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Public–Private Partnerships in the Health Care Sector: A Systematic Review of

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DOI: 10.1080/14719037.2013.792380

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Public–Private Partnerships
in the Health Care Sector:
A systematic review of the
literature
a b
Mariateresa Torchia , Andrea Calabrò & Michèle
c a
Morner
a
Reinhard-Mohn-Institute for Management and
Corporate Governance , Witten/Herdecke University ,
Witten , Germany
b
Witten Institute for Family Business , Witten/
Herdecke University , Witten , Germany
c
Chair of Public Management and Leadership , German
University of Administrative Sciences , Speyer/
Germany
Published online: 16 May 2013.

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Public–Private Partnerships in the Health Care Sector: A systematic review of the
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 Public Management Review, 2013
http://dx.doi.org/10.1080/14719037.2013.792380

Abstract
PUBLIC–PRIVATE
Public–private partnerships (PPPs) have
become popular worldwide as a way of
PARTNERSHIPS IN
improving health care service delivery. In
order to enhance our knowledge of PPPs in THE HEALTH CARE
the health care sector, we conduct a sys-
tematic review of forty-six articles published SECTOR
in peer-reviewed journals for the period of
1990–2011. Six lines of research in the PPP A systematic review of the
domain are identified: effectiveness, benefits,
literature
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public interest, country overview, efficiency

and partners. The main findings suggest that
although PPPs are used to address interna- Mariateresa Torchia, Andrea Calabrò
tionally emerging public health issues,
questions as to their actual effectiveness, and Michèle Morner
efficiency and convenience, still remain Mariateresa Torchia
unanswered. We propose viable recommen- Reinhard-Mohn-Institute for Management and
dations and ideas for future research. Corporate Governance
Witten/Herdecke University
Witten
Germany
E-mail: mariateresa.torchia@uni-wh.de
Key words
Public–private partnership, health care, Andrea Calabrò
systematic literature review Witten Institute for Family Business
Witten/Herdecke University
Witten
Germany
E-mail: andrea.calabro@uni-wh.de
Michèle Morner
Chair of Public Management and Leadership
German University of Administrative Sciences
Speyer/Germany
Reinhard-Mohn-Institute for Management and
Corporate Governance
Witten/Herdecke University
Witten
Germany
E-mail: michele.morner@uni-wh.de

© 2013 Taylor & Francis

 2 Public Management Review

INTRODUCTION

The delivery of public services can be located conceptually along a continuum that
ranges from direct government provision to full privatization. By the 1980s, growing
financial pressure on public accounts had prompted major reforms of the public sector.
These reforms consisted of a progressive disengagement of the state from various
sectors of activity, so that since then, governments that previously both produced
and provided services now tend to increasingly rely on the market either for inputs to
government production and provision, or for direct provision of services (OECD,
2008). Public–private partnerships (hereafter PPPs) are part of this trend.
PPPs are not a new concept, but there remains to this day no one single agreed-upon
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definition of PPP (Hodge and Greve et al., 2007). PPP has come to be used as an
umbrella term describing collaborative relationships between public and private actors
for the achievement of common goals (Singh and Prakash et al., 2010). Koppenjan
(2005) defines a PPP as a form of structured cooperation between public and private partners in
the planning/construction and/or exploitation of infrastructural facilities in which they share or
reallocate risks, costs, benefits, resources and responsibilities. This definition is reverberated in
that of Grimsey and Lewis (2007): PPPs can be defined as arrangements whereby private
parties participate in, or provide support for, the provision of infrastructure, and a PPP project
results in a contract for a private entity to deliver public infrastructure-based services.
Based on the various definitions in the literature, the significant characteristics of PPPs
include cooperation; durable relationships; development of mutual products/services; shar-
ing of risks, costs, and benefits; and mutual value addition (Klijn and Teisman, 2003).
Furthermore, compared to more traditional forms of collaboration, PPPs have three distinct
features, as suggested by Zhang and colleagues (2009). First, the partners in a PPP do not
share a common ownership structure: one side is a publicly owned organization, such as the
government, while the other is a privately owned organization, such as a business
enterprise. They therefore tend to pursue different operating and strategic goals. Second,
while traditional collaborations typically involve private goods as output, PPPs’ outcomes
are always public or quasi-public goods and services for the benefit of a third party. This
third party may be society at large, but is usually not a direct client of either partner. Third,
PPPs usually remain in effect between specific partners for long periods of time. Because
they are regarded as effective and cost efficient, PPPs have become a key mechanism for
implementing public and social policy (Osborne et al., 2000).
In recent years the use of PPPs has become increasingly popular, including in the
health care sector. Governments around the world are looking for ways of coping with
simultaneously increasing health care costs and decreasing governmental budgets
(Blanken and Dewulf et al., 2010). The problems in contemporary health care are,
to use Mason and Mitroff’s (1981) term, wicked problems that are too complicated for
governments to solve individually. Both the public and the private sector recognize
their individual inabilities to address the emerging public health issues that continue to
 Torchia et al.: PPPs in the health care sector 3

be tabled on the international and within-country policy agendas (Nishtar, 2004).

