Prerpints.org logo
Preprint
Review

This version is not peer-reviewed.

Pathways to Sustainable Public Health Systems: Integrating Economic and Social Strategies

Submitted:

30 January 2026

Posted:

30 January 2026

You are already at the latest version

Abstract
Public health system sustainability is increasingly challenged by rising costs, demographic change, urbanization, environmental stressors, and recurrent health emergencies, exposing limitations of traditional financing and delivery approaches. This narrative review critically synthesizes models that strengthen health-system sustainability by integrating economic and social strategies across diverse settings. We conducted a structured search of peer-reviewed and selected grey literature (2000 to present) across major databases and sources, and applied thematic analysis to extract mechanisms, enabling conditions, and reported system-level effects. The review maps six main model families: public–private partnerships, social enterprise approaches, health impact bonds and other outcome-based financing, value-based healthcare, technology and AI-enabled delivery, and community health financing. Across these models, recurring pathways to sustainability include diversified funding and risk-sharing, stronger accountability through measurable outcomes, improved service efficiency and continuity, and targeted strategies to reduce inequities in access. However, implementation is constrained by governance and regulatory complexity, data and verification requirements, capacity gaps, and risks of exacerbating inequities when incentives or coverage design are weak. Overall, the evidence suggests sustainability gains are most plausible when models are adapted to context, embedded within robust public stewardship, and paired with investments in information systems and equity safeguards, offering practical direction for policymakers seeking resilient, inclusive health systems aligned with global development goals.
Keywords: 
sustainable health systems
;  
public health innovation
;  
resilience health financing
;  
publicprivate partnerships
;  
social equity
;  
value-based healthcare
;  
health impact bonds
;  
global health models
Subject: 
Public Health and Healthcare  -   Health Policy and Services

Introduction

The sustainability of public health systems has emerged as a pivotal concern in global health discourse, particularly in response to the complex interplay of emerging infectious diseases, chronic health conditions, and escalating healthcare costs[1,2]. The 21st-century health landscape is marked by rapid demographic transitions, urbanization, and environmental challenges, all of which exert considerable pressure on health systems globally. The resilience of these systems against such diverse challenges is crucial not only for maintaining continuous service delivery but also for their capacity to adapt and respond to future health crises[3].
The sustainability of public health systems has emerged as a pivotal concern in global health discourse, particularly in response to the complex interplay of emerging infectious diseases, chronic health conditions, and escalating healthcare costs.
These disruptions underscore the urgent need to create sustainable public health models that can withstand such instabilities while ensuring equitable healthcare access. The global health landscape of the 21st century, marked by rapid demographic transitions, urbanization, and environmental challenges; demands resilient systems capable of adapting to both immediate crises and long-term pressures[4,5]. By integrating economic, social, and environmental strategies, sustainable public health models offer a pathway to address these multidimensional challenges, ensuring health systems remain robust, inclusive, and prepared for future crises[6].
Table 1. Dimensions of Sustainable Public Health.
Table 1. Dimensions of Sustainable Public Health.
Dimension Details
Economic Sustainability Traditional funding mechanisms for public health have often been reliant on external funding sources, which can be unstable and unsustainable in the long term[7]. This has led to growing advocacy for innovative financing models that ensure health systems can maintain operations independently. Public-private partnerships, social enterprise models, and health impact bonds represent such innovations, offering resilient funding mechanisms that also promote efficiency and accountability[8].
Environmental Sustainability The health sector is increasingly recognized as a significant contributor to environmental degradation, a realization that has spurred the integration of eco-friendly practices within healthcare settings. Sustainable health systems actively reduce their carbon footprint and manage waste[9] more effectively, aligning healthcare practices with broader environmental sustainability goals[10,11]. Research has shown that sustainable healthcare practices not only mitigate environmental impact but also improve health outcomes by reducing pollution-related diseases and conserving resources for future generations[12,13].
Social Sustainability Ensuring equitable access to healthcare services remains a fundamental objective of sustainable public health systems[14]. Disparities in health outcomes and access are prevalent across different populations, and influenced by socioeconomic factors, geographic locations, and systemic biases[15]. Sustainable models emphasize inclusivity and accessibility, ensuring that all community members can obtain the care they need without financial hardship. This aspect of sustainability is crucial for achieving the broader goals of public health, such as reducing morbidity and mortality rates across all demographics[16].
The global shift towards sustainable public health systems is also propelled by international health agendas such as the Sustainable Development Goals (SDGs)[17], which advocate for universal health coverage and sustainable cities and communities[18] (Goal 3 and Goal 11). These goals highlight the interconnectedness of health with other sectors and emphasize the importance of a holistic approach to sustainability that incorporates health into all areas of development.
As public health systems around the world strive to become more self-sustaining, it is imperative to explore and critically assess the various models that have been implemented to achieve these goals. The ongoing challenges posed by global health threats, alongside the opportunities presented by technological advancements and global cooperation, provide a rich context for investigating how public health systems can innovate and evolve to meet the needs of their populations effectively and sustainably[19].

Objectives

The primary objective of this review is to critically examine and synthesize the diverse and innovative models that have been successfully implemented to achieve self-sustainability in public health systems across various global contexts. This investigation focuses on identifying and analyzing the mechanisms through which these models primarily integrate economic and social sustainability to enhance health outcomes and system resilience. While environmental sustainability is acknowledged as an important dimension, its exploration remains supplementary in this review due to the limited emphasis in the analyzed models.
Specifically, the review aims to:
  • Assess the Impact of Innovative Financing Models: Explore how models such as public-private partnerships, social enterprise models, and health impact bonds have contributed to sustainable health financing, with a focus on their adaptability in different health systems and economic conditions.
  • Analyze Social Equity in Access to Healthcare: Examine models that have effectively reduced disparities in healthcare access and outcomes, particularly those that provide inclusive services to underserved and marginalized populations.
  • Draw Lessons for Policy and Practice: Provide evidence-based recommendations that can inform policymakers and health administrators on designing robust, self-sustaining public health systems that are prepared to face current and future health challenges.
By articulating these objectives, this review aims to contribute to the literature on sustainable health systems, offering insights and practical guidance that can support the advancement of global health goals, particularly in light of the Sustainable Development Goals. The findings and recommendations will be of interest to a broad audience including healthcare providers, policymakers, researchers, and global health practitioners, aiming to foster a dialogue on sustainable practices that can be scaled and adapted globally.

