No datasets are available on the basis of confirmed familial breast cancer patients and their respective mutation status for the South African Indian population. This dataset contains information collected in South Africa specifically for the South African Indian population (n = 223). The data involved a combined collection of laboratory confirmed genetic testing results, accompanied by immunohistochemical and anatomical pathology results. Various patient self-identified variables were also in measured. All the immunohistochemistry and anatomical pathology results were confirmed by a trained medical pathologist. Furthermore, mutation status and the detection of either benign polymorphisms or variants with an unknown clinical significance at the time of data collection were also reported. This dataset contains variables in a tabular format which includes the accompanying variables for each patient. All the patient-specific data were deidentified which allows for further exploration of the data with respect to the demography, immunohistochemistry and genetic material. This dataset has the potential to serve as the backbone for translational research and inquiries into this unique South African population. Furthermore, in the final dataset, only patients classified from the South African Indian population were used. The data was stratified into three overarching components namely: demographic insights, clinical evidence and genetic information. The final dataset (which includes the genetic screen and the data from the patient request form) is presented in a raw tabular data format, and consist of demographics data (prefix d), clinical- (prefix c) and genetic variables (prefix g), all of which are aimed to provide a clear assessment of what is needed to make an informed diagnosis for familial breast cancer in this population group. All of the variables within the dataset were categorical, and the validity of each variable was confirmed by either a medical officer, medical specialist or medical scientist. The demographic data is what was identified at time of first consultation . Apart fThe clinical data is a combination of family-specific clinical questions aimed at determining disease risk, in combination with confirmed immunohistochemistry and anatomical pathology results for each patient . For somBRCA1/2 genes BRCA1/2 genetic variants were annotated according to specified international nomenclature using the NCBI chromosomes and transcript reference sequences for each of the genes . The genetic data in the dataset is unique to the South African Indian population. Within the dataset, the type of genetic result, if the genetic result caused a frameshift mutation, deletion, or a premature termination was included. There are genetic variations that were classified as variants with an unknown clinical significance (VUS). These variants did not at the time of publication have a known clinical significance and these variants are still under investigation. In addition to this, if the genetic change was as a result of a shift from either a purine to a pyrimidine (or vice versa), or no change – then it was reported for each nucleotide combination.The genetic information is based on the laboratory-specific test results for each of the patients . All of The categorical parameters in this dataset contains a variety of different variables related to clinical genetic information specific to the South African Indian population.2BRCA1/2 variant, the patient is referred for genetic testing. Genetic testing generates the data related to the genetic features in the dataset. This entails the extraction and purification of DNA from blood representative of a specific patient. Once extracted, analysis is conducted using a series of investigative laboratory procedures, to collectively detect all the various types of potential variants, such as single nucleotide changes or copy number variants. All tests are founded on the exponential multiplication of highly specific areas in each of these genes to identify changes on both DNA and protein level. If any anomaly is detected , it will be scrutinized using various methodologies, including DNA sequencing, to confirm its presence. Once the presence of an anomaly is detected, the information is captured. The genetic screening process is broken up into several stages due to the large size of BRCA1 and BRCA2   .Fig. 2DaThere are instances where all processes occurred simultaneously . Under such circumstances, there will be no supporting data from the pathology results captured on the patient request form. In such an event where the first two tests were conducted prior to the request for genetic testing, the clinical information will accompany the clinical request form, where after genetic testing will commence. Once a pathogenic anomaly is confirmed, the information is stored in a secure database. This database contains all the relevant information about the patients that came from the patient request form as well as all the genetic data that was generated and confirmed through Sanger sequencing. Some of the variables and variable fields undergo feature engineering steps. These steps are introduced to deidentify the samples and stratify the information according to the experiments conducted. Each of the patients in the study underwent a further clinical justification step according to their risk profile which was further stratified into low, moderate, and high risk. At every step of the process, all the information was signed off by a senior medical scientist or medical specialist. The data is also collected and validated at each step of the data collection cycle by two medical scientists .Ethical approval for the study was obtained from the Health Sciences Research Ethics Committee at the University of the Free State (ECUFS 107/2014) and the Department of Health, KwaZulu-Natal (HRKM194/14). All the patients in this study completed an informed consent form. Only patients that allowed for further analysis of their samples were included in the dataset. Within this study and with this dataset there were no (none) patients that objected to the storage, study and follow-up analysis using their information. All of the procedures and standards of this study followed the strict and clear protocol of the project plan, under the guidance of the ethical measurements used in this study.By adhering to all the ethical guidelines, we confirm that informed consent was obtained for all participants in this study. The research in this study was carried out in accordance with the code of ethics from the South African Medical Research Council, the University of the Free State Medical School Ethics committee, and the Department of Health, KwaZulu-Natal which are in accordance with the World Medical Association's Declaration of Helsinki.H.M.V.E. Combrink: Conceptualization, Methodology, Formal analysis, Writing – original draft. N.C. van der Merwe: Resources, Conceptualization, Validation, Data curation, Writing – review & editing. R. Katarya: Conceptualization, Methodology. K. de Wet: Writing – review & editing, Writing – original draft. M.H. Motloung: Writing – review & editing, Writing – original draft.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:The authors declare that they have no known competing financial interests or personal relationships that could appear to influence the work reported in this paper.


Implementation of this method would entail the participation and collective action of various stakeholders. In this process, farmers are considered as the most important stakeholders; and limited studies have been conducted on their intentions to participate in collective actions of ASR management. In this regard, the investigation of farmers’ intention to participate in ASR and its determinants, using social identity models of collective action, was selected as the main purpose of the present study. For this purpose, using a cross-sectional survey, 330 Iranian farmers were interviewed. In this study, the ability of the dual-pathway model of collective action (DPMCA) and the encapsulation model of social identity in collective action (EMSICA) was evaluated and compared to explain farmers’ intentions towards participation in ASR management. The results revealed that the both models had good predictive powers. However, DPMCA was a stronger framework than EMSICA for facilitating farmers’ collective behaviors in the field of participation in ASR management. This is one of the most important results of the present research that might be used by various users including decision makers, managers, and practitioners of water resources management in Iran and generally the world. Finally, the creation of a “ Aquifer storage and recovery is an innovative method for water management.Collective action models are useful for implementation of aquifer storage and recovery.Formation of social identity is a crucial for collective aquifer storage and recovery.we thinking system as the best strategy for aquifer storage and recovery.The study introduces Iran has always been regarded as a dry country where only one-fourth of its surface has been suitable for agricultural practices; the remaining three quarters are covered by deserts and mountains . In IranIncreasing population and increasing water demand; as well as shortage of water resources, have a great impact on various agricultural, industrial, and service sectors ; thus, oASR, as an approach to water storage , is an iThroughout the year, Municipal sewage production is referred to an accessible water source for the agricultural and industrial sectors on the outskirts of metropolitan areas. This alternative water source might be used for artificial aquifer feeding and prevention of environmental pollution; that is, to achieve sustainable management of water resources and to reduce the economic, social, and environmental problems of metropolitan areas, waste water is one of the best subjects . The useQanats and significant decrease in the surface water of Karaj River which is caused by the construction of a dam upstream of it, the water inflow of this river to Fashafoyeh area has sharply decreased in the last few decades. This has led to the seasonality of rivers/surface currents entering the plain; besides, the agricultural sector of this region, owing to the interruption of Karaj River, relies on dam overflows, and therefore groundwater resources are not responsible for compensation of this shortage. In addition to the agricultural sector, residential sectors, airports, and large industrial hubs are applicants for having water in Fashafuyeh