Traditional public health groups are confronted by limited financial resources, complex
social and behavioural problems, rapid disease transmission across national boundaries,
and reduced state capabilities (Reich, 2000). At the same time, private for-profit
organizations have come to recognize the importance of public health goals for their
immediate and long-term objectives, and to accept a broader view of social responsi-
bility as part of the corporate mandate (Reich, 2002). Thus, many governments deal
with such problems now by establishing PPPs between health care providers (public
sector), building and management companies, and financers (private sector). PPPs in
the health care sector therefore seem to be both unavoidable and imperative.
The diffusion of the use of PPP in health care systems around the globe has resulted
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in the identification of an increasing number of problems related to the implementation

of PPP projects. As a result, in recent years there has been a proliferation of academic
articles focusing on the characteristics and implementation issues related to PPP
projects in the health care sector. To our knowledge, despite the increasing number
of research articles on the topic, there is still a lack of systematization of the most
relevant literature. We therefore believe that a systematic review of the literature on
PPP in health care sector would be useful when it comes to identifying current research
trends. This study addresses the following questions:

– Which topics have been covered in the PPPs for health care literature between
1990 and 2011?
– Which are the main contributions to the debate on PPPs in health care between
1990 and 2011?
– Which existing gaps still need to be addressed?

A sample of published journal articles has been identified using an adapted version of David
and Han’s (2004) and Newbert’s (2007) methodology. This sample is essentially a
representative sample of forty-six published journal articles focusing on PPPs in the health
care sector. The main results show that, although PPPs have become a common approach
to health care problems worldwide, there is no general agreement on their main benefits. In
particular, doubts remain concerning their actual effectiveness, efficiency and convenience in
the health care sector. This study contributes to this debate in several ways. The assessment
of the relevant literature on PPPs in the health care sector helps to define the state of the art
and to suggest future research directions in the field. Moreover, the study provides an
overview of the most important literature on the topic, showing how the debate has
evolved over the past decades (from 1990 to 2011) and how different issues and problems
related to PPP implementation and effectiveness arise in different national contexts. Key
findings derived from the systematic literature review on the topic are presented, and
recommendations offered for both the public and the private sectors as regards future PPP
projects for healthcare development.
 4 Public Management Review

The rest of the article is organized as follows: the debate on PPPs and the health care
sector is presented in the following section, followed by a description of the main types
of PPPs. The systematic literature review process is described in the third section. The
results and the descriptive statistics are presented in the fourth section. Discussion and
findings follow in the fifth section. Concluding remarks and future research directions
are presented in the last section.

Background of PPPs in health care

PPPs have become a common approach to health care problems worldwide, and
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recently there has been enthusiasm for using PPPs to improve the delivery of health
and welfare services for a wider range of health problems (Barr, 2007).
Following the introduction of reforms packages in the latter part of the 1990s, there was
a gradual shift to a modernization narrative that emphasized the values of social cohesion
(Newman, 2004) through network building, holistic governance, and partnerships. The
impact was visible at various levels. At the global level, institutions such as the World
Health Organization (WHO), which has played a significant role in formulating health
policies and prescribing standards of health care, welcomed and encouraged partnerships
between the state and the market in financing, provisioning, and researching health care
(Baru and Nundy, 2008). Furthermore, with growing financial pressures on service
providers, public and private community leaders were looking more and more at these
types of partnerships as a way of tackling a broad range of community health needs and
rationalizing the allocation of local health care (Bazzoli et al., 1997). The dominant rationale
that emerged was that fiscal constraints demanded a prioritization and restriction of public
expenditures, and that turning to the private sector could address cost and investment challenge,
improve efficiency, understood largely in terms of service provision and management at reduced costs,
and enhance service quality (Nikolic and Maikisch, 2006).
Moreover, the rapid change in the provision of health care, due mainly to ageing
populations, medical-technological developments, and policy changes, meant that govern-
ments around the world were dealing with problems such as booming health care costs and
decreasing governmental budgets. For many governments, PPPs between health care
providers and the private sector represented a way of coping with such problems. This
development conveniently overlooked the emerging evidence that questioned the myth that
competitive markets facilitate increases in cost containment, equity, or efficiency in health
care markets (Hsiao, 1994; Maynard, 1994). In this dynamic landscape, the role of the
public sector evolved, moving away from the direct provision of services towards the
formation of partnerships in community health planning aimed at improving community
health (Center for Studying Health System Change, 1996; Sofaer, 1992).
PPPs in the health sector can take a variety of forms depending on the degrees of
public and private sector responsibility and risk. They are characterized by the sharing
 Torchia et al.: PPPs in the health care sector 5

of common objectives, risks, and rewards, as might be defined in a contract or

manifested through a different arrangement (Nikolic and Maikisch, 2006).
PPPs, when appropriately structured and implemented, help address specific cost
and investment challenges, deliver improvements in service efficiency, and enhance
service quality. However, the structuring and implementation of PPPs may not be easy,
as in many cases they may not be the most effective or efficient option available. For
this reason, a careful evaluation of the conditions for success and sustainability is
required on a case-by-case basis so as to assess the costs and benefits and the likelihood
of success of such an approach (Nikolic and Maikisch, 2006).
The increasing importance of PPP development has meant that research articles pub-
lished on the topic is important both to researchers and practitioners in the field (Al-Sharif
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and Kaka, 2004; Marsilio et al., 2011). However, it is evident that despite the tremendous
enthusiasm internationally for the use of the PPP model to improve health care, there is no
common understanding as to what precisely constitutes a PPP (Barr, 2007), and which are
the main drivers and characteristics that lead to PPP success.
To bridge this gap, in this study we seek to order and explore the current status and
future trends through systematization of the most relevant literature on PPPs in the
health care sector. Systematization of the literature has also helped us develop new
research questions and suggestions for future research directions.

