Public-Private Investment Partnerships For Health An Atlas .
Public-Private Investment Partnerships for HealthAn Atlas of InnovationThe Global Health GroupUniversity of California, San FranciscoAugust 2010
Copyright 2010 The Global Health GroupThe Global Health GroupGlobal Health SciencesUniversity of California, San Francisco50 Beale Street, Suite 1200San Francisco, CA 94105 USAEmail: ghg@globalhealth.ucsf.eduWebsite: globalhealthsciences.ucsf.edu/ghgOrdering InformationThis publication is available for electronic download atglobalhealthsciences.ucsf.edu/ghg.Recommended CitationThe Global Health Group. Public-Private InvestmentPartnerships for Health: An Atlas of Innovation. SanFrancisco: The Global Health Group, Global HealthSciences, University of California, San Francisco.Produced in the United States of AmericaAugust 2010This is an open-access document distributed under theterms of the Creative Commons Attribution-Noncommercial License, which permits any noncommercial use,distribution, and reproduction in any medium, providedthe original authors and source are credited.Hospital de Dénia cover photo courtesy of Hospital deDénia.
TABLE OF groundDe ning PPIPs910What PPIPs Are10What PPIPs Are Not10The Goals of PPIPs10Critical Success Factors11The PPIP Atlas12Structure12Methodology12Audience12Map of PPIPs Worldwide14Core Public-Private Investment Partnerships16Australia—Joondalup Hospital17Lesotho—National Referral Hospital21Portugal—Centro Hospitalar de Cascais26Portugal—Braga Hospital30Romania—Outpatient Dialysis Units33South Africa—Polokwane/Mankweng Hospital37Complex’s Renal Dialysis UnitSpain—Hospital de La Ribera41Spain—Hospital de Torrevieja46Spain—Hospital Dénia Marina Salud50Spain—Hospital de Manises53Spain—Hospital del Vinalopó56Turks and Caicos Islands—National Hospitals59Non-Core Public-Private Investment Partnerships63Examples from Low- and Middle-Income Countries64Brazil—Hospital Geral de Pedreira64Egypt—Alexandria Hospitals64
The Gambia—Riders for Health64India—Rajiv Gandhi Superspecialty Hospital64Mexico—Mexico State Hospitals65Examples from High-Income Countries65Canada—Abbotsford Regional Hospital and Cancer Center65Germany—Berlin-Buch Hospital65Conclusion67References68
ACKNOWLEDGMENTSWe are grateful for the input provided by all of the expert contributors to Public-Private Investment Partnerships for Health:An Atlas of Innovation. While the Atlas was written and reviewed by the Global Health Group, much of the informationand insights contained in the Atlas was provided by the following organizations and individuals:AustraliaOf ce of the Auditor General for Western AustraliaMenzies Centre for Health PolicyRamsay Health CareLesothoThe Government of LesothoInternational Finance CorporationNetcare GroupPortugalCaixaBI—Banco de InvestimentoGroupo EdiferGrupo José de MelloHPP SaúdeInfrastructure JournalInternational Finance CorporationMillennium bcp InvestimentoMinistério da SaúdeRomaniaEuropean Bank for Reconstruction and DevelopmentInternational Finance CorporationSouth AfricaNephroCarePPP Unit, National TreasurySpainAgencia Valenciana de SaludDepartamento de Salud TorreviejaGeneralitat ValencianaHospital de La RiberaHospital de TorreviejaMarina SaludMicrosoft CorporationSanitasVinalopó SaludThe Turks and Caicos IslandsThe Healthcare Redesign Group, Inc.InterHealth CanadaPricewaterhouseCoopers5 Public-Private Investment Partnerships for Health: An Atlas of Innovation
6 Public-Private Investment Partnerships for Health: An Atlas of Innovation
OVERVIEWPublic-Private Investment Partnerships (PPIPs) are an innovative approach for improving healthcareservices and infrastructure. PPIPs are a special form of public-private partnership (PPP) that comprise longterm, highly structured relationships between the public and private sectors designed to achieve signi cantand sustainable improvements to healthcare systems at national or sub-national levels. While the term “PPP”has become somewhat ubiquitous, representing a wide variety of arrangements ranging from impromptudonations to elaborate contractual relationships, the term “PPIP” seeks to set apart a category of healthrelated PPPs that is potentially transformational for poorly performing government-run health systems.PPIPs position a private entity, or consortium of private partners, in a long-term relationship with a government to co- nance, design, build and operate public healthcare facilities, and to deliver both clinicaland non-clinical services at those facilities over a decade or more. PPIPs enable governments to prudentlyleverage private sector expertise and investment to serve public policy goals—speci cally the provisionof high-quality and affordable preventive and curative care to all citizens. PPIPs guarantee governmentownership of assets throughout the life of the partnership and aim to be “cost neutral” to patients, whoincur the same out-of-pocket payments, usually zero or minimal, as they did in the previous dilapidatedand poorly run public facilities.This Atlas provides