Methods

Literature Search

To ensure a comprehensive review of models that have successfully achieved self-sustainability in public health, a systematic search of the literature was conducted. We accessed multiple databases, including PubMed, Scopus, and the Cochrane Library, to collect peer-reviewed articles, grey literature, and case studies published from January 2000 to the present. The search strategy was designed to capture a broad spectrum of relevant studies using a combination of keywords and phrases related to our research themes: "public-private partnerships," "social enterprise models," "health impact bonds," "sustainable health systems," "environmental sustainability in healthcare," and "equitable health access."

Selection Criteria

Inclusion Criteria:
  • Studies that explicitly discuss models of self-sustainability in public health.
  • Publications that provide empirical data on the outcomes of these models.
  • Studies published in English.
  • Articles that include case studies or reviews of sustainable practices within health systems globally.
Exclusion Criteria:
  • Articles that focus solely on theoretical aspects without empirical evidence.
  • Studies that do not address the core aspects of economic, environmental, or social sustainability in public health.
  • Publications older than the year 2000, to ensure relevance and applicability of the data in the current health context.
  • Non-peer-reviewed articles and editorials were excluded to maintain the scientific rigor of the review.

Analysis Method

Data from the selected articles were extracted and synthesized using a thematic analysis approach. This method enabled us to identify and categorize key themes related to the mechanisms of sustainability within public health systems. The synthesis involved a qualitative assessment of how each model addressed specific sustainability challenges and opportunities, their scalability, and their impact on health outcomes. We also evaluated the evidence strength and consistency across different studies, which facilitated a comprehensive understanding of effective practices and areas requiring further research.
This systematic and structured approach to data collection and analysis ensures that the findings presented in this review are robust, reproducible, and reflective of a wide range of global experiences and perspectives. The methodological rigor adheres to the standards expected by high-impact journals like Lancet and BMJ providing a solid foundation for evidence-based recommendations and policy insights.

Results

Review of Different Models Case Studies Overview

This section summarizes the key findings from various global initiatives that have implemented self-sustainable public health models, providing insights into their operation, scalability, and impact on health outcomes.
Analysis of Models:
Public-Private Partnerships (PPPs)
Overview of Public-Private Partnerships in Public Health
Public-Private Partnerships (PPPs) have become increasingly prominent as a strategic approach to enhance health infrastructure, service delivery, and access to healthcare. By combining the strengths of both public and private sectors, PPPs aim to leverage private sector efficiencies and innovation in conjunction with public sector goals of equity and accessibility[20]. These partnerships are often employed to address gaps in healthcare provision, particularly in areas that require significant capital investment or technological expertise.
Case Studies and Efficacy
1. 
The Lesotho National Referral Hospital: One of the notable examples of PPPs in healthcare is the Lesotho National Referral Hospital project, which involved rebuilding and operating a hospital and its associated clinical services[21]. This PPP was structured to overcome resource constraints and improve healthcare quality. However, it also highlights the complexities of such agreements, including the high costs associated with private sector involvement. Despite these challenges, the hospital has seen improvements in healthcare quality and patient satisfaction, demonstrating the potential benefits of PPPs[22].
2. 
The Vaccine Alliance (GAVI): GAVI exemplifies a global PPP that has successfully improved access to immunization in low-income countries. By bringing together private sector capabilities in vaccine development and production with public sector outreach and funding, GAVI has significantly reduced the incidence of preventable diseases in participating countries[23]. GAVI's model demonstrates how PPPs can be effectively utilized to scale up public health interventions on a global scale.

Analysis of Outcomes

The analysis of PPPs shows that while these partnerships can drive improvements in healthcare delivery and infrastructure, they require careful structuring to ensure that public health goals are not compromised by profit motives. Successful PPPs typically involve clear agreements on roles, risk-sharing, and rewards that align with long-term health outcomes rather than short-term financial gains[24]. Studies indicate that PPPs can lead to enhanced service delivery, increased accessibility, and technological advancement in healthcare settings, but they also highlight the need for robust governance frameworks to manage these partnerships effectively[25].

Implications for Policy and Practice

For policymakers, the lessons from PPPs suggest that such partnerships should be designed with a strong emphasis on transparency, accountability, and alignment of incentives. Ensuring that both public and private partners are committed to public health objectives is crucial. Additionally, regulatory frameworks need to be established to monitor and guide PPP operations, ensuring that they contribute positively to health system goals without exacerbating health inequities[26].
The analysis of PPPs in public health underscores their potential to contribute to sustainable health systems when implemented with careful planning and robust oversight. These partnerships offer a pathway to harness private sector resources and innovation while addressing public sector challenges, providing a compelling model for enhancing health system performance and sustainability.

Analysis of Models: Social Enterprise Models

Overview of Social Enterprise Models in Public Health

Social enterprise models in public health integrate market-driven mechanisms with a focus on achieving equitable healthcare access. Unlike traditional public health initiatives that rely on donor funding, these models generate revenue through service delivery, reinvesting it to expand access and improve public health outcomes[27]. Social enterprises prioritize innovation, community engagement, and financial sustainability, making them a critical approach to addressing healthcare challenges in underserved areas.

