Intermediaries: The Missing Link in Improving Mixed Market Health Systems?

Despite the presence of government-provided healthcare services in the majority of low-and-middle income countries, many patients turn towards private sector providers, who are often perceived as providing higher quality, more convenient services. These private small-scale providers include non-profit and for-profit health clinics, local pharmacies, high-end hospitals, and even traditional healers. This proliferation of small-scale providers does help respond to patient needs and demands, but also contributes to confusion and fragmentation in mixed market health systems. When public and private health entities operate separately, the added administrative burden of coordinating contracts, purchasing supplies and services, and organizing patient care between the two sectors results in an ineffective system with hidden costs.

However, organizations that link the public and private sectors and yield gains for individual patients and health systems overall do exist, and can be strengthened even further. With research conducted through the Center for Health Market Innovations (CHMI), Results for Development (R4D) is pleased to release the latest brief on these intermediary organizations. Intermediaries: The Missing Link in Improving Mixed Market Health Systems? details the role of organizations who connect public sector goals with private sector actors.

In the brief, intermediaries are defined as organizations that form networks between small-scale providers to interact with governments, patients, and vendors. These organizations can perform key health systems functions which are typically more challenging for individual private providers to do on their own.

More importantly, intermediary organizations supported by policymakers, donors, and other health systems actors are able to help bridge the divide between sprawling public sectors and a wide array of small-scale private providers. R4D’s research has revealed that intermediary models hold the potential to address the four major challenges of fragmentation inherent in mixed market health systems, namely:

  1. Lack of proactive population management and continuity of care
  2. Lack of quality of care that is safe, effective, patient-centered, efficient, and equitable
  3. Lack of long term management capacity; and
  4. Lack of integration of providers into larger systems for payment and universal health coverage.


The brief points to the opportunity that exists for key health systems leaders to encourage the formation of effective intermediaries. Through the creation of networks of providers, intermediaries help small scale providers to more easily engage with government, contract with vendors, and improve care that responds to patient needs.

Examples of effective intermediaries mentioned in the brief include Population Services International (PSI), MedicallHome, and Health Builders. As a global intermediary operating on the country level, PSI is able to assure that care is safe, effective, and patient-centered by assessing providers in a social franchise network. Quality assurance officers help to ensure that poor populations receive quality, reliable care by conducting regular inspections of health facilities. In Mexico, MedicallHome facilitates comprehensive care by reaching patients through a primary care call center that provides a referral system. Over 90,000 patients access the telemedicine system every month, and either receive treatment instructions over the phone, or are referred to a hospital or in-person physician. Finally, HealthBuilders of Rwanda builds management capacity by evaluating performance through data driven tools. The organization trains all levels of management in staffing, stock, and physical infrastructure management, and uses a performance evaluation tool to help management track facilities and prioritize essential improvements.

R4D is also eager to share the “Six key elements of an effective intermediary” – advice based on our research that can help form intermediary organizations that improve mixed health markets. While the majority of the research studied intermediary organizations operating in Nigeria and documented in the CHMI database, the brief generalizes the findings in a way that is applicable for existing intermediaries, policymakers, donors, and other organizations interested in better understanding how to develop stronger intermediaries that effectively address the key challenges of fragmentation in health systems. The documentation of “promising practices” and successful models can help health leaders test the ideas of this brief in their own contexts to encourage the creation and development of intermediary models.

Click here to read the brief.


Photo: A Community Eye Health focus group discussion about glaucoma in Nigeria. © Peter Martin, 2012