Since the 2000’s, large cities in Brazil and India began to expand access to health care based on models of purchasing health care, while South Africa has started implementing the National Health Insurance (NHI) which seeks to purchase from public and private. These experiences are growing, with private and philanthropic providers hired to manage public facilities and deliver public services. There is preliminary evidence suggesting that under certain conditions these experiences are contributing to a quick expansion and improved access to care in peripheral and poor areas of big cities.

Despite these initial positive results there is widespread resistance to this modality of pluralistic service provision, based on the idea that it introduces a private logic in the public system. From our perspective, pluralistic modalities of public service provision may contribute to the improvement of public administration agility, but at the same time can create a coalition between state and private actors to the detriment of population health interests. For us, the strengthening of the public health system in LMIC countries will need to address deficiencies related to the six building blocks of the World Health Organisation (WHO) model: infrastructure, human resources, technology, medicines, financial resources, and evaluation systems and will be facilitated once community governance mechanisms crosscut all the building blocks providing glue to ensure community voice is harnessed for health system responsiveness to citizens’ needs and equity.