RESEARCH METHODOLOGY

Systematic literature reviews differ from traditional narrative ones by having a more explicit
selection process for articles. Synthesizing existing evidence in this way can be a powerful
tool for building up knowledge, and can be as important as conducting new research (David
and Han, 2004). A representative sample of published journal articles is identified using an
adapted version of David and Han’s (2004) and Newbert’s (2007) approach. This is a more
objective approach, thereby reducing the biased results of samples selected on the basis of
subjective criteria (Newbert, 2007). The aim is to make the literature review replicable,
scientific, and transparent (Tranfield et al., 2003), and establish a number of steps for
framing the enquiry and presenting the results. The review procedure comprised four steps,
which are summarized in Figure 1.

Step 1: Search published articles

A key tool in the search process was the database search. The databases used were ISI
Web of Science and Ebsco Host. We limited the search period to 1990–2011. This period
was selected because some scholars noted that before 1990 the term public–private
partnership rarely appeared in academic articles (Barr, 2007). The search covered peer-
reviewed articles written in English. The search terms applied across the databases
 6 Public Management Review

DATABASE SEARCHES

Step Public–Private Partnership* & health*

OR PPP* and health* OR project finance*
136 Articles
1
and health OR PF and health in title
or abstract

DUPLICATES
Step 118 Articles
2 Deletion of duplicate articles found in
both databases
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READ ABSTRACTS
Step 74 Articles
3 Eliminate not relevant articles
by reading abstracts

READ FULL PAPERS

Step 46 Articles
4 Eliminate not relevant full
articles

Figure 1: Summary of the systematic review process

Source: Own elaboration.

were: Public–Private Partnership* and health* OR PPP* and health* OR project finance*
and health OR PF and health in the title or in the abstract. We decided to use both PPP*
and Project finance* as keywords, as Project Financing is one of the most popular types
of PPP. The database searches resulted in 136 initial references. We used the reference
management software package EndNote to manage selected articles electronically.

Step 2: Delete duplicated articles

In the second step we deleted duplicated articles from the search carried out in two
different databases. Eighteen articles were eliminated from the sample.

Step 3: Read abstracts

In the following step, standards for inclusion were set and two researchers indepen-
dently assessed the relevance of the articles by reading the abstracts. Seventy-four
articles were considered relevant to our aim after this step.
 Torchia et al.: PPPs in the health care sector 7

Step 4: Read full articles

The seventy-four remaining articles were read in their entirety. Data extraction sheets
were designed and as a template for the full readings of the articles and application of
inclusion criteria. They include: details of the publication, aims of the research, research
design, definitions of key terms, relevance to the PPP framework, whether the article
was theoretical or empirical, country of analysis, and results and conclusions. The data
extraction sheets aided reading, analysis, and synthesis, and also provided an additional
quality control stage. The final number of research articles included in the systematic
review was forty-six.
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RESULTS

In this section we present the results of the systematic literature review. We used a
research protocol to codify the characteristics of each article. The following character-
istics were considered important for identifying the main trends in health care sector
literature as regards PPPs: year of publication, journal title, article type (empirical,
qualitative, and conceptual), method of analysis (survey, case study, etc.), country of
analysis, and the main research topic.

Evolution over time

Publication year is one of the used selection criteria. Articles published between 1990
and 2011 are included. The selected time frame is in line with previous research on PPP
suggesting that before 1990 the term PPP rarely appeared in academic articles (Barr,
2007). Figure 2 shows in relation to the time frame the main trends in PPPs literature.
As depicted, the first article was published in 1993. Studies on PPP in health care were
published irregularly during the two decades. However, it is possible to identify two
major peaks, the first in the late 1990s and the most recent one in 2010.

Journals

All the analysed articles were published in peer-reviewed academic journals (in English)
and are available through electronic databases (ISI Web of Science and Ebsco Host).
Our final sample consists of forty-six articles published in thirty-one different journals.
The majority of journals have a specific focus on health care issues while a few cover
more general public administration topics.
 8 Public Management Review

4
Number of article

1
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0
1990 1993 1996 1999 2002 2005 2008 2011
Year

Figure 2: Evolution over time

Source: Own elaboration.

In order to verify the relevance of the journals, a close look at each journal’s Impact
Factor (IF) has been given. Indeed, it is a key performance metric for the ranking and
comparison among journals (see Table 1 for more details).

Type of article

The analysis of the articles shows the predominance of qualitative methods (44.0 per cent),
mainly interviews and case-study analysis. This is probably due to the suitability of
qualitative methods in this research field, where, according to Yin (2003) researchers
have little or no control over events, and the focus is on a contemporary set of events
within some real-life context. Forty-one per cent of articles are conceptual/theoretical,
presenting cutting-edge solutions for PPP issues and presenting new insights for future PPP
project development and research direction. Fifteen per cent are empirical using survey
data, extracted from questionnaires sent out to PPP partners, managers, or patients.