an overview of the most innovative PPIPs worldwide, all of which were established tosystematically address healthcare challenges in a particular setting. It includes the key characteristics andgoals that de ne a PPIP and features detailed overviews of 12 PPIPs that epitomize this de nition. TheAtlas also contains seven PPIPs that meet some but not all of the de nitional criteria, dubbed the “noncore” list. This Atlas is a working document that serves as a snapshot of the PPIP landscape at one point intime. The information included was collected in late 2009 and early 2010. The information will thereforerequire routine amendments as governments continue to establish pioneering public-private initiatives andas more information becomes available about existing public-private projects.7 Public-Private Investment Partnerships for Health: An Atlas of Innovation
8 Public-Private Investment Partnerships for Health: An Atlas of Innovation
INTRODUCTIONBackgroundGovernment-run health systems across the developingworld are in disrepair, with poor quality services provided in dilapidated facilities. For example, a typical districthospital is rundown, lacking reliable water, sanitation orelectricity, with absent or broken equipment, inadequatesupply chains for essential commodities, chronic staffshortages, low service quality, overcrowding and poorclinical outcomes. Such secondary hospitals, and the restof the health system of which they form a part, suffer frompoor management and a lack of sustainable and suf cient nancing.Similarly, but less starkly, government-owned and -runhealthcare systems in rich countries frequently face challenges of insuf cient capital investment, low ef ciency,poor patient satisfaction and disappointing clinical outcomes. In both wealthy and poor countries, the skills required to deliver high quality health services ef ciently doexist, but are often concentrated in the private sector andunderutilized by governments. Historically, some governments have been wary of working with the private sectorin healthcare, partly because of general distrust betweenthe private and public sectors, and partly because of an inherited aspiration to create a public monopoly healthcaresystem, resembling the United Kingdom’s National HealthService as originally conceived and established.Through time, a recognition of the challenges faced by public health services and the positive experience of PPPs inother sectors, have caused an increasing number of governments to look to the private sector for long-term partnerships to improve healthcare infrastructure and the deliveryof healthcare services. In so doing, governments are recognizing the nancial, managerial and technical competencies that the private sector can bring and are seeking to harness the strengths of the private sector in the achievementof long-term public policy goals. Many varieties of PPPs inthe health sector have arisen as a result of this trend. Thisdocument deals with one particular model: PPIPs.PPIPs are a novel way for resource-constrained governments in both rich and poor countries to use the strengthsof the private sector to simultaneously improve healthinfrastructure and healthcare service provision, whilecreating a platform for addressing other systemwide inef ciencies. The PPIP model transfers substantial nancialand operational risk to a private entity which is contractually obliged to deliver a “complete bundle” of services,spanning construction, maintenance, clinical care, prevention and supplementary services such as pathology,procurement and even training.The rst-ever conference on PPIPs was organized at WiltonPark in April 2008 by the Global Health Group (GHG) atthe University of California, San Francisco and The Healthcare Redesign Group. The report of this conference canbe found at 0903/22291315/wp909-report. At this conference, participants requested the GHG to provide a comprehensive compendium or atlas of existing PPIPs andPPIPs under development. This rst-ever PPIP Atlas is theresult. In the main section of the report, we describe 12PPIPs in seven countries, using a standardized formatto document these programs. In the “Non-Core PublicPrivate Investment Partnerships” section, we document afurther seven programs in seven countries which are PPIPlike, as they do not meet all of the criteria for the most ambitious and fully-bundled PPIPs. We hope and intend thatthis comprehensive documentation will be a resource andstimulus to leaders in both the public and private sectorsworking to improve the quality, ef ciency and availabilityof healthcare services.The GHG is an “action tank” dedicated to identifying, elaborating and translating innovative solutions to major globalhealth challenges into large-scale action to advance healthand save lives in low- and middle-income countries. Aspart of its work on engaging the private sector to strengthen health systems, the GHG serves as a clearinghouse forinformation on PPIPs worldwide. The GHG studies PPIPsto identify promising practices that might inform governments embarking on PPIPs, and shares lessons learnedthrough print and web-based publications and structuredSouth-South learning exchanges. For more information onthe GHG and its PPIP activities, please visit: http://globalhealthsciences.ucsf.edu/GHG.9 Public-Private Investment Partnerships for Health: An Atlas of Innovation
