The role of the private sector in noncommunicable disease prevention and management in low-and middle-income countries: a series of systematic reviews and thematic syntheses

Noncommunicable diseases (NCDs) are the leading global cause of death (42 million deaths in 2019) with LMICs bearing over three-quarters of these deaths and 85% of premature deaths. Major risk factors are multisectoral (e.g., diet, physical inactivity, tobacco, alcohol), necessitating an all-of-society approach that includes the private sector. WHO and the UN have called for multi-stakeholder engagement, including private sector involvement, for effective NCD prevention and management. The for-profit private sector is a significant actor in health systems through innovation, service provision, financing, training, and infrastructure. However, evidence and guidance on its role in NCDs in LMICs are limited. To address this gap, the authors developed a framework with six pillars (PPPs; governance and policy; healthcare provision; innovation; knowledge educator; investment and finance) and conducted a systematic review for each to understand private sector roles in LMIC NCD prevention and management.

Design: Six separate systematic reviews, each corresponding to a pillar of an a priori framework, reported according to PRISMA. No preregistered protocol. Search: Comprehensive searches conducted March 2021 in Embase, PubMed, Web of Science, Cochrane Library, ProQuest ABI/Inform, and Business Source Premier. Grey literature searches (April–July 2021) included WHO, World Bank, UNICEF, OECD, American Cancer Society, NCD Alliance, UICC, CSIS, World Economic Forum, CDC, Harvard School of Public Health, USAID, and selected companies (e.g., Medtronic, AstraZeneca, Novo Nordisk, Merck). Inclusion criteria: English-language publications from 2000 onwards focused on the for-profit private sector, NCD prevention/management, LMIC settings, and the specific pillar of interest. Exclusions: News articles, press releases, presentations, and studies without full text. Screening and Data extraction: Conducted using Covidence by one reviewer per review using a pre-piloted extraction form (Appendix B). Reference lists of included studies were also screened. Quality assessment: Performed by the same reviewer using Hawker et al.’s tool assessing nine domains, scoring each 1–4 with total grades A (30–36, high), B (24–29, medium), C (9–24, low). Synthesis: Inductive thematic synthesis (Thomas & Harden, 2008): coding extracted data, categorizing codes, and deriving overarching themes to answer how the private sector acts within each pillar in LMIC NCD prevention and management. Patient and public involvement: None.