plain. However, the increase in water abstraction over the past few decades has severely affected the aquifer in terms of quantity and quality. Thus, most areas have EC values greater than 2000 thousand μs/cm. This has made villages down the plains face salinity problem in drinking water supply; besides, drilling wells for agricultural and industrial purposes has caused the aquifer to experience an extreme groundwater level decline.ASR management has the potentiality to be used in various regions such as Iran that are struggling with many problems as to excessive abstractions of groundwater and decline of groundwater levels . FashafuDue to the existence of these issues in Fashafuyeh plain, it seems that ASR management might be one of the best ways for achieving sustainability in water resource management in this area; where the agricultural sector is the main consumer of water in that. Therefore, farmers are certainly considered as one of the most significant stakeholders in ASR, the behavioral intention of whom towards participation would be of great importance . In otheMany sustainability-related issues, such as sustainable management of water resources require collective action of farmers and must be done in coordination with all farmers. For example, ASR management, integrated pest management, watershed management, and wetland management require long-term and large-scale measures. In other words, they need collective action . CollectDPMCA was first developed by Stürmer and Simon . This moEMSICA was developed by Like DPMCA, social identity or we thinking system is one of the key variables in team building and collective actions to address different challenges such as ASR. However, in this model social identity is more important and it is believed that it can influence the effects of participative efficiency and negative emotions on collective behaviors . NegativThe present study was conducted in Fashafuyeh plain. With an area of about 330 square kilometers, this plain, being located in the south of the capital of Iran (Tehran), is positioned on the bed of the Karaj River. The average annual precipitation and evapotranspiration are 155 and 1,061 mm, respectively. This plain covers the city of Robat Karim, Imam Khomeini International Airport and 20 more villages. Geologically, the maximum aquifer thickness exceeds 150 meters.The statistical population consisted of farmers in Fashafuyeh plain in Tehran province . According to The research instrument used was a closed-ended questionnaire that used the opinions of a group of academic experts in the technical and social fields of water resource management and also the opinions of practitioners of sustainable water resource management interventions; thus, the face validity and content validities of which were confirmed. After some modifications, the questionnaire was evaluated using a pilot test. The reliability of the tool was examined using criteria including Cronbach’s alpha coefficients, items’ composite reliability, corrected item-total correlation coefficients, and loading factors of measurement models for the variables. Cronbach’s alpha coefficients were calculated after a pilot study and interviews with 30 farmers. The pilot study resulted in some insightful lessons; besides, it implied that all alpha coefficients were greater than the acceptable value of 0.7. The main survey was performed following the pilot study; after the survey, the composite reliability (CR) and the corrected item-total correlation (CITC) coefficients were examined. The values obtained for CR and CITC coefficients were higher than the valid values of 0.7 and 0.3, respectively. Calculation of the loading factors for the measurement models of each composite constructs demonstrated that all their values were greater than the logical value of 0.4.To appraise the validity of the cross-sectional survey’s questionnaire, convergent or average variance (CV), or Average Variance Extracted (AVE) and divergent validity indices were employed. To evaluate the divergent validity of the research tool in SEM, we first used the average shared squared variance (ASV) index; then, the maximum shared squared variance (MSV) was applied as a supporting criterion.Generally, there were seven variables in the two frameworks of collective action that were applied to analyze farmers’ participation in ASR management. The method of measuring and operationalizing these variables has been thoroughly presented in Intention towards participation in ASR management (IPASRM): Indicates the farmers’ willingness to participate in collective actions of ASR management.Social identity towards participation in ASR management (SIPASRM): Refers to farmers’ identity-oriented beliefs about their participation in collective actions of ASR management.Subjective norms of participation in ASR management (SNPASRM): Refers to the farmers’ perceptions of the way those surrounding them think about their participations or non-participations in collective ASR management.Perceived behavioral control towards participation in ASR management (PBCPASRM): Represent the farmers’ perception of their ability to participate in collective ASR management.Attitude towards participation in ASR management (APASRM): Stands for the positive or negative orientation of the farmers towards participation in ASR management.Collective efficacy of participation in ASR management (CEPASRM): Indicates the degree of individual belief in the effectiveness of collective action in ASR management.Negative emotions about participation in ASR management (NEPASRM): Refers to the strong reactions of farmers  to the lack of participation of other farmers and stakeholders in ASR management.26 and AMOS25 were employed.To gather the needed data, face-to-face interview with farmers in Fashafuyeh plain was conducted. In general, 331 questionnaires were distributed, out of which 330 questionnaires were collected. A single questionnaire, owing to many deficiencies in the respondent’s answers, was discarded. Eventually, 330 questionnaires were analyzed; for this purpose, SPSSMardia’s coefficients of skewness and kurtosis were employed to test the normality of the data. The estimates of measurement and structural models were used to analyze the data using SEM.r = 0.781; p < 0.01), SNPASRM , PBCPASRM , and SIPASRM  have positive and significant correlations with IPASRM  and SIPASRM  in EMSICA had positive and significant correlations with IPASRM. The results of the research done by r = 0.413; p < 0.01) significantly correlated with IPASRM. This result reflects this insight that with the increase of NEPASRM, IPASRM decreases and vice versa. Similar results can be found among the findings of r = 0.465; p < 0.01) and NEPASRM  with SIPASRM was significant. However, since the direction of correlation between them is opposite, the direction of their effects would be different.According to the theoretical frameworks, the results of correlation relationships between the variables showed that in DPMCA, four variables of APASRM , PBCPASRM , and SIPASRM  had positive and significant effects on IPASRM . Taken together, the independent variables were able to predict 65.4% of the variance changes of IPASRM in DPMCA  and SIPASRM  on IPASRM were positive and significant; that is, with increasing and reinforcing these variables, IPASRM is strengthened. However, NEPASRM  affected IPASRM negatively. This variable had a significant negative effect on SIPASRM . CEPASRM  was the second variable that was predicted to have a positive and significant effect on SIPASRM in EMSICA. And the results of structural model estimates confirmed this hypothesis. In general, the results indicated that the independent variables in EMSICA could account for about 36.5 and 33.5% of the changes in IPASRM and SIPASRM, respectively  effects of independent variables on IPASRM . The resIn order to evaluate the fitness of structural models, seven evaluation criteria including Comparative fit index (CFI), Goodness of fit index (GFI), Adjusted Goodness of Fit Index (AGFI), Normed fit index (NFI), Incremental Fit Index (IFI), Root Mean Square Error of Approximation (RMSEA), and chi-square normalized by degrees of freedom (CMIN/DF) were applied. Acceptable obtained values for the two structural models tested in this study have been presented in The main purpose of the present study was to analyze the intentions towards participation in ASR management, using two EMSICA and DPMCA frameworks. The results demonstrated that in DPMCA, APASRM is the strongest determinant of IPASRM. According to DPMCA, farmers’ positive attitudes toward participation in collective ASR management measures, highly depend on the understanding of the positive consequences of their participation. In other words, farmers should recognize that by participating and taking collective actions for ASR management, they  and the whole region would have tangible benefits in terms of water, agriculture, and economy. Therefore, it is recommended that some local training workshops and courses get arranged for farmers in this area. It is worth mentioning that in these training course,s the outcomes and benefits of farmers’ participation in collective measures of ASR management shall be addressed and emphasized. The main outcomes and benefits are including solving agricultural water shortage problems, preventing migration, raising groundwater level, reducing water pollution, and producing healthy agriculture crops. In fact, it should be kept in mind that each of the aforementioned points should be supported with valid reference to the scientific contents. (which have become understandable messages for farmers). The results of running DPMCA also revealed that PBCPASRM positively and significantly affected IPASRM. This result indicated that according to the DPMCA social identity model, farmers believed that participation in the collective actions related to ASR management was not beyond their capability and control; that is, they have reached a desirable level of self-confidence in their ability to participate in the collective actions of ASR management, and this self-confidence has a positive effect on their IPASRM. Such a result might be recognized as a turning point for sustainable water resources management programs, interventionists and managers/policy-makers of ASR management. Because, in such circumstances, there is no need to spend much time and financial or human resources for strengthening the self-efficacy and self-confidence of farmers, so that they can participate in collective actions of ASR. The insignificance of the effect of SNPASRM on IPASRM supports such