Community participation and contracting between state and non-state actors in primary care: A scoping review of evidence.

Background: Health systems worldwide increasingly involve non-state actors in governance and service provision, often to address perceived limitations in public sector capacity to achieve or maintain universal health coverage. Contracts are a key mechanism for structuring such cooperation, enabling governments to define public priorities, specify the resources and services required to achieve them, establish performance requirements for contractors, and define accountability mechanisms. Moreover, community participation in the design and monitoring-or governance-of contracts could enhance the effectiveness of contracting by making services more locally responsive and accountable. This article reviews the global evidence on contracting out-with and without community participation-and its effects on access to primary care services, the quality of these services, and equity in health.

Methods: A scoping review was undertaken following the PRISMA checklist for evidence synthesis. A common search string was applied to five databases - SciELO, LILACS, EBSCOhost, Scopus, and Google Scholar - to search for articles relating to our research questions in English, Spanish and Portuguese, with no restrictions on publication date. After three rounds of review, 81 articles were selected from a universe of 3,276 articles and subjected to full data analysis. These were complemented by 14 handpicked articles meeting our study criteria and 26 supplementary references.

Results: We find that community participation in the governance of contracting is rare, but can promote access and quality. However, it requires a contracting environment that supports transparency, cooperation from governments and providers, and resourcing commitments. More generally, contracting is often associated with access gains, but the evidence on quality and equity is mixed.

Conclusions: Contracting of non-state providers in pluralistic primary care systems that incorporates the participation of communities in its governance could be a feasible policy to promote universal health coverage while also effecting democratic rights of citizens to participate in healthcare governance. Primary research is required to better understand how to promote meaningful community participation, and to identify the contractual details and features of specific contractual environments that are connected to better outcomes.