Public-Private Partnership Policy in Primary Health Care: A Scoping Review Protocol

The private sector may be a crucial resource for countries’ work on universal health coverage. One of the most effective ways to engage the private sector in health system is Public-Private Partnership (PPP). Since, published experiences about PPP implementation in PHC in different countries have provided various and sometimes contradictory results, there is a need to examine the results of using PPP in PHC worldwide. Thus, the main objective of this scoping review is to perform an inclusive search for studies that report the experiences of implementation PPP in PHC worldwide. Methods This scoping review study will be conducted using the framework proposed by Arkesy and O'Malley. An extensive search of the literature will be done in five databases including PubMed, Embase, Scopus, Web of Science and Science Direct, and two Persian databases using a comprehensive search strategy to identify studies on PPP implementation in PHC. The search will be done from January 2000 to the end of 2019, completed by reference tracking, author tracking and expert consultation. Any study, which focuses on the results of PPP in PHC, will be included in the study. Two reviewers will screen the articles based on the title, abstract and full text, and extract data. Potential disagreements will be resolved by consulting a third author.

oriented to primary health care (1).
Based on the WHO's perspective, countries should make use of all domestic resources as part of their efforts to achieving universal health coverage (2). The private sector may be a crucial resource for countries' work on universal health coverage. The private sector (both for-profit and not-for-profit) plays an important role in most of the world's health systems. Its role is expanding in many countries. (1).
One of the most effective ways to engage the private sector in health system is Public-Private Partnership (PPP) that makes use of the capacities of both parties to achieve the goals (3)(4)(5). In PPP, a contract conclude between public and the private sector to share the risk, responsibility, benefits and to synchronize resources and expertise of both sectors (3). In PPP, the role of government change from investor, implementer and beneficiary to policy maker, regulator and supervisor of the quality and quantity of services provided (6,7).
Published experiences with PPP implementation in PHC in different countries (8)(9)(10)(11) have provided various and sometimes contradictory results on the use of PPP in PHC, and there is no study that thoroughly examines this issue. That is why there is a need to examine the experiences and achievements of PPP in PHC worldwide. Thus, the objectives are to (1) systematically review and identify literature on the use of PPP in PHC, (2) identify the various methods of implementation of PPP projects in different countries and (3) examine the results and achievements of using PPP in PHC.

Methods
We will use Arkesy and O'Malley framework to conduct scoping review, which includes six steps of Identification of the research question, Identification of relevant studies, Study selection, Data charting, Data analysis and reporting the results and Consultation exercise (12).
We will use the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) to report the results because its use would reduce the risk of flawed reporting and increase the transparency and clarity of the systematic review reports (13) (see checklist in Additional file 1).
Step one: Identification of relevant studies The main research question of the present study will be "What are the outcomes and achievements of 4 PPP in the provision of PHC in different countries?" which specifically include: In what countries using PPP in the provision of PHC is prevalent?
How is the time trend of using PPP in the provision of PHC worldwide?
In different countries, in which environments (urban, rural, suburbs, etc.) using PPP in the provision of PHC is most prevalent?
Which models of PPP used to provide PHC?
What are the role of the public and private sector in the PPP contracts?
What are the goals of using PPP in the provision of PHC in different countries?
For what tasks and services of PHC, PPP has been applied?
What are the achievements of implementing PPP in PHC, worldwide?

Eligibility criteria
All articles and reports on PPP projects in PHC, published in English and Farsi languages between 2000 to the end of 2019 will be included in the study. The studies which reports implementation of PPP in other health sectors (other than PHC) will be excluded. The included studies will not be limited based on study type. Articles will be excluded if the researchers do not have access to the full text.
Step two: Identification of relevant studies In this phase, an extensive search of the literature will be conducted in 5 databases including PubMed, Embase, Scopus, Sience Direct and Web of science. Persian equivalent of the above searches will be performed on Persian sites like MagIran and SID.
In addition, after searching databases, selected journals and articles references, plus Google scholar, published organizational reports and government documents, websites and other available information sources, will be manually searched.
Articles related to PPP in PHC will be collected based on different areas of primary health care. The various areas of PHC will be determined by the research team consensus and through expert consultation. Table 1 shows the search strategy proposed for the PubMed. This strategy will be used with some modification for other databases.
Step three: Study selection After completing the search, the retrieved records will be imported into the EndNote software (V.X8), and then the duplicate records will be deleted. Two independent reviewers will screen the articles based on the title, abstract and full text, and extract data.
Given that the structure of primary health care delivery varies across countries, to determine whether the studies are about PHC, two researchers will examine the information provided in each study and 5 determine whether related to PHC or not. Disagreements will be referred to the third person with more experience and expertise in the field of PHC.
PRISMA flowcharts (14-16) will be used to screening and study selection and to report the results.
Step four: Data charting Two data extraction forms, to extract quantitative and qualitative studies information, will be designed. The information will be extracted independently by two researchers and the potential discrepancies will be resolved by consensus with a third researcher. Information extractable using quantitative study form include: author, year of publication, country of study, study context (city, village, settlers, etc.), aim of study, study design, participants (private and public sector), the subject of study, the interval between the implementation of the PPP plan and the performance evaluation, the role of the public and private sector, the public-private partnership model, the indicators studied, the results, the overall outcome, and the conclusions. Data extractable using the qualitative studies form included: author and year of publication, country of study, aim of study, participants, method of data collection and results.
On the other hand, in case of studies that do not directly refer to the above information, two researchers will determine based on the information provided by the study, and the disagreements will be refered to the third researcher Step five: Data analysis and reporting the results In this phase, the extracted data will be manually analyzed, summarized and reported using the Content-Analysis Method. Data will be coded independently by two researchers. In cases of disagreements between the two coders, the discrepancies will be referred to third researcher.
Step six: Consultation exercise Based on the results obtained and the opinions of the research team members, tips and suggestions will be presented in the form of article discussion.

Discussion
Given the problems and shortcomings in the providing PHC services in different countries, specially low and middle income countries, the use of private sector capacities and capabilities in the form of PPP, can be effective and useful solution. To Design and implement effective PPP projects in PHC, the 6 regional and local conditions should be considered through extensive studies at the national and regional levels. We are hopeful that this scoping review will provide useful results in identifying experience and results of different countries with different context. We hope the result of this scoping review will make robust and valuable evidence for informed policy making. However, we note that we are still at the beginning of a long journey, and the need to conduct studies in this field is felt more than ever.

Consent for publication: Not applicable
Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.
Competing interests: The authors declare that they have no competing interests.  private OR "public private partne "public private participation" OR private mix" OR "public-private cooperation" OR "mixed system" privatiz* OR "public-private coord OR "public-private collaboration" "contract* out" OR outsource* OR contract*" OR "management con OR "lease* contract*" OR "Privat Initiative Contract*" OR "concess contract*" OR "divesture contrac #2 Primary health care "primary health care OR "primary services" OR PHC OR "basic heal OR "primary care" #3 Tuberculosis TB OR tuberculosis