a conclusion either. This result shows that farmers in their decisions to participate in collective ASR management activities, are not influenced by possible beliefs dictated by others.collective will and the effectiveness of participatory measures in projects such as ASR management can overcome many problems.CEPASRM was the strongest direct determinant of IPASRM in EMSICA, which affected that positively. From this result, it can be inferred that farmers’ beliefs about the effectiveness of their collective and participatory actions might play an important role in increasing their intentions and motivations to participate in ASR management. In other words, if farmers conclude that collective actions of ASR management can have significant and positive consequences for improving water-related crises in the region, then they would be more willing to participate in that action. They may even spontaneously initiate such collective actions and encourage other organizations and stakeholders to play more active roles. One of the best strategies to raise awareness and enlightenment on the effectiveness of collective actions in ASR management is the application of successful national and international experiences of collective/social environmental crisis management actions. In this regard, it is suggested that the institutions responsible for the implementation of sustainable water management programs use such strategies to form this belief that relying on personal selves have no meaning without each other. In such a situation, the individual interests of each farmer would be in line with the collective interests of the group involved in ASR management. Such convergence in the individual and group interest of farmers might have a synergetic and constructive effect on IPASRM and effectiveness of ASR management. In this regard, it is recommended that policy-makers, planners, managers, and practitioners of sustainable water resources management programs (like ASR management projects) use the participation and consensus of farmers in various stages of the projects such as diagnosis and contextualization of the problems, plannings, implementations, and evaluations. This would lead to the formation of a social identity and then they would consider ASR management project as their own; therefore, achieving collective goals would be equivalent to achieving individual goals. Such a collective and we thinking system would ultimately strengthen IPASRM and the effectiveness of policies and programs.NEPASRM negatively and significantly affected IPASRM. It can be concluded that beliefs, feelings, and reactions such as anger, pessimism, etc. towards collective actions in the field of ASR management can reduce farmers’ willingness towards participation. Considering that the formation of such negative feelings about participation is generally related to farmers’ previous and personal experience of disputes with various stakeholders , lack of mutual trust, and stakeholders’ effort to maximize their share of the collective interest, it is recommended that the share of participation, decision-making power, authority, job descriptions, etc. be specified accurately in the implementation of ASR management. Furthermore, it is recommended that each stakeholder involved in the collective ASR management, provide an executive guarantee/commitment to perform his/her duties. This would build trust in the agricultural community. Building trust also reduces negative emotions and strengthens IPASRM. Based on the results of running DPMCA and EMSICA frameworks, SIPASRM affected IPASRM positively and significantly. This suggests that both social identity models of collective action see SIPASRM as an undeniable requirement for farmers’ willingness to participate in collective ASR management. In other words, in order to strengthening IPASRM, they need to find an identity and feel that the group members and their collective and we thinking system, as a significant basis of any policy, program, and intervention in the field of sustainable ASR and water resource management, in agricultural communities.The main take-home massage of the present research is that for the first time in the world, social identity models of collective actions have been used in conceptualizing IPASRM. The results of this study showed that social identity models of collective action have a good capability in predicting IPASRM; though, DPMCA has more explanatory power than EMSICA. This study introduces the formation of a This research had three limitations that should be mentioned and suggestions for future researchers should be made based on them. First, in this study, the self-reporting system was used to collect the required data, and the results were interpreted based on the self-reports of the respondents in Fashafuyeh plain. Future researchers can use non-self-reporting methods such as case studies, focus groups, etc. to collect similar information. This can help increase the plausibility of research results. Second, in this study, in order to strengthen the feasibility of the research process, simplified versions of social identity models of collective action were used. Future researchers can develop these models by adding other social and cultural variables. Thirdly, this study was conducted only in Fashafuyeh plain and its results can be used in other geographical areas that have common characteristics with this plain. However, in other geographical areas that have different characteristics, separate researches should be conducted. Conducting such researches can help to cross-validate the results of the current research and increase their generalizability. In this regard, it is suggested that future researchers use social identity models of collective action to manage groundwater water resources in other plains.The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Private health care facilities working in partnership with the public health sector is one option to create sustainable health systems and ensure health and well-being for all in low-income countries. As the second-most populous country in Africa with a rapidly growing economy, demand for health services in Ethiopia is increasing and one-quarter of its health facilities are privately owned. The Private Health Sector Program (PHSP), funded by the United States Agency for International Development, implemented a series of public–private partnership in health projects from 2004 to 2020 to address several public health priorities, including tuberculosis, malaria, HIV/AIDS, and family planning. We assessed PHSP’s performance in leadership and governance, access to medicines, health management information systems, human resources, service provision, and finance.The World Health Organization’s health systems strengthening framework, which is organized around six health system building blocks, guided the assessment. We conducted 50 key informant interviews and a health facility assessment at 106 private health facilities supported by the PHSP to evaluate its performance.All six building blocks were addressed by the program and key informants shared that several policy and strategic changes were conducive to supporting the functioning of private health facilities. The provision of free medicines from the public pharmaceutical logistics system, relaxation of strict regulatory policies that restricted service provision through the private sector, training of private providers, and public–private mix guidelines developed for tuberculosis, malaria, and reproductive, maternal, newborn, child, and adolescent health helped increase the use of services at health facilities.Some challenges and threats to sustainability remain, including fragile partnerships between public and private bodies, resource constraints, mistrust between the public and private sectors, limited incentives for the private sector, and oversight of the quality of services. To continue with gains in the policy environment, service accessibility, and other aspects of the health system, the government and international communities must work collaboratively to address public–private partnerships in health areas that can be strengthened. Future efforts should emphasize a mechanism to ensure that the private sector is capable, incentivized, and supervised to deliver continuous, high-quality and equitable services. To improve universal health coverage (UHC) and attain the Sustainable Development Goals, countries must work with different partners toward a common goal of improving population health , 2. The Despite acknowledgement of the importance of PHFs in care provision, specific policies and mechanisms to effectively engage them are lacking . The divEthiopia has achieved impressive milestones in improving the health of its population—increasing child survival, reducing maternal mortality, and improving overall life expectancies –20. DespPublic–private partnerships in health (PPPH) are agreements that allow governments and private sector actors to collaborate to address health issues , 25. TheIn support of these objectives, the United States Agency for International Development (USAID) supported Abt Associates and its partners in implementing the Private Health Sector Program (PHSP) from 2004 to 2020. PHSP’s strategy focused on developing and implementing the public–private mix (PPM) model to contribute to the mitigation of the impact of diseases of public health importance. PPM partnerships are generally implemented for short periods, are non-contractual, and focus on strategic collaboration for vertically addressing a disease . EvidencThe PHSP facilitated and supported the development of PPM guidelines in these priority health areas to serve the purpose of building a strong PPPH. The PHSP’s role was to work as a an external broker, building collaboration among different government institutions, including the MOH, regional health bureaus (RHBs), and PHFs; defining responsibilities among the partners; and formalizing the partnership through memorandums of understanding (MOUs) . SupportAssessment and evaluation of PPPH have identified areas of challenges for public–private collaboration, including inadequate policy framework and ineffective stakeholder engagement, as well as potential benefits such as enhanced efficiency and effectiveness of health service delivery , 36, 37.The World Health Organization’s (WHO) health systems strengthening framework identifies six health systems building blocks: leadership/governance, financing, service delivery, health workforce, health information systems (HMIS), and access to essential medicines . This frThis study