Case Studies and Efficacy

1. 
Living Goods (Africa):
  • Living Goods empowers a network of community health workers who deliver essential healthcare services, medicines, and health education directly to families. Operating as independent entrepreneurs, these health workers sell low-cost products such as malaria treatments, clean cookstoves, and water filters, enabling them to earn a livelihood while improving public health. The initiative uses mobile technology to support its network, providing real-time data on service delivery and monitoring health outcomes. By reducing child mortality by 27% in the regions it operates, Living Goods demonstrates the power of social enterprises to improve health outcomes while fostering economic empowerment within communities[28].
2. 
DRIVE (Direct Delivery of Routine Immunization Vaccines and Other Medical Essentials) by UNICEF:
  • UNICEF’s DRIVE initiative represents an innovative and large-scale approach to overcoming systemic bottlenecks in vaccine delivery. Designed to strengthen last-mile immunization supply chains, DRIVE focuses on reaching underserved populations, including urban poor, remote rural areas, and conflict-affected communities[29].
The initiative employs a hub-and-spoke model, integrating data-driven tools and advanced technologies like blockchain-enabled smart contracts to improve transparency and efficiency.
By collaborating with local community organizations, private sector providers, and young entrepreneurs, DRIVE leverages cross-sectoral partnerships to build a resilient supply chain[30]. The program tackles critical challenges, including stock-outs, vaccine wastage, and inequities in healthcare access, ensuring lifesaving vaccines and medical supplies are available to the populations that need them most.
A key feature of DRIVE is its holistic approach to healthcare. The initiative links immunization services with broader maternal and child health interventions, reinforcing the idea that immunization is a gateway to comprehensive primary healthcare.

Analysis of Outcomes

Social enterprise models like Living Goods and DRIVE demonstrate the capacity to overcome structural barriers in healthcare delivery while maintaining financial viability. These models enhance access to care, reduce disparities, and promote innovation. They also illustrate how targeted interventions can be scaled to address broader public health goals, including the Sustainable Development Goals (SDGs).

Implications for Policy and Practice

The success of these models offers several important lessons for policymakers and practitioners:
  • Building Partnerships: Collaboration with the private sector, community organizations, and technology innovators is essential for creating scalable and efficient health programs.
  • Data-Driven Strategies: The use of digital tools, such as blockchain for supply chain management and mobile health technologies for monitoring, ensures transparency and improves outcomes.
  • Sustainability and Scale: Governments can support these models by integrating them into national health strategies, providing financial incentives, and fostering environments that encourage social entrepreneurship.
  • Holistic Health Approaches: Linking immunization with broader healthcare services amplifies the impact of such models, addressing multiple health challenges simultaneously.
Social enterprise models like DRIVE and Living Goods prove that addressing healthcare inequities is not only a moral imperative but also an achievable goal through innovative and sustainable approaches. These models highlight the importance of combining local knowledge, global expertise, and cutting-edge technology to build resilient and inclusive health systems.

Analysis of Models: Health Impact Bonds

Overview of Health Impact Bonds in Public Health

Health Impact Bonds, also known as Social Impact Bonds, are innovative financing mechanisms designed to fund public health programs through private investment based on the achievement of agreed-upon outcomes. These bonds incentivize high-impact health interventions by making funding contingent on measurable health improvements, thereby aligning investor returns with social benefits. This model encourages efficiency and effectiveness in health programs, with investors bearing the financial risk if interventions fail to deliver the expected outcomes[31].

Case Studies and Efficacy

1. Development Impact Bond (Rajasthan, India): Implemented in Rajasthan (2018–2021), this outcome-based financing model used upfront private capital to fund technical assistance helping private maternity facilities meet defined quality standards (Manyata and NABH). Investors were repaid by outcome funders based on independently verified achievement of these quality standards. Endline modelling using the Lives Saved Tool estimated that quality improvements in participating facilities could avert maternal and neonatal deaths and prevent stillbirths over the modelled period, illustrating the potential of outcome-based funding to accelerate measurable quality improvements in maternal and newborn care. [32].
2. Cameroon Cataract Development Impact Bond: The Cameroon Cataract Bond is a Development Impact Bond (DIB) launched in March 2018 to expand access to high-quality cataract surgery in Cameroon using upfront private capital and pay-for-performance financing. Under this model, private investors such as the Overseas Private Investment Corporation (now U.S. International Development Finance Corporation) and the Netri Foundation provided initial funding to the Magrabi ICO Cameroon Eye Institute to scale service delivery. Outcome funders including the Conrad N. Hilton Foundation, The Fred Hollows Foundation, and Sight savers agreed to repay investors with agreed returns based on achieving predefined targets, such as delivering cataract surgeries to underserved patients, achieving quality benchmarks and equity targets, verified independently. This instrument aimed to draw new sources of capital, increase accountability and measurement of impact, and support the hospital toward financial sustainability while expanding surgical services for avoidable blindness[33].

Analysis of Outcomes

Health Impact Bonds have shown a capacity to mobilize private capital for public health initiatives, addressing funding gaps and focusing resources on effective interventions. The success of these bonds lies in their ability to foster collaboration among governments, private investors, and healthcare providers, ensuring that financial incentives are directly tied to positive health outcomes. This model has particularly been effective in resource-limited settings where traditional funding mechanisms are inadequate or unsustainable[31].

