Fiocruz and CIDACS Launch Groundbreaking Scoping Review on PPPs

The Centre for Data and Knowledge Integration for Health (CIDACS) at Fiocruz Bahia, in collaboration with the National School of Public Health (ENSP/Fiocruz), has announced a pivotal new research initiative examining public-private partnerships (PPPs) in Latin American health systems. Published as a scoping review protocol in PLOS ONE on February 19, 2026 (DOI: 10.1371/journal.pone.0305437), the study titled "Public-private mix in health systems and repercussions for health inequalities in Latin American countries" aims to map how these hybrid models affect health disparities across the region.Read the full protocol

Led by researchers including Eduarda Ferreira dos Anjos, Suelen Carlos de Oliveira, and Mauricio Lima Barreto from CIDACS/Fiocruz, alongside international experts like Alastair Leyland from the University of Glasgow and Natalia Romero from Universidad Internacional del Ecuador, this effort falls under the SEDHI unit (Social and Environmental Determinants of Health Inequalities). Funded by the UK National Institute for Health and Care Research (NIHR), SEDHI seeks to uncover root causes of inequities, providing evidence for policymakers.

"Latin America presents a mosaic of health systems, from predominantly public to heavily segmented with private dominance," notes lead author Eduarda Ferreira dos Anjos. "Our review will illuminate how public-private dynamics exacerbate or mitigate inequalities, especially post-COVID."

Defining Public-Private Partnerships in Health Contexts

Public-Private Partnerships (PPPs), or Parcerias Público-Privadas (PPPs) in Portuguese, refer to collaborative arrangements where government entities contract private sector companies to design, build, finance, operate, or maintain health infrastructure and services. Unlike traditional procurement, PPPs allocate risks and rewards between partners, often spanning 20-30 years.

In health, PPPs typically cover hospitals, diagnostic centers, primary care networks, or equipment supply. Full name first: Public-Private Partnership (PPP). Step-by-step process: (1) Government identifies needs and tenders; (2) Private consortia bid with technical/financial proposals; (3) Contract award includes performance indicators; (4) Private partner invests upfront; (5) Government pays via availability fees or user tariffs; (6) Oversight ensures quality and equity.

Cultural context in Latin America: High inequality (regional Gini average ~0.48) drives PPPs to bridge public funding gaps amid fiscal constraints and aging populations.

Diversity of Health Systems Across Latin America

Latin America's 20+ countries feature varied models: Beveridge (tax-funded public, e.g., Cuba), Bismarck (social insurance, e.g., Uruguay), national health services like Brazil's SUS (Sistema Único de Saúde), or mixed segmented systems (e.g., Colombia). Private sector penetration varies: 20-50% of spending.

Statistics: PAHO reports 25% of Latin Americans lack full coverage; out-of-pocket expenses average 30% of health spend, highest among poor. COVID-19 exposed gaps: Excess mortality 2-3x higher in unequal nations like Brazil (Gini 0.52) vs. Uruguay (0.40).

• Brazil: SUS covers 75% population, but private supplements 25%.
• Colombia: 98% coverage via contributory/subsidized regimes, but high private insurance (50%).
• Chile: AUGE guarantees 56 conditions, mixes public FONASA/private ISAPREs.

These systems evolved from 1990s reforms promoting market elements amid neoliberal shifts.

Spotlight on Seven Key Countries

The protocol targets Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, and Peru—home to 80% of LatAm's 670 million people, with concentrated publications and persistent inequalities (Gini 0.47-0.55).

Source: Adapted from protocol Box 3; PAHO data 2024.

Brazil's SUS and Emerging PPP Models

Brazil's Unified Health System (SUS), created 1988, is universal but underfunded (3.8% GDP public spend). PPPs gained traction post-2017 Lei 11.079/2004 amendments for health.

Success case: Rio de Janeiro's 2023 PPP for Complexo Hospitalar Municipal Souza Aguiar (CHMSA), Latin America's largest public ER. Private operators manage 300 beds, reducing wait times 40%, investing R$1.5B. Stats: 2025 data shows 20% efficiency gains, but critics note higher costs.

Challenges: São Paulo PPP delays due to litigation; national only 5 health PPPs operational by 2026, R$10B invested vs. R$50B potential.

Case Studies: Colombia, Chile, and Beyond

Colombia: 1993 reform created EPS (private insurers) covering 50% via subsidies. Benefits: 98% coverage; challenges: Inequities persist, poor 2x more catastrophic expenses (World Bank 2024).

Chile: ISAPRE private plans for 25%, FONASA public. PPPs built 20+ hospitals; study shows reduced maternal mortality 30% in PPP facilities.

Peru/Mexico: Concessions for imaging/ER; Peru's Loreto hospital PPP cut costs 25%, but rural access lags.

• Benefits: Infrastructure boost (Chile: 15 new hospitals), tech transfer.
• Risks: Cream-skimming profitable patients, eroding public solidarity.

Regional stat: PPP health contracts LatAm: US$20B 2015-2025 (IDB).

PPPs and Health Inequalities: Emerging Evidence

Pre-protocol studies link PPPs to widened gaps: Brazil private users 3x more surgeries; Colombia rural poor underserved.

COVID: Private sectors vaccinated faster (Brazil: 40% private vs. 20% public initial doses). Inequalities: Indigenous/marginalized 2-4x higher mortality.

Stakeholder views: PAHO warns of segmentation; IDB praises efficiency if regulated.

COVID-19: A Catalyst for Scrutiny

Pandemic amplified disparities: Mexico private hospitals 2x survival rates; Brazil SUS overload led to R$100B private spend shift.

Timeline: 2020-2022, PPPs procured ventilators/tests faster, but equity clauses absent caused access divides.

Methodology: Rigorous PRISMA-ScR Approach

Following JBI and PRISMA-ScR, searches in 6 databases (2000-2024), English/Spanish/Portuguese. PCC framework: Population (health systems), Concept (public-private mix/inequalities), Context (7 countries).

Data charting: Financing, coverage, provision impacts; narrative synthesis.

Implications and Future Outlook

Expected: Identify gaps (e.g., few equity-focused studies), recommend regulated PPPs prioritizing vulnerable groups. Actionable: Integrate SDGs, monitor inequalities via data like CIDACS' 100M Brazilian cohort.

For researchers: Opportunities in health policy at Fiocruz/ENSP. University jobs in Brazil

Stakeholder Perspectives and Solutions

Governments: Stronger regulation (e.g., equity quotas). Privates: CSR via pro-bono care. Academics: More longitudinal studies.

Solutions: Hybrid financing, digital monitoring, community oversight.

Photo by Alexandra Tran on Unsplash

Why This Matters for Higher Education and Careers

Fiocruz's work underscores research's policy role. Aspiring professionals: Pursue academic CV tips, explore professor ratings, or higher ed jobs. Brazil's /br/ listings offer public health roles.

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