retrospectively assessed the performance of the Private Health Sector Program using the six WHO health systems building blocks as an analytical framework. The PHSP offers a case study for exploring the challenges and opportunities of integrating PHFs in government-led health systems to improve service coverage of essential health services in a low-income country health system context. Findings from this study aim to generate implementation insights for strengthening PPPHs and the PPM in LMICs.The evaluation design was a retrospective, mixed-method, cross-sectional assessment conducted at program endline without a comparison group. Data sources included qualitative interviews with key informants and a health facility assessment of selected PHFs.We purposively selected stakeholders at national, regional, and facility levels as key informants who were familiar with the PHSP’s activities and were involved in the program and PPM processes. National-level interviews included MOH representatives from directorates involved in priority areas of PHSP support ; government and regulatory bodies, such as the Ethiopian Food and Drug Administration (EFDA) and Ethiopian Pharmaceutical Supply Agency (EPSA); and professional associations, such as the Ethiopian Medical Laboratory Association (EMLA). Additional key informants were advisors from the PHSP who provided technical support and guidance to the MOH and RHBs in the implementation of PPMs. At the regional level, we interviewed representatives from RHBs in Tigray, Amhara, Oromia, Addis Ababa, Afar, and Harari; PHF owners; and representatives of regional PHF associations (PHFA). Health facility owners covering different service sectors  were interviewed to understand their perspectives and experiences implementing the PPM. A total of 50 key informant interviews (KIIs) were conducted Table .Table 1KThe health facility assessment (HFA) collected data from 106 of the 332 PHFs supported by the PHSP in 2020. The PHFs were purposefully selected to represent all PHSP regions, types of health facilities, and service delivery technical areas   between July and October 2020. Most data were collected over the phone and digitally recorded.The data collection team administered an open-ended, semi-structured interview guide appropriate for different types of stakeholders. The interview guide included questions on the improvements from and contribution of the program, challenges, and gaps; issues of sustainability in the policy environment; service delivery and service utilization; and the overall functioning of the private healthcare system. A team of six interviewers experienced in qualitative research received orientation on the data collection tools, conducted phone interviews in Amharic, took notes, and recorded the interviews with participant consent and permission. The interviewers also conducted some in-person interviews in English, mainly with PHSP staff and government bodies, with proper COVID-19 precautions. If any interviews needed further clarifications, the interviewees were reached through follow-up calls. The qualitative research team translated and transcribed all interviews in English.Transcripts were analyzed using a coding framework based on the program’s purpose, content of the interview guides and the application of broad key themes . We coded and analyzed the texts by type of respondents and thematic areas to group and identify patterns. The research team discussed iterations of the framework during the coding process as well as evolving themes and data saturation and any interpretations of translations that seemed vague.A pretested, structured questionnaire programmed onto a tablet was used to collect quantitative data for the HFA using Open Data Kit software. A team of six research assistants with medical backgrounds conducted phone interviews and recorded the responses on the tablets. In most cases, the respondents needed to review their records for information on stock-outs and number of trained personnel, and the data collectors called them a second time to retrieve this information. Additionally, the study team requested that HFA respondents take pictures of facility records and send them via telegram, and about half the health facilities did so.The PHFs in the sample responded to questions about the services they provided. We selected key indicators aligned with the thematic areas of support provided to the health systems, including training, supervision, and the availability of medicines. Descriptive analyses were conducted in Stata to assess the status of the health systems-related indicators.This study was carried out in mid-2020, at the height of the first wave of COVID-19 restrictions. Data collection had to be carried out remotely due to the travel constraints and mandatory lockdowns enforced during the pandemic. As a result, KIIs were scheduled and conducted as telephone interviews. A minor proportion (< 10) of interviews were carried out in-person. Likewise the HFA questionnaires were carried out by telephone. Clarifications were confirmed through follow-up calls to participants, as needed. While a typical HFA often includes the observation of services and patient flow and the visual inspection of drug and equipment inventories, this was not possible as a remote study. Given these limitations, we adapted the HFA approach to seek information on key performance indicators and to verify reported data remotely.We also used triangulation across different methods and participants to further strengthen the credibility of the study’s findings. Triangulation allowed the emergence of comparisons and patterns that were important to our analysis. The main instruments consisted of closed-ended and open-ended HFA questionnaires and semi-structured, in-depth interview guides. Respondents included a range of stakeholders from national, regional and health facility levels and included perspectives from policymakers, facility owners, managers and health workers. These different ways of gathering information from different types of respondents allowed a comparison and verification of responses, which increased the validity and dependability of the data.Finally, the evaluation that formed the basis of this study was carried out by an independent, external organization that followed best practices in sampling and remote data collection processes, including providing a clear rationale for the sampling design and sampling frame, determination of qualitative data saturation, and maintaining ethics in the research design. An independent evaluation increases the likelihood of an unbiased performance assessment and enhances the credibility of the findings.Results from the KIIs and HFA are presented jointly, organized by health systems building block. PHSP’s support toward HIV stopped in 2018 due to the termination of funding by the donor. As such, the assessment did not focus on HIV. In addition, PHSP was involved in MNCH for less than two years due to the late initiation and early ending of the program . Due to The MOH and regional health system levels demonstrated leadership through the involvement of RHBs and woreda health offices in support of PHFs for the provision of TB, malaria, HIV/AIDS, and MNCH services. The MOH strengthened the private health system by formulating policies and strategies toward a PPPH, including initiating a form of PPP, PPM-DOTS, in 2004. In 2018, the MOH established a full unit of PPPH within the Partnership and Collaboration Directorate to strengthen the implementation of the 2013 PPPH strategic framework. The MOH developed and revised the PPM for TB twice and developed a PPM for malaria and for MNCH and FP between 2004 and 2020, with extensive technical support from partners, especially from the PHSP.The public-private partnership is one of the pillars in [the] Health Sector Transformation Plan…to create an enabling environment for the private sector to invest in health. The private health sector is cross-sectoral and goes beyond the health sector; there is a PPP [public-private partnership] proclamation, policy and direction, and implementation guideline[s]...approved by the Ministry of Finance. These are ventures where the private and public sectors can mobilize their resources and invest for improving the health system.The commitment and involvement of RHBs were tangible through their direct support to the PHFs. For example, RHBs made an autonomous decision to provide logistics and technical support to PHFs for HIV/AIDS services, even though the MOH did not have any PPM implementation guidelines and the donor and PHSP’s support ceased for HIV/AIDS. Key informants from the PHSP and RHBs perceived that the MOH’s commitment and leadership was the culmination of several converging factors: increasing demand for health care services from the private for-profit and non-profit sectors ; persistThe federal and regional governments were not yet able to formulate private sector engagement endeavors to implement PPPH and PPM policies effectively and independently on a large scale without technical and financial support from donors. Some stakeholders perceived a disconnect between the PPPH Unit and the overall MOH because the Unit had not been incorporated in the MOH organogram to support private sector engagement for health, and no specific government resources were allocated. Another disconnect was the vertical establishment of PPMs. With support and advocacy from partners, such as the PHSP, different directorates developed PPM guidelines for individual diseases. For example, as of 2020, PPM guidelines had been finalized for TB, malaria, and MNCH and FP; however, these MOH directorates did not have a formal linkage to the PPPH Unit, exposing a weakness in the system.The PPMs currently focused on free social franchising programs; there is a lack of understanding of the concept of other modalities of PPPH among the authorities…Although we have more than a decade of experience in PPPH, our experience is limited to free public health services.Another gap was the absence of a dedicated person or unit for PPM at the RHB level. Although the PPM programs and private sector engagement were operationalized at the regional level and below, the lack of a formal position was a major gap. It was also revealed that the private sector was not included in regional planning or budget allocation processes. One PPPH Unit representative described::The previous requirements recommended by the FMHACA  were very rigid and not suitable for the Ethiopian context  and it didn’t have the incentives to encourage private facilities.The regulatory standards previously