Country of analysis

With regard to the country of analysis, the majority of articles focus on the United
Kingdom/United States. This is not surprising, as the United Kingdom and the United
States were the first countries to experiment with PPP solutions for the health care
sector. Figure 3 provides a complete overview.
 Torchia et al.: PPPs in the health care sector 9

Table 1: Journals/articles’ analysis

Journal No. of articles IF

BMC Health Services Research 1 1.72

Bulletin of the World Health Organization 2 5.54
Californian Management Review 1 1.70
Capital and Class 1 –
Development 1 –
Development Southern Africa 1 0.22
European Journal of Health Economy 1 1.75
European Journal of public Health 2 2.26
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European Public–Private Partnership Law Review 2 –

Health Affairs 1 –
Health and Social Care in the Community 1 1.00
Health Care Analysis 1 0.88
Health Policy 7 1.38
Health Policy and Planning 4 2.79
Health research Policy and System 1 1.40
International Journal of Project Management 1 –
Journal of Construction Engineering and Management 1 –
Journal of E-governance 1 –
Journal of Health Care finance 1 –
Journal of Health Politics, Policy and Law, 1 –
Journal of Healthcare Management 1 –
Management and Organization Review 1 2.80
Policy and Practice 1 –
Policy Studies 1 –
Public Administration 1 1.29
Public Management Review 1 1.29
Public Money & Management 2 –
Public Performance & Management Review 1 –
The Australian Journal of Public administration 3 0.77
The International Executive 1 –
The Milbank Quarterly 1 –

Source: Own elaboration.

Main PPP issues for health care

In order to provide an overview of the main issues addressed in the articles, we decided
to divide the articles into six main groups according to their main focus. We identify
the following main research lines:
 10 Public Management Review

10
9
8
Number of article

7
6
5
4
3
2
1
0
a e a a s e a a l
in ec di Italy ore and por fric pain land and UK
S
U iona ifie
d
us ca

Ca ia
da
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Ch Gre In
l
fri

na

S hai
tra

K erl ga A g a t e c
A

th Sin uth U n p
T ter t s
A

Ne So In No
Country

Figure 3: Country of analysis

Source: Own elaboration.

– Effectiveness (19.0 per cent of articles)

– Benefits (17.0 per cent of articles)
– Country overview (15.0 per cent of articles)
– Public interest (13.0 per cent of articles)
– Partners (9.0 per cent of articles)
– Efficiency (7.0 per cent of articles)
– Overlapping (20.0 per cent)

In 20 per cent of the cases we were not able to include the articles in one of the
research lines identified. Indeed these articles deal with multiple topics. We included
these overlapping articles in a residual group.
Table 2 gives more details on the clusters and on the overlapping articles. In this
table, nine articles have been considered to be overlapping: one article deals at the same
time with the topics of effectiveness and public interest; in two articles the overlapping
topics are PPPs benefits and public interest; two additional articles focus on public
interest and PPPs efficiency; finally, three articles focus on efficiency and partners.

DISCUSSION AND MAIN FINDINGS

In this section the main results are discussed and the main findings presented. The
section is divided into six main parts, according to the six lines of research (the findings
related to the articles included in the cluster ‘overlapping’ are integrated in the six lines
of research in order to make the discussion section easily understandable) The aim is to
 Downloaded by [Andrea Calabrò] at 14:48 17 May 2013

Table 2: Main PPP issues for health care

Effectiveness Benefits Public interest Country overview Efficiency Partners

Effectiveness Barr (2007); Blanken and Labuschagne (1998) Ruane (2001)

Dewulf (2010); Fischbacher
and Beaumont (2003);
Galvin (2003); Maarse
(2006); McKee et al.
(2006); Saltman (2003);
Samper et al. (2004); Singh
and Prakash (2010).
Benefits Barlow and Köbler-Gaiser Sharma and Seth
(2009); Buse and Waxman (2011); Widdus
(2001); Field and Peck (2001).
(2003); Frenk (1993); Pappa
and Niakas (2006);
Pannarunothai and Mills
(1998); Maarse and
Bartholomée (2006); Sekhri
et al. (2011).
Public Holden (2009); Hellowell
interest Holmes et al. and
(2006); Molinary Pollock
et al. (1998); (2009);
Nishtar (2004); Vecchi
Van Doorslaer et al.
et al. (2008). (2010).
(continued )
Torchia et al.: PPPs in the health care sector 11
 Downloaded by [Andrea Calabrò] at 14:48 17 May 2013

Table 2: (Continued )

Effectiveness Benefits Public interest Country overview Efficiency Partners

Country Allard and Cheng (2009);
overview Birungi et al. (2001); De
Costa and Diwan (2007);
Kümpers et al. (2002);
Liaropoulos and Kaitelidou
(1998); Liaropoulos and
Tragakes (1998); Lim
12 Public Management Review

(2004).
Efficiency Barretta and Becker and
Ruggiero Patterson
(2008); Di (2005);
Matteo Ovretveit
(2000); (1996);
Smith Jeong
et al. (2005).
(2000).
Partners Bazzoli et al.
(1997);
Raptopoul-
ou (2009);
Zhang
(2005);
Zhang et al.
(2009).

Source: own elaboration.

 Torchia et al.: PPPs in the health care sector 13

give a more clear and detailed overview of the current debate on the use of PPPs in
health care.