De ning PPIPs—What PPIPs ArePPIPs possess the following four key attributes:A Design, Build, Operate and Deliver (DBOD) ModelThe private partner or consortium designs, co- nances,builds, operates and delivers clinical care in one or morehealth facilities, often including a tertiary hospital and surrounding primary and secondary facilities. This model iscommonly called a “DBOD.” Unlike other PPPs, PPIPs gobeyond private investment in buildings and maintenance;the private partners are also responsible for delivering allclinical services at the facilities, from surgery to immunization to ambulances.Government Ownership of AssetsThe healthcare facilities are owned by the government during all phases of the contract. Because PPIPs are carefullydesigned vehicles for achieving public healthcare policygoals, they do not relinquish control or ownership of assetsto the private sector.Long-Term, Shared InvestmentA PPIP comprises a long-term commitment by both thegovernment and the private partners to provide healthservices for a de ned population. Both partners investsigni cant resources into the project, ensuring long-termdedication and a common interest in successful outcomes.A successful PPIP must exist for a decade or more to giveboth partners suf cient time to develop sustainable systemwide processes and infrastructure, and allow for moreinformed strategic planning, and improved feedback loops.Risk TransferUnder the DBOD model, the private partners, not thegovernment, are responsible for meeting stringent servicequality benchmarks. In addition, the private partners assume risk for delays and cost overruns in the construction phase, and for human resource issues and failure toachieve ef ciency in service delivery.What PPIPs Are NotIt is important to differentiate PPIPs from other models ofPPPs that do not attempt to be as comprehensive or aswell integrated into the wider health system. Following areexamples of models that fall short of the PPIP de nition:Private Finance Initiatives (PFIs)PFIs are limited to construction and/or non-clinical maintenance of facilities. In PPIPs, however, the private sector’sresponsibility goes beyond the delivery of a xed asset toinclude clinical service provision that must achieve acceptable quality levels over long periods.PrivatizationUnlike the private ownership in the privatization model,ownership of all the facilities within a PPIP remains withthe government.Contracting OutAs co-investors with an equity stake in the success of thePPIP, the private partners are not merely contractors providing outsourced services.Co-locationThis model exists when public and private enterprises sharea physical space, but maintain separate management. Forexample, a private clinic may have a wing within or adjacent to a public hospital. Several critical components ofPPIPs are left out of this model, including shared investment and risk transfer.ConcessionIn a concession arrangement a private company managesthe operations of a public facility, but with curtailed powers. A concession contract is generally limited such thatthe private manager inherits signi cant responsibility butpossesses little authority. For example, the private enterprise may manage the workforce, but may not possess hiring and ring privileges. PPIPs necessitate that the privatepartner have signi cant authority to ensure accountability.The Goals of PPIPsBeyond the overall structure of PPIPs, what sets them apartfrom other PPPs is the core set of goals they aim to achieve.PPIPs necessitate that both the public and private partnerscarefully agree on desired outcomes and construct metricssystems for independent authorities to routinely monitorusing the following goals.Quality of CareThe primary purpose of PPIPs is to serve the government’s public policy goals, both for better access and forimproved quality of care for all, including the poorest andthe most marginalized.Cost NeutralityBy design, patients utilizing a new PPIP healthcare facilityexperience no change in out-of-pocket payments at thepoint of care. In some cases, the PPIP may also be costneutral to the government, ensuring its annual expenditure for the new PPIP facilities and services is equal tohistorical expenditures. These instances can be referred toas “cost neutrality squared,” or “(cost neutrality).2”10 Public-Private Investment Partnerships for Health: An Atlas of Innovation