in place were considered too stringent and not conducive for service delivery by PHFs. One high-level MOH respondent who was familiar with the standards describedThe PHSP and representatives from PHFA coordinated with the MOH and the FMHACA (later named the EFDA), the lead regulatory agency for commodity quality standards. This advocacy resulted in the government revising several service quality standards to ensure that the regulatory standards were realistic, transparent, feasible, and applicable to both public and PHFs .We conduct supervisions as per a standardized checklist. For example, we come across health facilities that don’t adhere to the TB infection prevention guidelines. [….] We give feedback and discuss with the owner if the standards are not met. Based on the supervision outcomes, there were facilities that might be disallowed to provide specific services. We try to strengthen these facilities.Relaxing the regulatory standards did not imply a relaxation of monitoring of compliance with the standards by PHFs and periodic checking of licensing standards. With support from the PHSP, the FMHACA/EFDA developed and implemented a modernized health standards monitoring system with digital equipment connected to a server. Based on the inspections, the RHBs exercised full authority for regulatory oversight and for licensing and relicensing of all health facilities at the regional level. An RHB representative stated:It is easy to regulate the private health sector and take action against them for not following the standard, but when you come to the government facilities you can’t control them. Sometimes the authority doesn’t accept the issues with the public health centers, as it may lead to conflict, so the control is focused on the private sector.Despite improvements in the partnership between the RHBs and PHFs, some stakeholders indicated that there were still ongoing tensions around the implementation of regulatory standards. One regulatory representative expressed concern that bias against PHFs might lead to double standards in actions for the inspection of private and public health facilities. Regulators could cancel licenses or take other administrative actions against PHFs if they deviated from the standards, but they could not take any action against public health facilities for the same deviation. Some PHF respondents and regulators alluded to this issue of double standards, with one regional regulatory body expressing that:Historically, there has been deep-rooted mistrust at both MOH and RHB levels toward the private sector. Key informants, especially those from the PHSP team, indicated that increased trust and better working relationships between the government and PHFs had evolved slowly over time, partly a result of the PHSP’s persistent advocacy between the MOH and relevant stakeholders to create a more positive and trustworthy partnership. Regional-level stakeholders expressed the view that engaging RHBs and local health offices in advocacy, the signing of MOUs, and the implementation of PPM had helped shift some RHB staff’s perceptions about working with the private sector.Government used to consider the private sector as just organizations established only for profit, hence there was no interaction between those bodies. People come for our services and they make the decision for their own benefit. The negative view has been changing.Making regulatory standards more transparent and less punitive for the private sector, delivery of services, and continuous involvement and support through regular interactions and supervision by the RHBs also contributed to establishing a baseline level of trust, especially between the RHBs and PHFs. One PHF owner explained the relationship as follows:Despite improvements, mistrust between the public and private health sectors persists. Some key informants mentioned that there was reluctance among certain professional groups at the MOH, including a pharmacy association, to shift tasks, such as dispensing antiretrovirals or anti-malaria medications from pharmacies to nurses. Some RHB representatives shared their belief that because PHFs were profit-oriented, they would not look after the best interests of their clients.There is a low commitment of facility owners to keep providing the service since these services are not profitable. Both TB and malaria medications and laboratory services are free according to the country’s law. But sometimes, patients are asked to buy the medicine from outside. They [PHF] also charge high for laboratory services.One of the major concerns expressed by the public sector stakeholders was that PHFs might misuse the subsidized or free medicines by seeking financial benefits instead of providing the medications to clients for free or at a minimal cost. One RHB representative expressed:The integrated pharmaceutical logistics system (IPLS) strategy ensured that the PHFs that signed MOUs with the RHBs would get government-purchased, free medicines, supplies, and reagents for TB, malaria, and FP services through the EPSA’s distribution system. The national IPLS also included the PHFs in training manuals and the accurate estimate of medicine requirements by the PHFs in the national supply chain and stock level quantification process in 2017 .:We have seen some hope for malaria elimination which is our goal. The PPM guideline provides guidance and approval to the PHFs to give malaria treatment free of charge including free medication, allowing only payment for diagnosis.The importance of having the provision of free or affordable medicines is part of the PPM guidelines. For example, a stakeholder from the national malaria unit of the MOH saidWe give health education which has increased people’s awareness and demand [for service]. Even with malaria being sporadic, the number of patients increased compared to before. People are aware that medication is free. […] Not only for malaria but also for HIV and TB, the medication supply has to be sustainable and continuous for quality service.PHF providers also described how important it was to have continuous supplies to provide sustained care to the community:Despite the policy to ensure sustained supplies of medicines, PHFs commonly experienced stockouts of critical medications and supplies, mainly to treat malaria, and of laboratory reagents for TB and malaria testing. Table Widespread opinions that the PHFs sold the free medicines in the market and/or to patients may have led them to get lower priority in receiving the required quantity or consistency of medicines. Some PHFs reported sensing this lack of prioritization from the woreda and regional logistics systems.We submit requests for medicine to government health facilities. A stronger connection with the government HF is needed so that we can get medicines when we request. There are times even when the drugs are available in their stocks at the [public] health facilities but we don’t get them on time.Although 57% of the PHFs interviewed expressed satisfaction with the supplies from the woredas, 43% were unsatisfied. Of the 43% unsatisfied, 53% cited irregular supplies, and 47% reported not being a priority for the woreda as the reasons for dissatisfaction. Malaria-sector PHFs expressed the most dissatisfaction. One malaria PHF provider explained:Private health facilities do not always place the request [for drugs] on time and sometimes ask for supplies at the very end […], we try to arrange from public facilities nearby so the service was not interrupted.One RHB representative indicated that even though the PHFs were trained in stock level quantification and were supposed to request medicines and supplies in advance, the PHFs often failed to submit information about the quantities needed early enough:It is required by law that PHFs report to the national HMIS to determine the contributions of PHFs in the provision of services. However, respondents stated that PHFs reporting to the national HMIS is not common practice.Just like public facilities, proper trainings are provided to PHF representatives on how to use the HMIS system and proper reporting. We identify gaps during supportive supervisions and try to improve their reporting qualities.A key impetus for timely reporting that was enforced by the PHSP through an MOU was that without reports, the PHFs would not be able to restock their supply of medicines from government sources. Supported PHFs received training and regular monitoring, which greatly increased their reporting. An RHB informant described the support that they provided to PHFs for the HMIS:Similar gaps are [found in] both private and governmental facilities; the HMIS reports are not submitted timely; they do the work and keep registers at the health facilities but do not take reporting seriously. However, this is more common in the PHFs—to submit poor quality data. Data quality gaps include not reporting timely. When you go to the zonal, woreda, and other lower levels, you might find other problems, but these are the problems at the regional level.Representatives from PHFs and the RHBs highlighted several challenges in the PHFs’ reporting to the HMIS, including the lack of trained personnel, staff turnover, the reporting burden, and a misunderstanding about the purpose of reporting. The reporting burden varied by area of clinical service. One RHB representative explained:Reporting and recording formats are frequently being changed. Sometimes we will be given a single sheet of reporting paper and logbooks, and we were told to duplicate them. This is costing us additional money.Routine reporting for TB and malaria services by the PHFs was relatively straightforward because they are disease-specific and do not require multiple registers or record keeping. Yet even PHFs providing TB services indicated that the availability of reporting forms and changes in the reporting format created issues. One PHF TB representative stated:Regarding the data quality, a deep assessment is required to identify the underlying causes, such as workload, negligence, or lack of knowledge. If I take our facility as an example, the workload is the reason for low data quality not knowledge. It is good to have regular internal monitoring to improve data quality and add more trained staff.The PHFs noted the most challenges in reporting MNCH and FP services, which require multiple registers and additional workload. In addition, poor data quality, although not unique to PHFs, was stated to be a limitation of reported data. A PHF provider of MNCH services noted:The most significant gap in private sector reporting to the national HMIS was the