Implications for Policy and Practice

The implementation of Health Impact Bonds suggests several key implications for health policy and practice:
  • Risk-sharing Mechanisms: Properly designed Health Impact Bonds can distribute risks among stakeholders, potentially leading to more sustainable funding of public health programs.
  • Data and Accountability: The success of these bonds depends heavily on the availability of reliable data and robust methods for measuring outcomes, necessitating significant investment in health information systems.
  • Policy Frameworks: Governments should develop clear policy frameworks to facilitate the adoption of Health Impact Bonds, including regulations that define outcome measurements and the conditions under which investors receive returns.
Health Impact Bonds represent a promising tool for advancing public health objectives by leveraging private investment to fund interventions that might not otherwise receive sufficient public funding. By focusing on outcomes, these bonds ensure that funds are used effectively to generate tangible health improvements, providing a compelling model for addressing complex health challenges in a financially sustainable manner.

Analysis of Models: Value-Based Healthcare

Overview of Value-Based Healthcare

Value-Based Healthcare (VBHC) is a transformative approach that aligns healthcare spending with patient outcomes, aiming to increase the value of healthcare delivered. This model prioritizes health outcomes that matter to patients relative to the cost of delivering those outcomes. By focusing on value rather than volume, VBHC encourages healthcare providers to optimize the entire care cycle rather than individual services. This approach has the potential to transform how care is delivered, paid for, and evaluated, making it a crucial model in the pursuit of sustainable healthcare systems[34].

Case Studies and Efficacy

1. Stockholm's Orthopedic Services, Sweden: In Stockholm, the implementation of VBHC at orthopedic centers involved restructuring payments and care processes around patient outcomes. This model was associated with significant improvements in clinical outcomes, such as reduced recovery times and higher patient satisfaction rates, while also achieving cost savings by minimizing unnecessary interventions and complications[35].
2. Cleveland Clinic, USA: Cleveland Clinic has embraced VBHC by integrating services and focusing on long-term health outcomes rather than discrete treatments. This holistic approach has led to higher quality of care and improved patient outcomes, particularly in chronic disease management, demonstrating how VBHC can enhance efficiency and patient experiences in a complex healthcare ecosystem[36].

Analysis of Outcomes

The shift to VBHC has shown promising results in various settings, driving improvements in healthcare quality and patient satisfaction. The model’s focus on outcomes rather than services rendered encourages healthcare providers to consider long-term health impacts and cost efficiency simultaneously. Research indicates that VBHC can lead to significant reductions in healthcare costs while improving patient outcomes, especially in chronic disease management where continuous care coordination is crucial[37].

Implications for Policy and Practice

For policymakers and healthcare providers, the implications of adopting VBHC are profound:
  • Integrated Care: VBHC requires the integration of various health services to focus comprehensively on a patient's health journey rather than isolated treatments.
  • Investment in Measuring Tools: Effective implementation of VBHC necessitates robust systems for measuring health outcomes and costs, highlighting the need for investments in health information technology.
  • Incentive Structures: Redesigning payment structures to reward value rather than volume is essential, requiring changes at both the policy and practice levels to support sustainable healthcare financing.
Value-based healthcare represents a critical step towards more sustainable health systems by ensuring that resources are utilized to maximize patient health outcomes efficiently. This model not only supports financial sustainability but also enhances patient-centered care, offering a roadmap for health systems aiming to optimize both health outcomes and the use of resources in a rapidly evolving healthcare landscape[38].

Analysis of Models: Leveraging Technology and AI

Overview of Technology and AI in Healthcare

Incorporating technology and Artificial Intelligence (AI) into healthcare systems represents a pivotal shift toward enhancing efficiency, precision, and patient outcomes. These technologies are reshaping health delivery by improving diagnostics, streamlining treatment protocols, and optimizing management practices, thereby aligning with the core principles of sustainable healthcare systems[39]. The proliferation of AI in healthcare settings from predictive analytics to robotic-assisted surgeries, demonstrates the vast potential of technology to transform care delivery, making health systems more responsive and cost-effective[40].

Case Studies and Efficacy

1. AI in Diagnostics: AI-driven tools for diagnosing diseases such as diabetic retinopathy and melanoma have achieved accuracy rates comparable to or exceeding those of human experts, significantly advancing early and accurate disease detection[41]. These technological advancements not only improve clinical outcomes but also enhance the accessibility of diagnostic services, especially in regions lacking specialized healthcare professionals.
2. Remote Patient Monitoring: The adoption of remote patient monitoring systems exemplifies how technology can extend the reach of healthcare providers into community settings, improving the management of chronic diseases and reducing hospital readmissions. These systems are particularly crucial in contexts where direct patient-provider interactions are limited. During the COVID-19 pandemic, such technologies were instrumental in maintaining continuous care for chronic patients while minimizing the risk of virus transmission[42].

Analysis of Outcomes

Integrating AI and other technological innovations in healthcare has led to:
  • Enhanced Clinical Efficiency: Technologies automate and refine the processing of vast datasets, enabling faster and more precise clinical decision-making.
  • Increased Access to Care: Digital health solutions, including telehealth, expand access to essential health services, thereby improving equity in healthcare delivery.
  • Cost-effectiveness: Automation and improved disease management associated with health technologies can significantly reduce long-term healthcare costs by preventing expensive emergency interventions and reducing the incidence of disease complications.

Implications for Policy and Practice

To maximize the benefits of technology and AI in healthcare, several strategic approaches are required:
  • Development of Regulatory Standards: Policies must be developed to ensure the safe and ethical use of AI, protecting patient privacy and setting quality standards for AI-generated health interventions.
  • Investment in Health IT Infrastructure: Robust digital infrastructures are essential to support the integration and scaling of technology solutions across healthcare systems.
  • Training and Workforce Development: As technologies become integral to healthcare, educational programs for health professionals should include training in digital competencies and data analytics to equip them with the necessary skills for a technologically advanced health environment.
The strategic integration of technology and AI into healthcare practices not only aligns with but actively promotes the objectives of sustainable healthcare by enhancing service quality, accessibility, and cost-efficiency. This analysis underscores the transformative potential of technological innovations in driving forward the goals of value-based and patient-centered care[43].

