national health priorities [15]. Findings reveal that PPPs risk perpetuating system fragmentation if not governed by transparent, accountable frameworks that promote shared objectives, rather than divergent sectoral interests [19]. This echoes prior literature emphasising the need for genuine trust-building, clear accountability, and community engagement to transcend mere transactional collaborations [20]. It highlights the institutional challenge of balancing legitimacy and compliance with innovation and sustainability goals. The alignment of private sector innovations with the WHO’s HSS building blocks provides a useful heuristic for evaluating their systemic contributions and limitations. Service delivery and workforce development benefit from models like Unjani Clinics, yet information systems, governance, and financing elements require stronger integration and oversight. This systemic perspective echoes the literature advocating for a systems-thinking approach, incorporating public and private actors as complementary, rather than competing, forces [15, 18].
Institutional theory further illuminates how regulatory, normative, and cognitive pressures influence the extent to which private innovations contribute to public health goals. For example, the Unjani model’s embeddedness in a hybrid financing structure reflects a response to institutional demands for financial sustainability and social legitimacy [32, 34, 35, 36, 45]. Meanwhile, retail clinics’ commercial orientation must be reconciled with health equity mandates through stronger normative and regulatory controls.
While this review highlights promising private sector contributions, it also surfaces enduring equity, sustainability, and system coherence challenges. The dualistic nature of South Africa’s health system, with a well-resourced private sector serving a minority, complicates integration efforts. The risk of exacerbating inequalities through market-driven models necessitates careful policy calibration to ensure that private sector innovations advance social justice and universal coverage goals. Moreover, the ongoing policy shift towards NHI presents an important context for future research. Understanding how private sector models can align with and complement NHI objectives is critical, particularly as new regulatory and financing mechanisms are introduced.
Several recommendations offer valuable lessons for other countries based on the study’s key findings. First, to improve the scalability and sustainability of private sector initiatives such as Unjani Clinics, it is crucial to bolster public sector support through targeted funding, robust policy frameworks, and comprehensive capacity-building programmes. Encouraging greater collaboration between government and private nurse-led clinics can foster community ownership and ensure these models remain responsive to local health needs. Policymakers should also explore mechanisms to integrate such models formally into the national PHC framework to enhance coordination and resource allocation.
Regulatory frameworks should be updated to better accommodate the growing role of retail pharmacies in delivering primary health care services. This includes establishing clear quality and service delivery standards to protect patients and ensure continuity of care. Furthermore, equitable financing mechanisms, such as expanding insurance coverage or subsidising services, are needed to prevent these private retail-based services from deepening health disparities, ensuring they contribute effectively to universal health coverage goals.
Through strengthened governance structures and transparent contract management, PPPs must be supported to maximise their potential in addressing health workforce shortages and service gaps, especially in rural areas. Clear guidelines and monitoring systems should be developed to ensure PPPs align with national health priorities and maintain high-quality standards. Building trust and communication channels between public and private actors will be vital for long-term sustainability and system integration.
This study underscores the importance of partnerships and collaboration between the public and private sectors in advancing common public health goals, highlighting how innovative models such as nurse-led Unjani Clinics, retail pharmacy services, and public-private partnerships contribute to strengthening South Africa’s primary health care system. These approaches have demonstrated potential in improving accessibility, scalability, and resource optimisation, addressing the public health sector’s key challenges. To maximise their impact, future efforts should explore how such models can be effectively integrated into the broader health system to benefit the greater population and enhance equitable access to care. Their success will depend on appropriate policy alignment, regulatory oversight, and a shared commitment to equity and universal health coverage principles.
The authors declare no conflicts of interest related to this study.
Acknowledgements and use of AI
While preparing this chapter, the authors utilised Grammarly and QuillBot for language editing, polishing, and plagiarism detection. All outputs generated by these tools were critically reviewed and edited by the author, who takes full responsibility for the final content presented in this publication.
Funding
No external funding was received to conduct this research or prepare the chapter.
Data availability
The data used in this study were derived from secondary sources compiled through a comprehensive literature review. All data are publicly available and have been appropriately cited in the chapter.
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Written By
Michael Mncedisi Willie, Samantha Iyaloo, Kgothatso Nkoana, Phakamile Nkomo, Selby Masekela, Percy Daames and Musa Gumede
Submitted: 05 June 2025Reviewed: 07 July 2025Published: 30 January 2026
Open access peer-reviewed chapter