lack of disaggregation of indicators (except for TB services) by the public health facilities or the sub-regional offices to which the PHFs reported their numbers. The woreda or zonal levels merged the reports from the PHFs with those from the public sector making it impossible to analyze the private sector’s contribution in the HMIS dashboards or reports.Before the training on malaria [detection], we used to send patients with fevers for typhoid screening only, now patients are tested for malaria also as per the guideline.The MOH and RHBs developed a workforce within the PHFs that was trained on clinical, laboratory, and logistics, with financial and resource mobilization support by the PHSP. The benefits of the training were shared by a PHF providing malaria services:There was a gap in up-to-date knowledge on maternal health services between government and private facility staff before we received training on BEmONC. Previously, when staffs from the public facilities talked in different professional meetings, we [private facilities staff] used to get confused as our education was limited from the university training. We now have same knowledge.PHSP respondents reported that clinical and laboratory training, and specialized training, such as basic emergency obstetric and newborn care (BEmONC), which required in-service follow-up mentoring, were resource-intensive and logistically demanding. However, recipients expressed benefitting from the intense training:Training alone was not enough to deliver the quality services expected from the PHFs. Stakeholders mentioned that supportive supervision and onsite mentorship were efficient ways to improve training quality and motivation for adherence to treatment guidelines.There are government facilities that get training, but private facilities haven’t been involved. Private facilities are providing similar services as the government facilities, yet we are not getting refresher training. A recent example is the family member index training for HIV/AIDS, where we were not invited and didn’t get the training. This is something that has to be corrected.The HFA found that 73% of the 106 PHFs perceived that the training they had received was adequate; however, one-quarter of the respondents thought that the training or the refresher training needed further improvement. Despite the inclusion of PHFs in the RHB’s training system, some PHF owners shared that they were not included:The MOH put in place several enabling strategies that served as an impetus to PHFs for service provision, including training and mentoring of providers, improved diagnostic services, access to free or reasonably priced services, and free medications (and free follow-up services). Stakeholders perceived that these strategies contributed to increased demand and service use.We have developed a guideline for sample referral linkages across regions and national laboratories among private and public laboratories.One key policy strategy was to link the PHFs with laboratory services for HIV/AIDS, malaria, and TB with the national External Quality Assessment (EQA) program that ensures the quality of laboratory diagnostics. This not only improved the quality of laboratory services but also helped to build trust between the public and private sectors and improved the confidence of the public sector in the quality of services offered by PHFs. An EMLA representative stated:In addition to the EQA program, the government included the private sector in the national laboratory sample transportation system to bring samples  to a network of government-owned regional laboratories. The PHFs were connected to the government postal services to transport specimens to the regional laboratories for advanced laboratory testing. According to stakeholders, this referral linkage benefitted service delivery and demonstrated MOH and RHBs’ commitment to the integration of PHFs in the health system.The postal service does not access all the PHFs. Sometimes the specimen transport from some health facilities was done with public transport. There is a shortage of specimen transportation material, triple packaging materials, etc. at the postal services as well.Although the HFA results showed a high coverage of EQA in the past six months, both regional and health facility key informants expressed concerns that the already-stretched regional laboratories might be too overburdened to accommodate the PHFs. Moreover, there were inefficiencies in the transport of laboratory samples and referral linkages with regional laboratories. Stakeholders from the PHFs, PHSP, and Ethiopia Public Health Institute noted that specimen transport to the regional laboratories for further testing did not always work efficiently, and that the government postal system might have limited capacity to cover sample transportation from all PHFs due to time and resource constraints. An RHB representative said:Our community members when they are sick, they often go to the private health facilities. As they find PHFs as accessible and less time-consuming. By strengthening the private sectors, we are filling the gap in the public sectors, decreasing the load from public facilities, and supporting the health of the community.PHF stakeholders stated that the PHFs were able to treat additional patients due to the policies that enabled them to have a trained workforce, access to medicines, and overall support from the RHBs and the PHSP. Stakeholders said that the idea of a “one-stop shop” with a diversity of professionals in one place and less waiting time made seeking services from the private sector a preferred option for the community. Some RHB informants perceived that the increased provision of health services by the PHFs decreased the workload at public health facilities. An RHB representative stated:PHFs contribute about 15% of TB case detection in the National TB program, though only 700  PHFs are trained and engaged in TB program. Our lesson is to increase the enrolment of PHFs for TB case detection.The national TB program recognized the PHFs’ contributions in the identification of suspected TB cases and referrals at primary healthcare clinics to reach missed TB cases and it included PHFs in the national strategic plan. A representative from the TB directorate said:Table The MOH malaria prevention and control program was initially resistant to PHFs and delayed approval of the PPM malaria implementation guideline. However, it later expressed appreciation for the PHFs’ engagement. According to the HFA, almost all facilities surveyed 96%) reported screening patients with fever for malaria with blood film; 96% conducted internal quality control either always or sometimes; and 88% reported to the public health emergency management weekly. A high percentage (78%) mentioned experiencing stockouts of at least one malaria drug in the six months before the survey. Table % reporteWe have received training on malaria diagnostics. But, after the lab technician left, there is none […] it would have been better if more, at least two, lab technicians were trained.One of the major challenges according to the key informants was the high staff turnover at the PHFs which affected the availability of trained clinical staff. Trained staff often leave without the proper transfer of clinical knowledge to other staff likely disrupting the provision of services according to national guidelines and protocols across the PHFs. Some PHF owners mentioned that there was also inadequacy in the capacity of clinical staff who provided similar services as a result of the selected number of providers receiving training and mentoring. One of the PHF owners for malaria commented:Supervision previously helped us to get feedback and solution to our issues and helped improving services. Now, it has stopped and we don’t when we will get supportive supervision.Reduced frequency and irregular supportive supervision, mentoring, and supervision on data quality were challenges for quality services. A malaria PHF staff member stated:Another challenge for service delivery was the lack of enthusiasm on the part of private for-profit providers to continue providing certain services, such as TB treatment as they sometimes didn’t perceive any monetary or other incentives. Initial participation in implementing the PPM-TB guidelines by PHFA provided them opportunities for capacity building and capturing a higher number of patients at their facilities. Due to these services, the PHFs also incurred additional costs including uncompensated staff time which might have discouraged PHFs from retaining TB patients for long-term treatment.A variety of financing mechanisms support PPM and PPPH; many rely on external assistance. The PPPH Unit was established through donor support and is currently receiving technical assistance from CHAI. The PPMs were largely dependent on the PHSP bearing the major costs of key activities, such as training, refresher training, trainees’ per diem, and logistics. MOH policies enabled the PHFs to have free medicines and supplies, use government referral facilities for patient referrals, and benefit from the EQA program. The TB PPM is currently supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria.It is unclear how the support of PPMs will be financed in the future. In general, the banks in Ethiopia do not have the practice of lending to the health sector because of their lack of knowledge in the financial feasibility of the health sector industry, and the perception that lending to PHFs is riskier than lending to known borrowers with collateral. Using the USAID development credit authority (DCA) mechanism, the PHSP increased access to finance from banks by building the capacity of the private sector to prepare business plans, apply for loans, and manage post-loan monitoring.When support stopped, the quality of care is affected. We are providing services as per previous training, we are not getting the updated knowledge on HIV/AIDS treatment.The future roles and responsibilities of PPMs in the absence of clear financial support have been raised as a concern. Stakeholders acknowledged that the RHBs have limited human and financial resources to continue the work of managing, mentoring, and supervising the private sector without external support. It was stated that health planning at national and regional levels did not consider the financial support needed for stewardship of the private sector and, therefore, no resources were allocated to the government bodies to support service delivery at the PHFs. One example came from a PHF working in HIV/AIDS. The HIV/AIDS sector’s funding ended