Effectiveness

The articles grouped in this topic study the main elements considered to result in effective
PPPs, and provide some guidelines for the implementation of effective PPPs in the health
care sector. While PPPs can provide a mechanism for achieving the comparative advantages
of public and private sectors in mutually supportive ways, several issues are critical and need
to be carefully considered when implementing a PPP.
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To start with, despite the involvement of the private sector in PPP projects, the
government needs to continue playing the role of regulator, especially in sectors (e.g.
health care) where accountability is critical and the public interest is at stake. In
particular, the public sector should continue to set standards and monitor product
safety, efficacy, and quality, and ensure that citizens have adequate access to the
products and services they need. In other words, PPPs do not imply ‘less government’
but a different governmental role, as suggested by Jamali (2004). Moreover, because of
the stronger position of the private partner in such partnerships, more active govern-
ment participation is often needed (Scharle, 2002).
The same view is also expressed by Widdus (2001), who in analysing the poor–reach
health disparity in developing countries, explains that one of the major areas requiring
attention is the inefficiency of the pharmaceutical distribution system. In this context,
partnerships between the public and the private sector have a contribution to make in
improving the health of the poor by combining the different skills and resources of
various organizations (public and private) in innovative ways. However, in order to be
beneficial, the public sector should continue to: fund fundamental research; set
standards for product safety, efficacy, and quality; establish a system whereby citizens
have adequate access to health product and services; use public resources in an efficient
manner; and create environments in which commercial enterprises are appropriately
motivated to meet the needs of the entire population.
Another important element considered fundamental to PPPs’ effectiveness is the
regulatory framework in which they take place. Pongsiri (2002) emphasizes the
establishment of a transparent and sound regulatory framework as a necessary precursor
to private sector participation. Regulation provides assurance to the private sector
(protection from expropriation, respect of contract agreements, etc.) and to the public
sector as well, by ensuring that essential partnerships operate efficiently and optimizing
the resources available to them in line with broader policy objectives (Di Lodovico,
1998; Zouggari, 2003). In addition, PPPs’ implementation should consider the interests
of all the stakeholders that have an interest in it. To this end, Fischbacher and
Beaumont (2003) in their study focus on the importance of process and decision-making
 14 Public Management Review

during the implementation phase. Drawing on the experience of an English PPP in the
health care sector, they examine key aspects of PPP processes such as structural
characteristics affecting the design and implementation of the project and the nature
of stakeholders’ involvement. They outline that the decision-making process can be
dysfunctional and inefficient. This is partly due to the design of the PPP project where
there is not enough emphasis on the extent and nature of stakeholders’ involvement.
The importance of stakeholders’ involvement is also underlined by Singh and Prakash
(2010), who found that power is asymmetrically distributed in the partnership, and that
there is greater reliance on informal mechanisms of coordination. However, for PPPs to
be effective, it is important to reduce the power asymmetry between partners and to
rely on informal mechanisms of coordination and trust.
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The importance of PPP effectiveness is also outlined by Blanken and Dewulf (2010).
A multiple-case study on seven PPP projects in England and the Australian state of
Victoria found that PPP effectiveness can be achieved by addressing the way contractual
arrangements are structured and the degree of flexibility they generate. Moreover, they
identified certain features that appear to be particularly significant in determining the
flexibility of PPPs in health care, such as knowledge and expertise, combined with
competent management of the contractual arrangements; the contract; the way the
project is financed; and the existence of a dependency between the funding for the
clinical services and the expenditure of the health authority on PPPs. They conclude by
suggesting that health authorities should address those determinants in order to prevent
the development of hospitals that lack the ability to respond adequately to the
uncertainties associated with their immediate contexts.
Despite the increasing attention paid to PPP effectiveness in the health care sector,
few studies provide a protocol for evaluating PPP effectiveness, mainly because there is
a lack of firm evidence of the effectiveness of PPP projects. Barr (2007) points out a
number of elements that should be considered when evaluating the effectiveness of a
PPP. He proposes a protocol for evaluating the effectiveness of a PPP as a means of
improving health worldwide. The research protocol presented in this article has been
drawn up by a panel of nine scholars from around the United States, each with
expertise in a discipline relevant for health. There are eight principal aspects to the
protocol:

1. The relationship between the public and private sectors.

2. The nature of the partnership between public and private sector participants.
3. The financial arrangements of the PPP project.
4. The government policy enacted to promote partnership efforts.
5. Identification and quantification of PPP outcomes.
6. Assessing issues of equity.
7. Identifying the potential weakness of the analysis.
 Torchia et al.: PPPs in the health care sector 15

He concluded his study underlying the need for more research on the effectiveness of
PPPs, using standardized research protocols, before substantial resources are invested in
the expansion of PPP efforts.
PPP effectiveness is not always guaranteed. PPPs can be helpful but they are not a
panacea (Widdus, 2001). Moreover, because of the complexity of PPPs, during the
implementation phase several issues can arise, as pointed out for example by McKee
and his colleagues (2006). They discuss several issues that emerge with the implemen-
tation of PPPs for hospital building. These elements are:

1. COSTS – The costs involved in PPPs are frequently underestimated. Moreover,

it is difficult to make accurate cost comparisons between the cost of PPPs and
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more conventional methods.