Analysis of Models: Community Health Financing

Overview of Community Health Financing

Community Health Financing (CHF) strategies are pivotal in improving access to healthcare services, particularly in low-resource settings. CHF models involve community-based health insurance, micro-insurance schemes, and health savings accounts, which aim to pool resources to reduce individual financial barriers to healthcare access[44]. These models emphasize community engagement and shared responsibility, making healthcare more accessible and sustainable for underserved populations. CHF is particularly effective in promoting equity and sustainability in healthcare by aligning community resources with health system needs.

Case Studies and Efficacy

1. Rwanda’s Community-Based Health Insurance (Mutuelles de Santé): Rwanda's Mutuelles de Santé is one of the most successful examples of CHF, covering approximately 90% of the population. This model has significantly increased healthcare utilization and improved health outcomes across the country, particularly for maternal and child health services. The success of the scheme is attributed to its high community involvement and government support, which ensure broad coverage and sustainability[45].
2. The Ghana National Health Insurance Scheme (NHIS): Ghana's NHIS provides another robust example of CHF, offering financial risk protection against the cost of basic healthcare services. Funded through government support, premiums, and other public funds, the NHIS has expanded healthcare access to millions of Ghanaians, demonstrating a sustainable model for pooling resources to ensure comprehensive health coverage[46].

Analysis of Outcomes

Community health financing models have demonstrated substantial benefits in terms of healthcare accessibility and financial protection:
  • Increased Healthcare Utilization: By reducing the cost barriers to healthcare, CHF models encourage higher utilization of medical services, especially preventive and primary care.
  • Improved Financial Sustainability: CHF models distribute healthcare costs across a larger pool of members, reducing financial strain on individual households and contributing to the overall sustainability of health systems.
  • Enhanced Health Equity: These models benefit low-income families and marginalized communities, helping reduce health disparities and promote equity within the health system.

Implications for Policy and Practice

The implementation of community health financing models offers several key insights for policy and practice:
  • Community Engagement: Successful CHF requires active community involvement in both planning and implementation phases to ensure that the schemes are culturally appropriate and widely accepted.
  • Government Support: Policy support is crucial for the sustainability of CHF models, including legal frameworks that mandate contributions or provide subsidies to lower-income groups.
  • Integration with National Health Systems: CHF should be integrated with broader national health strategies to enhance its effectiveness and reach, ensuring that these local initiatives align with national health objectives and resource allocation.
Community health financing represents a vital strategy for enhancing the sustainability and equity of healthcare systems. These models show how leveraging community resources and collective responsibility can lead to more resilient and inclusive health systems[1]By focusing on community-based funding mechanisms, health systems can promote a more equitable distribution of healthcare resources, which aligns closely with the objectives of sustainable healthcare development.

Discussion

Interpretation of Findings

The models analyzed in this review demonstrate a variety of approaches that contribute significantly to the sustainability of public health systems. Each model leverages specific mechanisms to address the triple aim of improving healthcare access, enhancing patient care, and reducing healthcare costs:
  • Public-Private Partnerships (PPPs) harness both public accountability and private efficiency, enhancing resource allocation and infrastructure development within health systems[20].
  • Social Enterprise Models bridge the gap between social mission and business methods to provide sustainable, community-focused healthcare services[28].
  • Health Impact Bonds offer innovative financing solutions that tie investments to measurable health outcomes, encouraging accountability and efficiency[32].
  • Value-Based Healthcare (VBHC) shifts the focus from volume to value, emphasizing patient outcomes and cost-effectiveness, which leads to higher quality care at lower costs[35].
  • Technology and AI Integration enhance diagnostic accuracy, treatment personalization, and operational efficiencies, contributing to scalable and sustainable health interventions[39].
  • Community Health Financing models promote universal health coverage by mobilizing local resources, thus ensuring financial sustainability, and reducing health disparities[47].
These models reflect a shift towards more integrated and patient-centered healthcare systems that not only aim to be self-sustaining but also adapt to meet the evolving health needs of populations.

Comparison with Traditional Models

The Table 2 highlights the advantages and limitations of sustainable health models compared to traditional public health systems:

Challenges and Barriers

Implementing these models involves several challenges and barriers:
  • Resource Allocation: Effective implementation requires significant upfront investment and ongoing financial support, which may be challenging in resource-limited settings.
  • Cultural and Behavioral Change: Shifting from traditional models to innovative practices requires changes in behavior and culture among healthcare providers and patients, which can be resistant and slow.
  • Regulatory and Policy Frameworks: Establishing supportive policies and regulatory frameworks is crucial but can be complex, particularly in regions with unstable political climates or where health is not prioritized.
  • Technology and Infrastructure: Especially for technology-driven models, adequate infrastructure, such as broadband internet and interoperable health IT systems, is essential but not always available.
  • Equity and Accessibility: While these models aim to reduce disparities, there is a risk that poorly designed systems could exacerbate existing inequalities, especially in heterogeneous populations.Top of Form

Conclusions

This review has highlighted the effectiveness of several innovative models in achieving sustainability within public health systems, offering valuable lessons for enhancing global health infrastructure. The integration of public-private partnerships, social enterprise models, health impact bonds, and technology-driven solutions has demonstrated significant potential to improve healthcare accessibility, efficiency, and outcomes. These models advocate for a shift from traditional, often inefficient health systems to more dynamic, outcome-oriented frameworks that prioritize patient care and cost-effectiveness[20]. However, successful implementation requires robust policy support, intersectoral collaboration, and continued innovation to adapt to the diverse needs of populations. Moving forward, policymakers and health administrators must leverage the insights provided by these models to build resilient public health systems that can withstand future health challenges while ensuring equitable access to care for all individuals. This strategic focus will be instrumental in advancing the global health agenda, particularly in the face of emergent health crises and ongoing healthcare disparities[48].

