Public-private partnerships (PPPs) are becoming increasingly embraced as mechanisms for delivering public services and infrastructure. In Kenya, PPPs have mainly supported public transport, housing, infrastructure and energy projects, demonstrating that public and private actors can collaborate for public good. While PPPs remain nascent, experiences from other sectors suggest that they can contribute towards the universal health coverage goal. 

While PPPs have potential to expand access to primary healthcare, translating intent into scalable partnerships remains a challenge in a fairly complex policy ecosystem.On the surface, such complexities mainly arise due to differences between public and private interests. However, Strathmore Prism’s experience suggests a far more nuanced driver – intra-government fragmentation. 

On the outside, government looks like a cohesive unit moving in one direction, but in practice, the concept of ‘government’ is a relatively amorphous one. In truth, Government is an umbrella entity housing institutions with different responsibilities, priorities, and mandates. These may align or conflict across different undertakings, affecting decision-making processes. We call these the hidden governance challenges.

This challenge formed the basis of discussions during the session on Digital Innovations at the UCL East Marshgate in London Symposium in May 2026. Prof. Francis (Frank) Wafula (Strathmore University’s Prism Centre and Open Phences) contended that viewing government as a single actor creates underrated hitches encountered during health PPP development processes. 

Drawing on his experience in academia and policy, Frank highlighted how different government agencies’ roles can create competing priorities that slow innovation and service improvement. His reflections offer important lessons for anyone seeking to build effective PPPs in healthcare.

The biggest challenge in public-private partnerships is often not the schism between government and private sector. It is the divide within government itself.

A House Divided Cannot Stand

Innovators and investors proposing PPPs frequently approach government as a single entity capable of making unified decisions. They will usually anticipate some tension trying to align public and private interests, but few foresee challenges arising from the government heterogeneity, and additional effort needed to unify government interests in light of their diverse mandates, cultures and interests. 

It is worth factoring the numerous faces of Government:

• The policy leader defines long-term strategic directions and establishes legal and regulatory frameworks to support them
• The regulator enforces rules and controls to safeguard economic and public good
• The service provider delivers services, including running hospitals, usually with a strong focus on equity and universality
• The treasury wants to optimize revenue streams and contain costs so that Government can play its roles effectively, including protecting individual and property rights
• The innovation driver wants to encourage experimentation and innovation to drive economic and technological progress
• The investment catalyst wants to create an enabling environment (limit costs and risk) for private investment to bolster the economy 

Beyond this, Government plays the legislative and judiciary roles, which may also stop or slow down other Government intentions and initiatives.

These functions often result in internal fragmentation that creates friction in the process of scaling solutions through PPPs, not just in healthcare, but across all sectors. 

Different Definitions of Success

State actors responsible for the above mandates define their success differently. Likewise, each entity’s role defines its priorities differently: the regulator values quality, safety and compliance, the service provider values access and operational effectiveness, the innovation driver values novelty and innovativeness, and the investment catalyst values growth stimulation. 

These are useful priorities in their own right, but they often collide, leading one part of government to stall scaling because another part of government is fulfilling its mandate. For instance:

• Innovation vs regulation – scaling digital health solutions may lead to task-shifting or new ways of delivering care. Regulators may be hesitant to implement such changes from a risk-management perspective
• Innovation vs standards enforcement – innovation leads to accelerated importation of components, facilitated by economic/trade government actors. Government standards agencies may enforce rigorous checks and quality controls, slowing down importations that power innovation 
• Innovation vs legal frameworks – some innovations may require procurement flexibility to move with speed and adopt new tools/ideas, but these frameworks exist to uphold accountability and transparency. 
• Innovation vs established workflows – new technologies can change existing workflows and processes, and this often leads to resistance, even when such innovations promise public good

This does not mean there is any inherent malice in the way any government entity executes its mandates; rather, it highlights the unintentional obstructions that can come from everyone simply ‘doing their job’. 

Alignment in the Private vs Public Sectors

Aligning private sector within itself is often more straightforward, because, regardless of the particulars of any single actor, they have a narrow but crucial set of shared objectives. Innovators, healthcare providers, investors, and tech companies all need governments to provide an enabling business environment for their varied activities. Such an environment favours innovation adoption, growth, market access, affordability (from a taxation perspective), and easy scaling and sustainability of these innovations. 

In contrast, government institutions must simultaneously balance public safety, accountability, budget stewardship, revenue collection, equity, service delivery, regulatory oversight, and even the political priorities of reigning governments. This creates a complex decision-making environment, which demands deliberate coordination to achieve scaling of healthcare innovations.