2. QUALITY – Usually when a problem arises in PPPs, there are trade-offs
between three variables: cost, time, and quality. While cost and timing seem
to be fixed in PPP contracts, concerns arise concerning the quality of projects
and many hospitals built under PPPs in the United Kingdom have experienced
such problems.
3. FLEXIBILITY – While the delivery of health care is changing rapidly, partly in
response to altered demands on health-care systems, PPP contracts are often
specified in very great detail, with large penalties for introducing changes and
elements of flexibility.
4. COMPLEXITY – PPP projects involve many different types of stakeholders.
They also require the active participation of universities and research
funders. The difficulties in reaching an agreement with all of these stake-
holders, combined with the high costs of the projects, have led to the
collapse or to the failure of many projects in the United Kingdom and
worldwide. These experiences raise questions as to whether this model can
be simplified sufficiently for use with very complex projects.

Benefits

Partnerships between the public and the private sector are often seen as offering innovative
methods with a good chance of producing the desired outcomes. One primary benefit is
that each sector contributes what it most has to offer, and the combination of these skills,
abilities, and powers has the potential for producing the best results. Yet neither the public
nor the private sector is capable by itself of solving the numerous problems the health
sector is facing worldwide. In contrast, PPPs combine the best of both worlds: the private
sector with its resources, management skills, and technology; and the public sector with its
 16 Public Management Review

regulatory actions and protection of the public interest (UNECE, 2008). This balanced
approach is considered particularly beneficial in the delivery of health care services.
PPPs can produce innovative strategies and positive consequences for well-defined
public health goals, and they can create powerful mechanisms for addressing difficult
problems by leveraging the ideas, resources, and expertise of the different partners
(Reich, 2002). Sharma and Seth (2011) argue that PPPs in the health sector can not
only fill the gaps in the spread and prevalence of the health care infrastructure, they also
offer a range of other potential benefits, such as

– Enabling existing health infrastructures to be used with enhanced efficiency.

– Health, poverty alleviation and development programmes run primarily by
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governments can be speeded up with PPPs.

– The primary constraint in relation to the effective execution of the develop-
mental efforts is improper communication and government work culture, which
leads to the demotivation of the programme execution teams and beneficiaries as
well. Motivation can be restored by PPPs (and this is the first level of achieve-
ment to be achieved).
– Some parts of the population, i.e. those living in the country and the poor, need
to be considered as markets and their status as a market can be established
through a PPP.

The relatively new trend in global health care of cooperation between the public and the
private sectors also opens up significant possibilities for tackling problems that previously
seemed intractable, particularly those requiring increased research and development on
drugs and vaccines for diseases that disproportionately affect the poor (Buse and
Waxman, 2001). For example, several partnerships are achieving positive results in
the fight against infectious diseases. Partnerships with the private sector have also
demonstrated an ability to advance public health messages and create industry incentives
for the development of healthier products, but also risks for the public sector and for
public health. This means that PPPs need to be carefully implemented if the expected
benefits are to be reaped. Barlow and Köberle-Gaiser (2009), for example, using a
multiple-case study on six hospitals built under Private finance initiatives (PFI) in the
United Kingdom, found that to be beneficial a PFI needs a rigorous risk analysis and
optimal risk allocation; synergies through improved integration of design, construction,
operation, and maintenance; and a focus on whole-life costing and long-term perfor-
mance management. Furthermore, they state that consideration needs to be given to
whether the PPP will deliver the desired benefit in terms of stimulating innovation in
new hospital schemes. Finally, it has been argued that major improvements in health
systems require an approach that simultaneously addresses not only infrastructure and
financing, but also access, service delivery, and management, to achieve better patient
outcomes (Sekhri et al., 2011).
 Torchia et al.: PPPs in the health care sector 17

Public interest

One of the main concerns relating to PPPs in health care sector is their impact on
public interest. This is understandable, as the private partner may not necessarily have
public interest as a primary goal (Friend, 2006). PPPs either can be interpreted as
purely commercial ventures with an economic interest or can be seen as public policy in
action. This means that partnerships can play out at any point along a spectrum from
integrity–trust to unethical, scheming–political behaviour (Johnston and Gudergan,
2007). For example, Hellowell and Pollock (2009) found that PPPs in the UK
National Health System are driven by a questionable politico-economic rationale.
In England they are associated with reduced health system capacity. Indeed, PPPs
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have reduced the provision of health services, harming the public interest. This is
due to the underfunding generated by the cost of PPPs, which creates pressure for
cuts in service provision in order to reduce deficits.
As noted by Nishtar (2004), despite the potential that exists in collaborating with the
private sector, certain measures must be taken at a global level to assist global
partnerships and set a framework within which efforts at the country level can emanate.
As a first step there is a need to develop a set of global norms and ethical principles. It
is critical that the driving principles of such initiatives be rooted in the benefit for the
society rather than the mutual benefit for the partners and that they should centre on the
concept of equity in health (Nishtar, 2004).
The implementation of a PPP requires critical policy reflection, especially when the
interactions between public and private sectors are likely to positively and negatively
impact the achievement of health for all. It requires adopting the well-proven policy
paradigm in which public–private relationships are seen as potentially problematic
interactions between two separate spheres. It means being very clear about the aim
of private partners, which is to generate a profit for their companies. It is about asking
Who wins what?, Who risks what?, and about exercising appropriate caution in order to
preserve the public interest.

