Introduction

As populations age worldwide, the number of older adults living with chronic illness continues to rise [1]. Research indicates that later-born generations of older adults, such as those who are 65 and older today, are more likely to have multiple chronic conditions compared to their predecessors, which exacerbates the strain on healthcare systems and insurance frameworks. [2]. This demographic shift brings into sharp focus the need for healthcare systems capable of addressing complex, long-term health needs. In many countries, privatized health services have become a significant component of the healthcare landscape, impacting how older adults receive care [3]. Privatized healthcare refers to healthcare services provided by non-governmental entities, often funded through private insurance or out-of-pocket payments [4]. This system contrasts with public healthcare, which is funded and managed by government agencies [5].

Public healthcare systems, such as those in the United Kingdom and Canada aim to ensure universal coverage for all citizens [6]. In contrast, private healthcare systems, like those in the United States, rely heavily on private insurance and out-of-pocket payments, with limited government intervention [6,7]. However, many countries, such as Australia, adopt hybrid models that combine elements of both public and private systems to provide a comprehensive range of services [8,9]. Even in predominantly public healthcare systems, such as Canada, there are often private costs associated with healthcare [10]. For instance, while the Canadian public system covers essential medical services, patients may still incur out-of-pocket expenses for prescription medications, dental care, vision care, and other non-covered services [10,11]. Additionally, some Canadians choose to purchase private health insurance to cover these additional costs and to gain access to private healthcare providers for faster or more specialized services [12]. Many employers also include health insurance as part of compensation packages [13]. This blend of public funding and private expenditure highlights the complexity of healthcare financing, even in systems designed to provide universal coverage.

To address the growing pressures within public healthcare systems, there has been a noticeable shift towards privatization and hybrid models [14–18]. For example, online medical clinics, subscription-based models for rapid doctor access, private specialist and screening clinics (such as those for MRIs and X-rays) represent a trend towards expanding private sector involvement in healthcare delivery in counties with public health care [19–21]. These privatization measures are often proposed as solutions to systemic issues like physician shortages and prolonged wait times [16]. However, this shift introduces a complex dynamic that significantly impacts older adults, a population that may experience unique challenges as public systems evolve. The implications of these privatization trends on aging populations need to be carefully examined, as older adults often face distinct healthcare needs and may be disproportionately affected by changes in healthcare accessibility and quality [22,23]. Understanding these impacts is crucial to ensuring that reforms support the needs of all patients, particularly those with chronic conditions, as such diseases often require ongoing, comprehensive care that can be significantly affected by shifts in healthcare delivery models [24].

The rise of privatized healthcare is driven by factors such as increasing healthcare costs [25] and the desire for more efficient and specialized services [25,26]. Studies have found that individuals with private insurance may experience less access to care, higher costs, and decreased satisfaction compared to those with public insurance [27]. Moreover, some research indicates that private sector healthcare systems may have greater risks of low-quality care, particularly in less regulated environments [4]. This includes issues such as unnecessary testing and treatment, and higher risks of complications [4]. Yet, in countries like Canada, debates around privatization highlight the potential benefits of reducing surgical wait times and alleviating pressure on public systems, although concerns about increased inequality and resource diversion persist [16,21]. On the contrary, other scholars suggest that private healthcare systems may struggle to provide the comprehensive, coordinated care that many older adults require, especially those with multiple chronic conditions [28].

Overall, research on the experiences of older adults in privatized healthcare systems reveals a mixed picture. One USA study found that older adults living with multiple chronic conditions who lacked private insurance were more likely to experience depressive symptoms [29]. On the other hand, private insurance and Medicare helped mitigate the risk of cognitive impairment, particularly among non-Hispanic Whites with multiple chronic conditions and among Blacks regardless of the number of chronic conditions [29]. These findings suggest that private insurance can play a crucial role in reducing mental health disparities among individuals coping with multiple chronic conditions [29]. Furthermore, in a 2017 study of 1,593 older adults living in an urban center in Brazil, access to a private health plan was associated with an increase in hospitalization rates, independent of multimorbidity. These findings suggests that private healthcare may be associated with health service use, although further investigation would be required to clarify the details of this potential relationship [6,30,31].

Given the complexities and varied experiences associated with privatized healthcare, there is a critical need to synthesize the state of knowledge on this topic. This scoping review is timely as it seeks to compare the healthcare experiences of older adults living with chronic illness across geographical settings, to identify and explore potential solutions to diverse health system challenges. To the best of our knowledge, this is the first scoping review to explore the perspectives of older adults living with chronic illness on privatized healthcare, in all countries with a public or hybrid system. While previous studies in the field have explored the experiences of older adults using public or private services in designated countries, more research is needed to examine findings across landscapes and identify central themes and considerations. Therefore, the goal of this scoping review is to provide a comprehensive, narrative analysis of published literature in the field, with the intention of informing future research and healthcare decision-making. This scoping review focuses on individuals aged 60 and above, a demographic increasingly impacted by early-onset chronic conditions and healthcare challenges [32], particularly in privatized or hybrid healthcare systems. The Arskey and O’Malley guidelines will provide a structured approach to defining the research question, identifying relevant literature, and determining the scope of the review [33].

Methods

Scoping reviews aim to comprehensively map and synthesize evidence on a broad topic area, often encompassing diverse study designs and methodologies. Unlike systematic reviews, which prioritize the critical appraisal of individual study quality to assess the reliability and validity of findings, scoping reviews focus on identifying the breadth and depth of existing literature [33].