Misalignment of government actors does not come cheap:

• Public sector scaling of useful innovations becomes difficult, if not impossible
• Promising innovations remain trapped in pilot stages while useful research remains in reports gathering dust on shelves
• Procurement processes become fragmented
• Innovators and investors struggle to understand processes of compliance, and may eventually fold and move on
• Trust between the public and private sectors may deteriorate

Innovations have historically scaled through markets rather than public systems. This means that vulnerable populations that rely on government services end up being excluded from the benefits of such innovation. This is a problem for both innovators and the government.

Trust Before Co-Creation

Most public-private partnership discussions tend to begin with mutual suspicion – often with good reason. Government and private actors carry assumptions and even myths about each other, informed by each party’s experience dealing with an entity from the other sector. 

Therefore, simply bringing together representatives from both sectors may not lead to automatic collaboration. Parties may even appear to be listening or engaging, but the undercurrent of lack of trust in the good faith of each party means that they leave unconvinced. 

Prof. Wafula gave an illustration from past a co-creation activity in Kenya that used the Open Phences Engage to Action Model.

When government officials were asked why they did not want to work with private providers, they complained that private hospitals refused to admit COVID-19 patients at the height of the pandemic, which they (government) interpreted to mean they were unwilling to support public good. However, on tabling this concern during co-creation, private providers mentioned that they were mishandled by Government when they reported COVID-19 fatalities during the pandemic’s early days. Owing to public pressure, Government conducted relatively harsh, fault-finding audits for each death, putting private providers on the defensive. This led to private facilities becoming more cautious about admitting very sick COVID-19 patients.

Each side had developed a narrative about the other side, and only through open discussion did participants realise that the conflict was the result of misunderstanding rather than deliberate hostility. 

It is impossible to scale partnerships without addressing relationships and accompanying perceptions, even before discussing business and financing. 

The Open Phences Engage to Action Model

Recognising that bringing actors together in a room does not sweep away competing priorities within government institutions or mistrust between public and private stakeholders, Open Phences developed the Engage to Action Model as practical approach to achieving collaboration during public-private partnership discussions. 

Designed to enhance ecosystem building tools, the model considers engagement, not as a one-time event, but as a participation sequence that first organises participants within their respective groups, helping them align their priorities and understand one another before engaging with ‘outside’ actors. 

Once internal alignment and mutual understanding have been achieved, cross-sector collaboration is more likely to become productive. Parties begin to engage on the basis of issues rather than personal sentiments, driving constructive dialogue that usually leads to mutually beneficial and sustainable public-private partnerships. 

Step One: Collate and Analyse

First, each group must assess the health systems challenges they face, and any existing innovation that may resolve them. This happens in isolation, where actors come together to create a shared evidence base to inform the rest of the dialogue process.

It is within this step that government actors engage with one another to identify priorities, clarify misconceptions and address concerns (mistrust can exist within government itself, especially between institutions with competing priorities). This process is mirrored for the private sector actors.

In this process, conveners may apply various tools and strategies to break the ice and arrive at cohesion. The facilitating team should use games and activities to foster understanding and break tension before inviting stakeholders to come together and discuss issues. 

Step Two: Convene and Share

Having aligned respective groups, the next step in the co-creation process is bringing public and private actors together. Before co-creation can begin, the same strategies applied to break the ice are applied to debunk myths, challenge misconceptions, and clarify misunderstandings that exist between the parties together at table. These activities move the conversation from defensiveness to problem-solving.

Step Three: Co-create and Embed

Each group then presents its priorities to the other, providing a shared starting point to inform dialogue. Participants collectively identify areas of alignment, explore ways to finance resource gaps, and co-create practical implementation structures and scaling. Because earlier stages have already addressed competing priorities, surfaced misconceptions, and dissipated sources of mistrust, discussions focus on problem-solving rather than defending institutional positions. 

The strength of the Engage to Action Model lies not only in bringing stakeholders together, but in preparing them to collaborate effectively once they do. By fostering internal coherence before cross-sector engagement, the model creates an environment in which participants can move beyond entrenched positions and work towards practical, mutually beneficial solutions.

From Push to Pull: The Partnership Before the Partnership

The Engage to Action Model demonstrates that fruitful public-private partnerships do not start when government and private actors sit around the same table. They begin when government actors appreciate their many roles, align them around shared priorities, and then create an environment in which collaboration can flourish rather than compete with institutional mandates.

As health systems increasingly look to partnerships and innovation to achieve Universal Health Coverage and other system goals, the challenge will not lie in eliciting more private sector participation. It will be ensuring that government itself speaks with greater coherence. When policymakers, regulators, service providers, innovation stewards, and investment actors work together rather than at cross-purposes, public-private partnerships become more than mechanisms for delivering projects—they become platforms for delivering meaningful and sustainable improvements in healthcare.

The future of public-private partnerships may depend less on helping the private sector understand government, and more on helping government understand itself.