References

  1. Kruk, M. E., Gage, A. D., Arsenault, C., Jordan, K., Leslie, H. H., Roder-DeWan, S., Adeyi, O., Barker, P., Daelmans, B., Doubova, S. V., English, M., García-Elorrio, E., Guanais, F., Gureje, O., Hirschhorn, L. R., Jiang, L., Kelley, E., Lemango, E. T., Liljestrand, J., Malata, A., … Pate, M. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global health, [Internet]. 6(11). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7734391/. [CrossRef]
  2. Thomas Cousins, Michelle Pentecost, Alexandra Alvergne, Clare Chandler, Simukai Chigudu, Clare Herrick, Ann Kelly, Sabina Leonelli, Javier Lezaun, Jamie Lorimer, David Reubi, Sharifah Sekalala. The changing climates of global health. BMJ Global Health [Internet]. 2021 Mar 23;6(3). Available from: https://gh.bmj.com/content/6/3/e005442.
  3. Rasanathan, K. How can health systems under stress achieve universal health coverage and health equity? Int J Equity Health. 2024 Nov 21;23:244. [CrossRef]
  4. Zanobini, P., Del Riccio, M., Lorini, C., & Bonaccorsi, G. Empowering Sustainable Healthcare: The Role of Health Literacy. Sustainability. 2024 May 9;16(10):3964. [CrossRef]
  5. Singh SK, Gupta GK, Agrawal D, Zaidi SHN, Batra J, Sharma L, Juneja S, Joshi KJ, Sethy G, Haile DA, Syed S. Leveraging Resource Centers for Strengthening Immunization Supply Chain. Cureus [Internet]. 2024 Apr 25;2024 Apr 25;16(4):e58966. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11126888/. [CrossRef]
  6. Khan, S., Gupta, G. K., Agrawal, D., Nawaz Zaidi, S. H., Batra, J., Syed, S., Sharma, L., Khambira, M., Haile, D. A., Sethy, G., & Singh, S. K. The Big Catch-up: Addressing Zero-Dose Children as a Surrogate of Vaccination Disruptions During Public Health Emergencies: A review of literature. ESJ. 20(36):19. [CrossRef]
  7. Rabiya Hanif, Wedzerai S. Musvoto. An evaluation of funding challenges in the Malawian public healthcare delivery sector. AOSIS [Internet]. 2023 Mar 31;11(1). Available from: https://apsdpr.org/index.php/apsdpr/article/view/654/1326. [CrossRef]
  8. Nabyonga-Orem, J., Christmals, C. D., Addai, K. F., Mwinga, K., Karenzi-Muhongerwa, D., Namuli, S., & Asamani, J. A. The nature and contribution of innovative health financing mechanisms in the World Health Organization African region: A scoping review. Journal of global health [Internet]. 2023 Nov 15;13. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10644850/. [CrossRef]
  9. Sethy G, Singh SK, Chisema MN, Ganizani A, Kafanikhale HM, et al. Healthcare Waste Management in Malawi: Overcoming Challenges, Seizing Opportunities. J Community Med Public Health [Internet]. 2024;8. Available from: https://www.gavinpublishers.com/article/view/healthcare-waste-management-in-malawi-overcoming-challenges-seizing-opportunities. [CrossRef]
  10. Shaban, M.M., Alanazi, M.A., Mohammed, H.H. et al. Advancing sustainable healthcare: a concept analysis of eco-conscious nursing practices. BMC Nursing. 2024 Sep 16;23:660. [CrossRef]
  11. Mohd Afjal, Jatin Trivedi. Greening healthcare: exploring economic and ecological synergies in the pursuit of net-zero carbon futures. Sustainable Futures [Internet]. 2024 Dec;8. Available from: https://www.sciencedirect.com/science/article/pii/S2666188824002302. [CrossRef]
  12. Andrea Smith, and Melissa Severn. Reducing the Environmental Impact of Clinical Care: CADTH Horizon Scan. Canadian Agency for Drugs and Technologies in Health [Internet]. 2023 Apr; Available from: https://www.ncbi.nlm.nih.gov/books/NBK596637/.
  13. Ejercito Mangawa Balay-odao, Paolo C. Colet, Joseph U. Almazan, Anargul Kuntuganova, Alma Syzdykova, Zulyar Kavashev, Meruyert Smagulova, Zhaniya Dauletkaliyeva, Aizat Seidakhmetova, Jonas Preposi Cruz. Environmental sustainability in healthcare: A qualitative study of the perspectives of nursing, medical and public health students in Kazakhstan. Nurse Education In Practice [Internet]. 2024 Mar;76. Available from: https://www.sciencedirect.com/science/article/abs/pii/S1471595324000465?via%3Dihub. [CrossRef]
  14. Alex Hoagland, Sarah Kipping. Challenges in Promoting Health Equity and Reducing Disparities in Access Across New and Established Technologies. Canadian Journal of Cardiology. 2024 Jun;40(6):1154–67. [CrossRef]
  15. Jignesh Patel, Sangita More, Pravin Sohani, Shrinath Bedarkar, Kamala Kannan Dinesh, Deepika Sharma, Sanjay Dhir, Sushil Sushil, Raj Shankar Ghosh. Reshaping the equitable and inclusive access to healthcare: A qualitative study. Clinical Epidemiology and Global Health [Internet]. 2024 Feb 9;26. Available from: https://www.sciencedirect.com/science/article/pii/S221339842400040X. [CrossRef]
  16. Winston, Nessa. Sustainable community development: Integrating social and environmental sustainability for sustainable housing and communities. Sustainable-Development [Internet]. 2021 Sep;30(1). Available from: https://www.researchgate.net/publication/354446860_Sustainable_community_development_Integrating_social_and_environmental_sustainability_for_sustainable_housing_and_communities. [CrossRef]
  17. The World Bank. Universal Health Coverage as a Sustainable Development Goal [Internet]. 2023. Available from: https://datatopics.worldbank.org/world-development-indicators/stories/universal-health-coverage-as-a-sustainable-development-goal.html.