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) checklist [34] was used to develop the protocol (S1 File)

Our research will follow the Arskey and O’Malley guidelines [33] and will be further informed by the Joanna Briggs Institute (JBI) framework for scoping reviews [35]. These guidelines emphasize a systematic method for scoping reviews, focusing on the breadth of evidence and mapping out key concepts. In parallel, the JBI framework will offer detailed guidance on the methodological processes, including the development of inclusion and exclusion criteria, data extraction, and synthesis of findings [35]. By merging these frameworks, our research will benefit from a robust methodological structure that combines the broad scope and mapping approach of the Arskey and O’Malley guidelines with the JBI framework’s emphasis on systematic assessment and practical application. Findings will be reported in line with the PRISMA extension for Scoping Reviews (PRISMA-ScR) [36]. We will incorporate de-identified interview material in our Results section to supplement central themes extracted from included studies. Our stepwise approach, in accordance with the scoping review framework, is outlined below.

Step 3: Selecting studies

Please refer to Table 1 for a comprehensive summary of inclusion and exclusion criteria.

Download:

• PNG
  larger image
• TIFF
  original image

Table 1. Inclusion and exclusion criteria.

https://doi.org/10.1371/journal.pone.0317184.t001

We will use EndNote (x21) to identify and remove duplicate studies extracted from the database searches. Studies will then be imported into Covidence software to complete two-step study screening. First, title-abstract (level 1) screening, followed by full-text (level 2) screening, will be conducted independently by two members of the research team. Discrepancies will be resolved with consultation from a third member of the research team (CS or LS). If agreement cannot be reached, a team meeting will be organized to resolve the remaining study screening conflicts. A team meeting will be conducted between level 1 and level 2 screening to clarify inclusion and exclusion criteria and address outstanding questions.

Knowledge translation

Our scoping review will employ an integrated knowledge translation (IKT) approach [43], which emphasizes collaboration with key stakeholders throughout the research process. This method enhances the relevance, usability, and applicability of our findings [43]. Specifically, the project team collaborated with knowledge user partners to input shaped the study’s objectives, the inclusion criteria, and the data extraction framework. The knowledge user partners consisted of two think-tanks within academic centers within Ontario, Canada and involved representatives from one public health organization within Canada.

The IKT approach facilitates the co-creation of knowledge by integrating diverse perspectives, ensuring that the review’s outcomes address practical needs [44]. This collaboration will continue during the dissemination phase, where knowledge users will be involved in interpreting findings and identifying strategies to implement them. Such an approach is particularly critical as countries like Canada increasingly incorporate private healthcare elements within publicly funded systems. This focus aligns with our goal of providing actionable insights that improve health outcomes for older adults and inform broader health system reforms.

Discussion

The prevalence of chronic illnesses among older adults is a growing concern worldwide, particularly in the context of aging populations and the consequent strain on healthcare systems. This scoping review protocol aims to outline the methodology of a forthcoming review that will explore the role, challenges, and limitations of privatized healthcare models in addressing the needs of older adults living with chronic conditions in countries with public or hybrid healthcare systems [24]. By synthesizing the available literature, this review seeks to provide a comprehensive understanding of how privatized healthcare impacts this vulnerable population.

The importance of this review lies in its potential to shed light on the varied experiences of older adults within different healthcare models. The inclusion of countries with public or hybrid systems allows for a comparative analysis, highlighting how privatized elements within these frameworks can influence experiences for older adults. This is particularly relevant as many countries grapple with balancing public and private healthcare provisions to meet increasing healthcare demands. The review will also explore the specific challenges faced by older adults, such as access to care, affordability, quality of care, and the availability of chronic disease services [24]. Lastly, this review will support the consideration of the social determinants of health, such as socio-economic status, which may influence the experiences and outcomes of older adults within privatized healthcare systems. Understanding these factors is essential for developing equitable healthcare policies that do not disproportionately disadvantage certain groups.

The findings of this scoping review will provide critical insights into how privatized healthcare models operate within public or hybrid systems, specifically their ability to address the unique and complex health needs of older adults living with chronic conditions. In countries like Canada, where shifts toward privatized elements are occurring, these insights can guide evidence-informed policymaking by identifying where privatized models may enhance care delivery and where they risk exacerbating inequities. For instance, the review may highlight whether privatized models improve access to timely, specialized care for older adults or create barriers due to cost or fragmentation of services. These findings can also inform targeted strategies for integrating privatized healthcare components to complement public systems effectively, ensuring that care remains accessible, affordable, and equitable for vulnerable populations.

Conclusion

This scoping review protocol outlines a comprehensive approach to examining the experiences and perspectives of older adults living with chronic illness in privatized healthcare settings within countries that predominantly have public or hybrid healthcare systems. By systematically mapping the existing literature, we aim to identify the potential impact of privatized healthcare models in addressing the complex health needs of this population. The findings will provide valuable insights into the current state of knowledge, highlight gaps, and inform future research directions and policy decisions. Our iKT approach, involving collaboration with various stakeholders, ensures that the review will produce relevant and practical knowledge, contributing to a more equitable and effective healthcare landscape for older adults. We anticipate that the results of this review will guide healthcare practitioners, policymakers, and researchers in improving care delivery and addressing disparities in access to and quality of healthcare services.

Supporting information