Trust in Healthcare Public-Private Partnerships in Delhi NCR: A Systematic Review of Stakeholder Perceptions and Governance Challenges

Abstract

Background: Trust is central to the success of healthcare public-private partnerships (PPPs) yet remains poorly understood in the Indian context. This review examines trust dynamics in PPPs within Delhi NCR, a region marked by complex governance and significant PPP activity. Objectives: To identify key trust factors and its dynamics discussed in the literature on healthcare PPPs across Delhi NCR; and to provide recommendations for building and sustaining trust in future healthcare PPPs. Methods: A systematic review was conducted following PRISMA 2020 guidelines. Searches were performed in PubMed, Scopus, Elsevier, institutional library repositories, and Google Scholar encompassing studies published between January 2000 – May 2025. Inclusion criteria targeted empirical studies, policy papers, and case reports on trust in Indian healthcare, particularly Delhi-NCR context. Data were thematically synthesised using Braun and Clarke’s Thematic Analysis method and analysed through McKnight’s and Institutional Trust frameworks. Case study analysis was conducted using Porter’s Value Chain. Results: Forty studies met inclusion criteria. Five interrelated trust factors were identified: transparency, accountability, stakeholder engagement, regulation, and payment. Transparency and accountability showed strong positive correlation (r = 0.72). A Delhi-based dialysis PPP case study validated thematic findings, highlighting systemic trust breakdowns. Limitations: This review's findings are limited by being sector specific, as trust dynamics in healthcare PPPs may not translate directly to other sectors. Geographic bias is evident, with limited representation of regions beyond Delhi NCR, reducing national applicability. Additionally, the cross-sectional nature of most studies restricts insight into how trust evolves over time. Conclusion: This review examined what builds and breaks trust in healthcare PPPs, with a focus on Delhi-NCR. Five interconnected trust factors: transparency, accountability, stakeholder engagement, regulation, and payment were consistently identified. Transparency emerged as the most foundational, enabling or disabling other trust mechanisms. Theoretical frameworks helped explain paradoxes, such as low trust in high-influence stakeholders. Ultimately, trust must be intentionally embedded into PPP design through inclusive, transparent, and accountable governance.