  18. UNDP. What are the Sustainable Development Goals? [Internet]. Available from: https://www.undp.org/sustainable-development-goals.
  19. Oleribe, O. O., Momoh, J., Uzochukwu, B. S., Mbofana, F., Adebiyi, A., Barbera, T., Williams, R., & Taylor-Robinson, S. D. Identifying Key Challenges Facing Healthcare Systems In Africa And Potential Solutions. International journal of general medicine. 2019 Nov 6;12:395–403. [CrossRef]
  20. Adegoke, Adegoke & Adegoke, Bisola & Abdul, Samira & Udedeh, Emem & Adeghe, Ehizogie. Public-private partnerships in health sector innovation: Lessons from around the world. Magna Scientia Advanced Biology and Pharmacy [Internet]. 2024 Apr;12(1). Available from: https://www.researchgate.net/publication/380971976_Public-private_partnerships_in_health_sector_innovation_Lessons_from_around_the_world. [CrossRef]
  21. Chelsea M. McGuire, Jeanette L. Kaiser, Taryn Vian, Elizabeth Nkabane – Nkholongo, Tshema Nash, Brian W. Jack, et al. Learning from the End of the Public-Private Partnership for Lesotho’s National Referral Hospital Network. Annals of Public Health [Internet]. 2024 Mar 7;90(1). Available from: https://annalsofglobalhealth.org/articles/10.5334/aogh.4377. [CrossRef]
  22. The World Bank. Lesotho Health Network Public-Private Partnership (PPP) [Internet]. 2016. Available from: https://www.worldbank.org/en/country/lesotho/brief/lesotho-health-network-ppp.
  23. GAVI The Vaccine Alliance. Annual Progress Report 2023 [Internet]. 2023. Available from: https://www.gavi.org/progress-report.
  24. Milward Tobias, Center for Research and Consultancy, Lilongwe- Malawi. A case study of Public Private Partnerships in the Health Sector in Malawi [Internet]. 2020. Available from: https://equinetafrica.org/sites/default/files/uploads/documents/EQ%20Malawi%20PPP%20case%20study%20May2020_1.pdf.
  25. Joudyian, N., Doshmangir, L., Mahdavi, M. et al. Public-private partnerships in primary health care: a scoping review. Public-private partnerships in primary health care: a scoping review. BMC Health Serv Res [Internet]. 2021 Jan 4;21(4). Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-05979-9. [CrossRef]
  26. Ebulue, Charles & Ebulue, Ogochukwu & Ekesiobi, Chukwunonso. PUBLIC-PRIVATE PARTNERSHIPS IN HEALTH SECTOR INNOVATION: LESSONS FROM AROUND THE WORLD. International Medical Science Research Journal [Internet]. 2024 Apr;4(4). Available from: https://www.researchgate.net/publication/379972562_PUBLIC-PRIVATE_PARTNERSHIPS_IN_HEALTH_SECTOR_INNOVATION_LESSONS_FROM_AROUND_THE_WORLD/citation/download. [CrossRef]
  27. Chandra, Yanto & Shang, Liang & Roy, Michael. Understanding Healthcare Social Enterprises: A New Public Governance Perspective. Journal of Social Policy [Internet]. 2021 Feb;51(4). Available from: https://www.researchgate.net/publication/348936829_Understanding_Healthcare_Social_Enterprises_A_New_Public_Governance_Perspective. [CrossRef]
  28. Living Goods. Empowering Community Health Workers: A New Era in Digitized Healthcare [Internet]. 2024. Available from: https://livinggoods.org/media/empowering-community-health-workers-a-new-era-in-digitized-healthcare/#.
  29. UNICEF. UNICEF’S CONTRIBUTION TO THE IMMUNIZATION SUPPLY CHAIN IN THE FIRST 50 YEARS OF THE EXPANDED PROGRAMME ON IMMUNIZATION [Internet]. 2024. Available from: https://clearinghouse.unicef.org/sites/ch/files/ch/sites-PD-Health-Knowledge%20UNICEF%20Health-Immunization-iSCM-Other-EPI%4050iSC-2.0.pdf.
  30. Sumeet Juneja *, Falah Wadi, Mandar Kannure and Snehil K. Singh. Strengthening immunization systems through effective supply chains: insights from global effective vaccine management initiative. International Journal Of Pharmaceutical Sciences And Research. 2025 Feb 1;16(2):387–94.
  31. Roy, Rabindra & Sinha, Rabindra. Social Impact Bonds: An Innovative Mechanism of Funding for Social Problems in Developing Countries. Journal of Comprehensive Health [Internet]. 2020 Oct;4(1). Available from: https://www.researchgate.net/publication/364148738_Social_Impact_Bonds_An_Innovative_Mechanism_of_Funding_for_Social_Problems_in_Developing_Countries. [CrossRef]
  32. The Palladium Group. The Utkrisht Impact Bond [Internet]. 2018 Jan. Available from: https://thepalladiumgroup.com/news/Worlds-first-healthcare-development-impact-bond-aims-to-reduce-mother-and-baby-deaths-in-Rajasthan-India.
  33. Cameroon Cataract Development Impact Bond [Internet]. 2021 Feb. Available from: https://globaleyehealthcommission.org/case-study/cameroon-cataract-development-impact-bond/.
  34. van Staalduinen, D.J., van den Bekerom, P., Groeneveld, S. et al. The implementation of value-based healthcare: a scoping review. BMC Health Serv Res [Internet]. 2022 Mar 1;22. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-022-07489-2. [CrossRef]
  35. The Economist. VALUE-BASED HEALTHCARE IN SWEDEN Reaching the next level [Internet]. 2019. Available from: https://impact.econ-asia.com/perspectives/sites/default/files/value-basedhealthcareinswedenreachingthenextlevel.pdf.
  36. Stoller J. K. The Cleveland Clinic: a distinctive model of American medicine. Annals of translational medicine [Internet]. 2014 Apr;2(4). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4200609/. [CrossRef]