early due to the termination of funding from the United States President's Emergency Plan for AIDS Relief (PEPFAR):According to PHSP staff and PHF owners, meeting the infrastructure and human resource requirements of stringent health facility standards became difficult for several PHF owners. One of the barriers to achieving the health facility standards was the lack of financing to expand their infrastructure (premises and equipment) and to employ the required number of health professionals. As a result, some owners downgraded their health facility’s level to lower levels of care.In the past five years, the Ethiopian MOH has opened up to and embarked on a journey to create an enabling environment to foster PPPs . This stThe WHO has emphasized that accountability of both public and private actors is critical to advancing PPPH; however, accountability structures are context specific . Areas iLinkages between participants in the PPPH are either tenuous or fragmented, resulting in unclear institutional arrangements. The PPPH Unit, which sits in the Partnership and Collaboration Directorate, has no clear linkages with the different disease-specific directorates that are implementing the PPMs. Although there are legal mandates, frameworks, and a unit at the MOH level, the RHBs work autonomously, without any guiding frameworks or any dedicated units or personnel to oversee the activities of the PHFs. This gap threatens the sustainability of the partnership, especially because the RHBs are overburdened and understaffed.Trust is a central tenet of consensus building and partnership. The importance of trust between public and private actors, the value of consensus building, and the need to find common ground have been emphasized by health system actors engaged in PPPHs across diverse health system contexts –44.Our findings similarly emphasize the importance of mutual trust; however, there was evidence that trust was fragile. The assessment demonstrated that it takes time and evidence to change the negative perceptions of government agencies and staff at all levels about engaging with the private sector. Per its mission, the PHSP focused on continuous dialogue—and perhaps most importantly, through evidence of the private sector’s contributions—for identifying and treating diseases of public health importance. This shifted the government’s perception. The experience of working with the public sector and its systems, and with more transparency and improved regulations, also helped shift perceptions on the private sector side. Yet, mutual trust building between two unequal partners having reservations about each other, especially when government actors hold more power, needs further dedicated work . Any chaIncorporation of the private sector in government systems—such as the EQA program, laboratory specimen transportation and referral, medicine and commodity supply chains, and the HMIS—formed a platform for sustainable partnership. However, these systems need to function effectively and efficiently, otherwise the PHFs run the risk of interrupting their service delivery. The challenges reported by the private sector in this study have been similarly identified in the public sector concerning coverage of the EQA  and issuThe PHFs that were part of an MOU have indisputably extended their portfolios and are providing services , and to Recent recommendations about engaging private providers toward UHC have highlighted the costs associated with building public sector capacity and the possibility that governments face tradeoffs in allocating public funds to existing public infrastructure or to the incorporation of private providers in government-led systems . The impAlthough policies and strategies adopted by the MOH have created opportunities for wider partnerships, the assessment found that the implementation of private sector engagement remains limited in scope. There are more than 5,401 private, primary, and lower-level facilities in Ethiopia. They are a huge resource for improving access to essential health services ; howeverIn the TB sector, RHBs and the stakeholders expressed concern about the lack of contact tracing and follow-up of referral cases for TB patients, which was low even at government facilities . AlthougFor malaria, the government expressed concern about whether the PHFs were strictly following the protocol and current treatment plans . AlthougThese challenges highlight the need for additional research on the quality of care (QoC) of services provided through PPM and how it compares across service areas. Evidence about QoC in the public versus the private sector is lacking . PreviouThis study has several limitations. First, the sampling frame for the HFA was confined to PHFs supported by the PHSP and prioritized PHFs participating toward the end of the program period to ensure avoidance of recall problems by respondents. This limited the collection of experiences from facilities that had graduated from the Program and that had started receiving only government support. Second, the KII and HFA data collection was conducted over the phone due to the COVID-19 pandemic, which limited interactions and participation. As such, the qualitative and quantitative information sometimes lacked in-depth information. Additionally, since about half of the PHFs sent pictures of their current records, it was not feasible to verify some of the self-reported information, such as stockout data. The confirmability of some of the data was not possible and therefore a limitation. However, portions of the records data from the remaining PHFs was triangulated with the pictures sent. Additionally, data collected from some key informant interviews were supported and/or replicated by the data collected from other key informants of the same type . Given this level of credibility, the findings of this study are trustworthy.Finally, while not a limitation of the study itself, it should be noted that since the study design and data collection tools were developed to meet the specific objectives of assessing PHSP’s performance in leadership and governance, access to medicines, health management information systems, human resources, service provision, and finance, we urge caution in interpreting the findings as an overall assessment of PPPH in general.This study explored PPPHs and PPM from the perspectives of stakeholders within the scope of the PHSP in Ethiopia. Analyzed according to WHO health systems building blocks, the findings reveal the achievements and areas of gaps and challenges to sustainability of the partnership. The study identified progress in developing an enabling policy environment, engaging PHFs in service delivery through PPM, integrating PHFs in government systems, and building trust through evidence-informed advocacy. However, challenges remain in improving institutional arrangements for governance at the federal and regional levels, ensuring sustainability of the reforms in the context of an overburdened public sector, continuing to build trust across partners, and ensuring service delivery quality. The lessons offer implementation insights to other low-income country health systems considering how to strengthen stewardship and integration of PHFs in government-led health systems to expand access to essential health services.Future efforts should emphasize a mechanism that ensures that the private sector is capable, incentivized, and supervised to render continuous high-quality equitable services. Additional research can assess the quality of services provided by the private sector, equity, and economic analysis of PPPH reforms. Continued evidence is needed to assess the specific health system levers that can best use existing private sector capacity toward UHC objectives.


This study examined the impact of selected personality traits—innovativeness, internal locus of control, need for achievement and propensity to take risks—on the entrepreneurial intention of Saudi students (young entrepreneurs). The study sample included 165 students from an applied college affiliated with King Faisal University. The participants completed an online self-administered questionnaire, the data from which were analyzed using the partial least squares structural equation modeling (PLS-SEM) method. The findings revealed that the characteristics of innovativeness, internal locus of control and propensity to take risks had a positive relationship with entrepreneurial intention. However, the need for achievement had no relationship with entrepreneurial intention. The study model predicted approximately 25% of the total variance in entrepreneurial intention. It is recommended that in future studies, the sample size should be increased and the scope of the study should be broadened. Entrepreneurship and small and medium-sized enterprises (SMEs), since their inception, have been considered key drivers for economic growth and development, the creation of new job opportunities, the mitigation of poverty, and the resolution of socioeconomic problems . EntreprThe significance of entrepreneurship to economic growth and development has compelled governments in both developed and developing countries to design and implement the essential tools and support needed to stimulate entrepreneurial endeavors and encourage an entrepreneurial mindset in individuals. Various initiatives have been launched for this purpose and have largely been directed toward young individuals as they are the economic producers of the future . SupportAccording to In the case of Saudi Arabia, which is a developing country largely dependent on oil revenue, the steady decline in oil prices worldwide has led to a notable budget deficit and the consequent struggle to cover its expenses. Accordingly, the Saudi government developed a comprehensive plan, named “Saudi Vision 2030,” to introduce large-scale reforms to various economic sectors. Included in these reforms is heightened support for entrepreneurship and SMEs, some explicit aims of which are to increase the contribution of SMEs to the national GDP from 20 to 35%, reduce the unemployment rate from 12.9 to 7% by 2030, and encourage participation by young females in the labor market . AnotherAccording to Therefore, to further support the Saudi government’s efforts to erect institutional structures and cultivate entrepreneurship among citizens, young citizens in particular, to better facilitate the launching of small businesses, it is important to expand knowledge about the key personal traits that contribute to entrepreneurial intention, especially among younger adults . In the In the extant literature on