Country overview

The main objective of 15.0 per cent of the articles included in our sample is to provide
an overview of the national context. In particular, seven articles included in the group
(country overview) focus on the United Kingdom, Italy, Spain, India, and Singapore.
We will accordingly briefly describe each of these contexts, focusing on the main
characteristics of the PPP market for the health care sector.
England’s National Health Service is the largest single market for health care PPPs.
PPPs were introduced by John Major’s Conservative government in the autumn budget
of 1992. This began the process of legal and bureaucratic changes necessary for the
 18 Public Management Review

application of the Design, Build, Finance and Operate (DBFO) model to the English
public sector (and indeed to that of the rest of the United Kingdom). Since that initial
budget statement, the policy has accounted for the vast bulk of large-scale public capital
projects in England, including defence, public transport, roads, education, social
housing, and waste management. PFI has become the dominant source of capital
investment for the country’s tax-funded National Health Service (NHS), in which a
major hospital rebuilding programme has been underway since the mid-1990s
(Hellowell and Pollock, 2009).
Typically, UK PPPs are arranged under PFIs and usually involve arrangements
between public and private organizations for the provision of a hospital, which the
private sector designs, builds, finances, and/or maintains (Hellowell and Pollock,
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2009). The private organization is reimbursed by the public organization based on

the services delivered in the hospital. Many PFI–PPP contracts are signed for a period
of much longer than 25 years.
The Italian health care system, the Servizio Sanitario Nazionale (SSN), has developed
into the second largest PPP market in Europe (Osservatorio Finlombarda, 2011). The
scope of these PPP projects varies from the construction of entirely new hospitals,
through refurbishment projects, to the delivery of small non-clinical assets, such as car
parks and training centres (Osservatorio Finlombarda, 2011). The Italian SSN is tax-
funded and provides health care to the entire population. The SSN is decentralized,
with regional governments being responsible for the funding and delivery of health care
services. The regional governments generate resources through local taxation, set
health care budgets, and direct resources to local health units (Vecchi et al., 2010).
In 2002 at a government–regions conference (Conferenza Stato Regioni), it was
assessed that a fifth of SSN hospitals needed to be replaced and 30.0 per cent
refurbished (Conferenza Stato Regioni, 2002). This financial gap formed the back-
ground for the introduction of PPPs in the health care sector. In line with UK practices,
PPPs in Italy’s health sector are typically arranged under PFIs, with the arrangements
between the public and the private sectors following English standards.
Allard and Cheng (2009) explore the history of PPPs in Spain, discuss how PPPs are
governed in Spain, and examine how PPPs are possibly improving the delivery and
efficiency of the Spanish health care system. Most PPPs in Spain follow the concession
model and are governed by the Law of Concessions and the Law on Contracts of Public
Administration. The procurement process in Spain consists of five phases. The first
phase comprises preliminary research, feasibility studies, and the drafting of contract
conditions by the relevant governmental body. The subsequent phases cover the open-
ing of the project to bidders, the bidding process, and the awarding of the bid. In the
final phase, both partners sign the final concession contract. Although PPPs in health
care have seen spectacular growth in Spain, it is still too early to make any reasonable
assessment of their success. Most hospitals have only recently begun operations, which
mean that whatever problems they are set to encounter have as yet had little time to
 Torchia et al.: PPPs in the health care sector 19

emerge. In addition, there appear to be few mechanisms in place that would make
public information available on the quality of the care being provided and the satisfac-
tion of patients. Thus it is not possible to venture conclusions as to whether Spain’s
reliance on PPPs for much of its new health care delivery brings it closer to its objective
of providing high-quality, affordable health care for its citizens.
The two articles focusing on India and Singapore are more oriented towards pointing
out the problems that emerge in implementing PPP in such contexts rather than
describing the PPP market for health.
De Costa and Diwan (2007) empirically demonstrate the size and composition of the
private health care sector in one of India’s largest provinces. Given that there is a large
established private sector in the province, they advocate that the state needs to move
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towards constructive oversight. They argue that the public sector needs to find a
balance between direct provision of services and new roles in coordination and
regulation. The state needs to take a lead in good governance, and forge viable
partnership with the dominant private sector to ensure equitable health outcomes for
everyone. It needs to develop methods and experience needed to improve and
strengthen the existing private supply and to integrate that capacity in achieving public
goals. The authors consider that PPPs positively mitigate the predominant role played
by the private sector in the health care sector.
Finally, Lim (2004) describes the situation of health care provision in Singapore. He
shows how a substantial portion of health care provision is being transferred to the
private sector. Moreover, Singapore’s experience represents an interesting case study in
PPP, illustrating how a hard-headed approach to health policy, tapping into public and
private resources to finance health care, can achieve national health goals while
balancing efficiency and equity concerns. Its experimental PPP model may even hold
lessons for others. The efficiency-driven health financing reforms, which emphasize
individual over state responsibility, appear to have been implemented at the expense of
equity. Singaporeans themselves seem unconcerned about any perceived inequity in the
health system. They appear content to pay part of their medical expenses, plus
additional monies if they demand a higher level of services.