Study yield: Included studies by pillar—PPPs (n=25), Governance and Policy (n=33), Healthcare Provision (n=22), Innovation (n=15), Knowledge Educator (n=14), Investment and Finance (n=42). Thematic findings by pillar: - Public–private partnerships (PPPs): Coordination (alignment of goals; leveraging complementary public/private expertise); Financial resources (mobilizing funds via donations, CSR, private investment; transformational partnerships); Provision (improving access to safe, effective, affordable medicines and technologies; supply chain reform; enhanced screening, diagnosis, and treatment quality/coverage); Health promotion (population education; promoting physical activity; improving nutrition access); Capacity building (training health workers; implementation research; system strengthening); Innovation (data sharing; research; access to innovative technologies); Policy (input to policy discussions—prone to conflicts of interest). - Governance and Policy: Lobbying (opposition to/weakening of policies; litigation; influencing policy drafts/discourse; government infiltration via relationships, revolving doors, funding; collaborations including PPPs); Industry perception (framing via CSR, media capture, hiring experts; emphasizing economic importance; shaping/scientific evidence); Regulation (voluntary self-regulation; efforts to evade public regulation through loopholes, bribes, sponsorships). - Healthcare Provision: Diagnosis and treatment (private sector as primary provider for many NCD services; greater likelihood to diagnose/manage NCDs; better access to medicines; provision of specialized care); Infrastructure (hospitals, labs, pharmacies; often better equipped than public facilities); Availability, accessibility, affordability (private sector increases availability/access but at higher costs and OOP expenditures; use of insurance and generics to improve affordability). - Innovation: Product innovation (new/improved medications; improved distribution and technologies including HIT/ICT); Process innovation (novel care models to extend outreach; innovative private insurance with health promotion); Marketing innovation (tailored pricing/services to socioeconomic contexts to improve access/affordability); Research (basic/applied research enabling new products/services); Innovation dissemination (strategies to promote adoption; funding publications; educational grants). - Knowledge Educator: Training (investment in research capacity; mentorship and training for local researchers and health workers, including device/process use); Health promotion (education to reduce information barriers; improve awareness and access to healthy activities/knowledge); Industry frameworks/guidelines (education on international standards; development of protocols to improve adherence and care). - Investment and Finance: Cost of treatment (higher and variable prices in private sector; elevated OOP expenditures; supply chain/manufacturing and retail mark-ups drive final prices); Regulation (self-regulation to standardize prices; taxation to generate revenue and incentivize healthier behaviors—balanced against potential availability impacts); Health insurance (private insurance can reduce OOPs and relieve public budgets but may be expensive and a barrier for some; insurers exploring risk management with ageing/NCD trends); Subsidization (private subsidies to improve affordability for services/products); Direct investment (CSR and targeted investments in best buys, equipment, and service delivery to fill financing gaps and catalyze innovations); Collaborative financing (multi-sector collaborations and PPPs to align objectives and mobilize funding); Innovative financing (micro-levies, rounding schemes, mobile apps; development bonds; development bank lending; MDTFs); Research (originator brands protected by IP elevate prices relative to generics; engaging generic manufacturers lowers costs; private funding supports innovation but may bias results). Quality assessment highlights: Across pillars, many studies were downgraded for incomplete methods, sampling, data analysis, and limited discussion of ethics/bias; quality ranged from high to low across reviews.

The reviews clarify extensive for-profit private sector roles across six pillars in LMIC NCD prevention/management. PPPs can align goals, mobilize resources, expand provision, promote health, build capacity, drive innovation, and contribute to policy—but are vulnerable to conflicts of interest (COIs), particularly with unhealthy commodity industries, and sometimes serve to delay stronger regulation. In governance and policy, private sector lobbying, framing, and influence often create policy environments favoring commercial interests over NCD mitigation; increasing transparency and regulation is essential. In healthcare provision, the private sector often fills gaps in availability and capability for both primary and specialized NCD care, yet higher prices and OOP spending compromise affordability and equity. Innovation by private actors enhances products, processes, and dissemination, frequently tailored to LMIC contexts to extend reach. As knowledge educators, private entities can strengthen research and health workforce capacity and contribute to guideline development, but awareness alone is insufficient to change behavior without enabling environments. In financing, private actors both increase costs (e.g., higher private prices, IP-driven constraints on generics) and provide solutions (subsidies, insurance, direct and innovative financing, PPPs). With strong, transparent, and enforceable regulatory frameworks, incentives, and accountability, the private sector’s contributions can be steered toward public health gains while mitigating harms from COIs and commercial determinants of health.

This series of systematic reviews synthesizes how for-profit private sector actors engage in LMIC NCD prevention and management through PPPs, governance/policy, healthcare provision, innovation, knowledge education, and financing. While private involvement offers resources, capacity, innovation, and expanded service provision, it is also prone to COIs and potential harms, especially concerning governance and affordability. Policymakers in LMICs can leverage these findings to design engagement strategies that incentivize beneficial roles (e.g., access to affordable medicines, high-quality services, unbiased research) while implementing robust, transparent regulation and continuous evaluation to minimize negative influences. Future efforts should strengthen evidence on STI-oriented PPPs for NCDs and assess effectiveness and equity impacts of private sector engagement models.

- Single reviewer conducted screening, data extraction, and quality assessment in each review, introducing potential bias despite clear inclusion/exclusion criteria and explicit instructions. - English-only inclusion may have excluded relevant non-English studies. - Many included studies were rated low quality, often due to incomplete reporting of methods, sampling, data analysis, and insufficient discussion of ethics/bias, potentially affecting reliability and generalizability of findings.