entrepreneurship in Saudi Arabia, it is noted that, despite the variety of existing studies, few examinations have been conducted on the personal traits responsible for the development of entrepreneurial intention. Instead, most research has focused on entrepreneurial education, psychological capital, formal institutions and related aspects . ComparaAccordingly, and based on calls by previous studies to continue to explore the key personal traits responsible for the development of entrepreneurial intention among young adults, the present research investigated selected personal traits believed to influence entrepreneurial intention among students enrolled at an applied college affiliated with King Faisal University. It was considered important to address this population as they will be the drivers of the future economy of Saudi Arabia. Additionally, as students of applied colleges (which offer only diploma programs) are less likely than bachelor’s degree students from other colleges to find employment within the government sector, encouraging them to become entrepreneurs is a worthwhile pursuit. The following research question was formulated based on this underlying rationale:1.Do internal locus of control, need for achievement, innovativeness and propensity to take risks enhance entrepreneurial intention among Saudi students at an applied college affiliated with King Faisal University?This article is organized into the following sections. Following the introduction, the literature review and hypotheses are presented. Then, the methodology of the study and the analysis of the research results are described, after which these results and their implications are discussed. Lastly, some conclusions based on the study are provided.Entrepreneurial intention can be influenced by a variety of factors, such as institutional factors, or so-called ecosystem factors , or persInnovativeness is the quality of being or producing something novel, unique, remarkable or original . In the H1: Innovativeness positively influences entrepreneurial intention among Saudi students.Conceptually speaking, the origin of locus of control can be traced to personality theory . In pracFor example, H2: Internal locus of control positively influences entrepreneurial intention among Saudi students.H3: The need for achievement positively influences entrepreneurial intention among Saudi students.The propensity to take risks also acts as a significant determinant of entrepreneurial intention. This propensity can be described as the degree to which one determines that the benefits of an action outweigh the risks. The propensity to take risks is often based on subjective risk assessments and interpretations . It is astudents.H4: The propensity to take risk positively influences entrepreneurial intention among Saudi via the administration of an online questionnaire to students of the Abqaiq applied college, which is affiliated with King Faisal University in Saudi Arabia. The college offers two diploma programs: a human resource management (HRM) program and a medical secretary program. The study sample comprised 165 participants, both male and female. These students were targeted because their diploma programs can be completed in a short duration of time and also because the students are expected to be potential entrepreneurs. The researchers adopted measures employed in previous studies and carefully translated them into the Arabic language. A pilot study was first conducted with 15 respondents to assess the validity of the questionnaire. As no validity concerns were raised, the questionnaire was administered to the students  in the main study, remaining online for 1 month. The study sample was recruited In The items investigated in the study were measured using a 5-item scale, with 1 representing “total disagreement” and 5 representing “complete agreement.”To analyze and interpret the research data, two steps were required: evaluating the measurement model, and evaluating the structural model.In the measurement model, the reliability and convergent validity of the measures used in the study were examined carefully. First, the indicator loadings were evaluated. In this test, the loading value was recommended to be 0.70 or above. If so, then the measured construct could be determined to explain 50% of the variance in the indicator, thereby demonstrating acceptable reliability . HoweverThe second step in the evaluation of the measurement model included the assessment of the reliability of internal consistency using the composite reliability test. In this test, the higher the composite reliability values, the greater the reliability. A composite reliability value between 60 and 70 is considered acceptable . The thiThe fourth step in the evaluation of the measurement model involved the assessment of the discriminant validity of the study constructs. This step specifically showed the extent to which one construct was distinct from other constructs in the structural model . In thisThe Fornell–Larcker criterion, as shown in Once the measurement model had been evaluated, the next step was to assess the structural model. However, before the structural relationships could be examined, the issue of collinearity had to be addressed to ensure that no bias existed in the regression results. The variance inflation factor (VIF) was employed here to examine collinearity. If the VIF was greater than 5, this would indicate a collinearity issue in the study constructs . Table 52), which refers to the sum of the influence of exogenous latent variables on the endogenous latent variable, was used to demonstrate the explanatory power of the structural model.As 2 in 2 as variations in its result might depend on the discipline and context.As the result of the RThis section demonstrates the bootstrapping procedure, executed with 5,000 resamples, employed to test the hypotheses.p < 0.10). Likewise, internal locus of control also had a significant positive relationship with the entrepreneurial intention of the students  . Furthermore, the propensity to take risks had a positive relationship with the entrepreneurial intention of the students  as well . In contrast, the need for achievement had no relationship with the entrepreneurial intention of the students . Accordingly, H1, H2, and H4 were accepted, whereas H3 was rejected.This study investigated the influence of selected personality traits—namely, innovativeness, internal locus of control, need for achievement and propensity to take risks. The study generated interesting results. Concerning innovativeness, a significant positive association was found with the entrepreneurial intention of the students . Indeed, this finding is unsurprising given that more innovative individuals tend to be more open-minded and to think and act innovatively with respect to commercial activities and strategies . These iThe study further examined the influence of internal locus of control on entrepreneurial intention and reported a significant positive result. This is because individuals with high internal locus of control can more easily control and manage their lives and hence have a stronger entrepreneurial intention and become entrepreneurs faster . The resConversely, the need for achievement had no association with entrepreneurial intention. This may be attributable to the young age of the participants—i.e., they may have yet to fully understand the importance of achievement and success in life. This finding is in line with As previously recommended in the existing literature, there is a need to continue to investigate the importance of personal traits with regard to entrepreneurial intention among young adults. This study sought to ascertain the impact of specific personal characteristics on the entrepreneurial intentions of Saudi students . The study yielded intriguing findings that may be of benefit to a variety of stakeholders in Saudi Arabia. First and foremost, the study expands the existing literature by contributing empirical evidence on the relationship between personal traits and entrepreneurial intention.This research also paved the way for other researchers to continue investigating the same issue by including other personal traits in the analysis as well as moderating and mediating variables in potential conceptual models. The study may also draw the attention of the Saudi government and other official entities to the need to continue to develop necessary training programs and initiatives designed to enhance personal traits among potential young entrepreneurs, particularly those related to developing innovativeness, internal locus of control and propensity to take risks. There is also a need to develop a suitable entrepreneurial ecosystem with appropriate institutional infrastructures that will support Saudi society and culture and encourage entrepreneurial activities.The Saudi government should also implement public policy programs that encourage entrepreneurial activity by reducing the challenges and barriers faced by potential young entrepreneurs. Furthermore, educational institutions, such as universities and schools, should incorporate the development of personal traits into their curricula and seek to raise awareness about the importance of cultivating such traits for their future endeavors. These educational institutions could work to instill and sustain these personal characteristics in young people, directing them toward entrepreneurial activities and venture creation.Personal traits have been identified as key factors influencing entrepreneurial intention in numerous studies. Because of their significance, the present study investigated the ways in which selected personal characteristics—innovativeness, internal locus of control, need for achievement and propensity to take risks—influenced entrepreneurial intention among Saudi students at an applied college. The findings of the study supported all but one of the proposed hypotheses: the hypothesized relationship between the need for achievement and entrepreneurial intention. This study had some limitations, including its small sample size and the restricted context, making it difficult to generalize the findings. Furthermore, no moderation or mediation constructs were considered in the study. It is thus recommended that future studies broaden the scope of research and increase the sample size. The moderating effect of self-confidence on the relationship between other personal characteristics and entrepreneurial intention could also be investigated.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Both authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.