  37. Leao, D. L. L., Cremers, H. P., van Veghel, D., Pavlova, M., & Groot, W. The Impact of Value-Based Payment Models for Networks of Care and Transmural Care: A Systematic Literature Review. Applied health economics and health policy. 21(3):1 February 2023. [CrossRef]
  38. Teisberg, E., Wallace, S., & O’Hara, S. Defining and Implementing Value-Based Health Care: A Strategic Framework. journal of the Association of American Medical Colleges [Internet]. 2019 Dec 10;95(5). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7185050/. [CrossRef]
  39. Bajwa, J., Munir, U., Nori, A., & Williams, B. Artificial intelligence in healthcare: transforming the practice of medicine. Future healthcare journal [Internet]. 2021 Jul;8(2). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8285156/. [CrossRef]
  40. Alowais, S.A., Alghamdi, S.S., Alsuhebany, N. et al. Revolutionizing healthcare: the role of artificial intelligence in clinical practice. BMC Med Educ [Internet]. 2023 Sep 22;23. Available from: https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-023-04698-z. [CrossRef]
  41. Kong, M., & Song, S. J. Artificial Intelligence Applications in Diabetic Retinopathy: What We Have Now and What to Expect in the Future. Endocrinology and metabolism (Seoul, Korea) [Internet]. 39(3). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11220221/. [CrossRef]
  42. Peyroteo, M., Ferreira, I. A., Elvas, L. B., Ferreira, J. C., & Lapão, L. V. Remote Monitoring Systems for Patients With Chronic Diseases in Primary Health Care: Systematic Review. JMIR mHealth and uHealth [Internet]. 2021 Dec 21;9(12). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8734917/. [CrossRef]
  43. Bull, David. The Transformative Impact of Health Technology and AI Integration on Patient- Centric Care: A Hypothetical Role of Strategic Planning. International Journal of Information Technology and Computer Science [Internet]. 2023 Dec;11. Available from: https://www.researchgate.net/publication/376481227_The_Transformative_Impact_of_Health_Technology_and_AI_Integration_on_Patient-_Centric_Care_A_Hypothetical_Role_of_Strategic_Planning.
  44. Fenny, A. P., Yates, R., & Thompson, R. Strategies for financing social health insurance schemes for providing universal health care: a comparative analysis of five countries. Global health action [Internet]. 2021 Jan 20;14(1). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7833020/. [CrossRef]
  45. Nyandekwe, M., Nzayirambaho, M., & Kakoma, J. B. Universal health insurance in Rwanda: major challenges and solutions for financial sustainability case study of Rwanda community-based health insurance part I. The Pan African medical journal, [Internet]. 2020 Sep 14;37. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7648486/. [CrossRef]
  46. Blanchet, N. J., Fink, G., & Osei-Akoto, I. The Effect of Ghana’s National Health Insurance Scheme on Health Care Utilisation. Ghana medical journal [Internet]. 2012 Jun;46(2). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3426378/.
  47. Katz, Amy & Brisbois, Ben & Zerger, Suzanne & Hwang, Stephen. Social Impact Bonds as a Funding Method for Health and Social Programs: Potential Areas of Concern. American Journal of Public Health [Internet]. 2017 Dec 21; Available from: https://www.researchgate.net/publication/321979489_Social_Impact_Bonds_as_a_Funding_Method_for_Health_and_Social_Programs_Potential_Areas_of_Concern. [CrossRef]
  48. Iroz, C.B., Ramaswamy, R., Bhutta, Z.A. et al. Quality improvement in public–private partnerships in low- and middle-income countries: a systematic review. BMC Health Serv Res [Internet]. 2024 Mar 13;24. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-024-10802-w#citeas. [CrossRef]
Table 2. advantages and limitations of sustainable health models compared to traditional public health systems.
Table 2. advantages and limitations of sustainable health models compared to traditional public health systems.
Model Advantages Limitations
Public-Private Partnerships Enhances capital investment, accelerates innovation, improves efficiency Risk of prioritizing profit over public health outcomes, complex contractual agreements
Social Enterprise Models Aligns financial objectives with social goals to promote community engagement Scaling challenges, dependent on continuous innovation and market stability
Health Impact Bonds Outcome-based funding encourages efficiency, aligns investor and public interests Requires robust data tracking, potential misalignment of goals if poorly structured
Value-Based Healthcare Focuses on patient outcomes, reduces wasteful expenditures Implementation complexity requires changes in provider compensation structures
Technology and AI Increases access to care, reduces costs, improves care quality Privacy concerns, high initial investment, need for ongoing training and adaptation
Community Health Financing Promotes equity, increases local engagement, reduces direct financial barriers to accessing care Potentially limited by local economic conditions, requires widespread community buy-in
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
Prerpints.org logo

Preprints.org is a free preprint server supported by MDPI in Basel, Switzerland.

facebook logotwitter logolinkedin logo
bsky
MDPI Initiatives
Important Links
Subscribe

Disclaimer

Terms of Use

Privacy Policy

Privacy Settings

© 2026 MDPI (Basel, Switzerland) unless otherwise stated