Equity of AccessNew PPIP facilities are open to all, regardless of a patient’sincome level or social status. Equity of access is especiallycritical for poor or disenfranchised populations which maynot have had access to quality healthcare services prior tothe PPIP.Predictable Government Health ExpendituresFixed payments and capped overall project costs add predictability that may otherwise be absent from governmenthealthcare budgeting. Inclusion of facilities maintenance,equipment replacement, staf ng and technology forecasting in program contracts promotes stability in nationalhealth expenditures.Systemwide Ef ciency GainsNew PPIP facilities are designed to operate within, andimprove, existing systems. Due to the use of stringent performance indicators and performance monitoring schemes,PPIPs strive to set high and transparent standards for service delivery and outcomes, thus raising the bar for theentire national healthcare system.Critical Success FactorsResearch indicates that the four following characteristicsshould be present to ensure the success of a PPIP.Political Will and CapacityIn all PPIPs, the government takes on the role of businesspartner, contract manager and informed purchaser, whileremaining responsible for leadership, regulation and moni-toring. Governments must have or commit to acquiringthese skills and must also ensure the support of the community. PPIPs necessitate a level of involvement by the publicsector that is well beyond that of PFIs or contracting out.Commitment from the Private SectorThough a pro t incentive exists for the private sector,commitment to serving its clients, both government andpatients, must be of foremost importance, and PPIPs takemeasures—including elaborate performance-based contracts—to ensure that this remains the case.Ensuring Trust Between SectorsLong-standing ideologies that reinforce distrust often hinder collaborations between the public and private sectors.PPIPs can draw on mechanisms to overcome challenges toeffective collaboration including: an open tender process,third-party facilitators, continuous open dialogue and increased transparency by all parties.Independent Monitoring and EvaluationAn independent private or public agency, responsible tothe government but commanding the respect and trust ofboth public and private partners, must be established tocollect and validate performance data, ensure all contractual obligations are met and administer or arbitrate nancial rewards and penalties. This agency can also play animportant role in maintaining public con dence in the newPPIP arrangements and in ensuring appropriate learningand course corrections as the partnership evolves.11 Public-Private Investment Partnerships for Health: An Atlas of Innovation
The PPIP AtlasStructureThis Atlas provides a high-level overview of the most innovative PPIPs worldwide, using the aforementioned de nition and goals as a template for each entry. Given therapidly growing and changing nature of PPPs, and PPIPsin particular, both the details of the PPIPs listed, and thenumber and categorization of them will likely change.Each PPIP model included in the body of the Atlas hasbeen analyzed based on the political landscape enablingthe PPIP, contract speci cs related to the partnership, important features and modalities of the PPIP, key outcomesto date and critical factors contributing to the success orfailure of the PPIP. To be included in this Atlas, PPIPs mustfollow the de nition of a PPIP on page 10 and must bedesigned to achieve the goals on page 10. Some examples,however, follow the de nition more stringently and placethe goals at the forefront of the model.In addition to the core PPIP examples, there are numerouspioneering PPIP-type arrangements in low-, middle- andhigh-income countries that do not t the de nition provided, but are often referred to during discussions on PPIPs.Though they might not exemplify the most comprehensivePPIP structure, these PPIPs leverage the private sector toful ll a government’s public health and public policy objectives in bold and novel ways. The “Non-Core PublicPrivate Investment Partnerships” section lists seven suchpartnerships and contracts awarded to private actors bypublic entities. In some cases the PPIPs include a speci cclinical support service and no infrastructure component;in other cases, the private partners provide the capital investment for a project and manage the government healthfacilities in unique ways, but do not assume responsibilityfor all clinical service provision.The PPIP models included in the Atlas have been takenfrom low-, middle- and high-income countries. Low-income countries expressed signi cant interest in learningfrom the successes and failures of other countries. The reasons to implement PPIPs, the key themes in their designand their major challenges are largely shared between richand poor countries.MethodologyThe GHG conducted grey and peer-reviewed literature reviews and performed qualitative interviews to inform thedevelopment of this Atlas. The resear
An Atlas of Innovation. While the Atlas was written and reviewed by the Global Health Group, much of the information and insights contained in the Atlas was provided by the following organizations and individuals:
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