Efficiency and value for money

The divergent goals of PPP public and private sector partners is the key factor that
brings into question the necessity of assessing project efficiency at microeconomic level
when judging the success or failure of a PPP.
The main reason for starting a PPP is the cost saving that arises from delivering a
project via PPP rather than traditional methods. These savings can result from the
greater innovation and efficiency of the private sector compared with the public sector
(Grimsey and Lewis, 2004). The private sector generally achieves higher operational
efficiency in asset procurement and service delivery by applying its expertise,
 20 Public Management Review

experience, and innovative ideas/technology. Overall project cost savings can be

achieved by striving for the lowest possible total lifecycle costs while maximizing
profits (Cheung et al., 2005).
Value for money (VFM) – defined by Grimsey and Lewis (2004) as the optimal combination
of whole lifecycle costs, risks, completion time, and quality in order to meet public require-
ments – is another important consideration, especially for the public sector (Cheung et al.,
2005; Grimsey and Lewis, 2004). There are six determinants of VFM:

– Risk transfer.
– Long-term nature of contracts.
– Competition.
–
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Performance measurement and the use of an output specification.

– Performance measurement and incentives.
– Private party’s management skills.

Often when the government approves a project in which it is seeking to involve the
private sector through a PPP, private sector bids are assessed against public sector
benchmarks to determine VFM. The public sector comparator is the tool most commonly
used by the public sector to show how much it would cost the government to build the
asset through public funding, which is then compared with how much it would cost to
build the asset as a PPP.
The main reason and justification given by governments for entering into PPPs is to
secure VFM and if this objective is not achieved, the arrangement will have no legs to
stand on. It is therefore essential to plan and design the partnership so as to achieve
VFM assurances, and this must be the guiding principle for governments right from the
start (Sethumadhavan, 2010). A novel feature of the VFM technique is that apart from
the expected financial costs, it also includes the costs of some of the risk associated with
the project. Since some of the risks are to be transferred to the private sector, the PPP
option should provide a greater VFM than a publicly financed alternative where the
public sector bears all the risks (Edwards and Shaoul, 2002).
Despite the importance of assessing VFM before starting a PPP project, some authors
have reported that this is often not carried out. Barretta and Ruggero (2008), for
example, in analysing six PPPs in the Italian health sector, found that (a) in the majority
of cases, recourse to a PPP was not due to an evaluation demonstrating that it would be
more advantageous than traditional public financing, but because the public sector
lacked the necessary resources to carry out the investment; (b) the failure to use
methodologies such as VFM is often the consequence of the behaviour of politicians at
the regional administration level; (c) analysis of the private partner selection process for
the PPPs in question showed that the most common economic criterion included in the
call for bids was the financial contribution of the private partner to the PPP. Similar
 Torchia et al.: PPPs in the health care sector 21

results were reported by Vecchi and colleagues (2010) in their analysis of fourteen PPP
projects in the health sector in Italy.
Furthermore, Hellowell and Pollock (2009) in describing the microeconomic argument
for PPP solutions stated that the cost-efficiency case for PPP appears weak, since public
finance is always cheaper than private finance. Moreover, they underlined that to be VFM a
PPP must more than offset the higher cost of finance through better management of risk by
the private sector. While in theory it is possible that the private sector will be able to
provide this, there is clearly a need for proper evidence to be supplied in support of this
analysis. However, the evidence base on PPP performance and efficiency is still poor.
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Partners

In the absence of viable and efficient alternatives for implementing large investment
projects, the use of PPPs seems inevitable. However, one major disadvantage to them is
the constant conflict of interest between the PPP partners. By definition, PPPs involve a
partnership between two structurally different organizations with different strategies
and operational goals (Zhang et al., 2009). While the partners belonging to private
sector aim either to maximize their profit margins or to enhance the performance of
their own business, the partners belonging to the public sector aim to optimize the
social, political, and budgetary objectives.
The major risk related to the relationship between partners is the creation of
unbalanced partnerships. Becker and Patterson (2005) reported that unbalanced part-
nerships are not to be expected and should be avoided. An unbalanced partnership may
result from one or more of the following conditions:

– In certain cases of fraud or abuse of office, public officials abrogate their

responsibilities for participation, oversight, or leadership.
– Public officials may not have the experience or training to be an effective partner
in such relationships. They may defer inappropriately to the substantive or
negotiating expertise of the private partner.
– The roles of the partners may not be clearly defined.
– The public partner may attempt to be the general partner when, in fact, it should
be the limited partner.

Given the importance of PPP partners, the selection of the right partners is critical. But
which criteria should be used for the selection of candidate companies? Although there
is no single and clear answer, it is fundamental that the public sector ensure that the
selection process for partners is fair and transparent. In the absence of such a process,
not only may the right partner not emerge to undertake the tasks, but also the entire
 22 Public Management Review

process may get bogged down in avoidable disputes, litigations, etc., which will impede
the progress of the projects (UNECE, 2008).

CONCLUSION AND FUTURE RESEARCH DIRECTIONS

The main characteristics of PPPs in health care have already been discussed by many
researchers in the past. This study contributes to the research debate, shedding light on
the ongoing debate on PPPs in the health care sector. The systematic review of the
relevant literature (published in the period 1990–2011) on PPPs in health care has
allowed us to define the state of the art and the main research trends.
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The results of the review of forty-six published articles were synthesized and
grouped into six lines of research, each with a specific focus: effectiveness; benefits;
public interest; country overview; efficiency; and partners. The main issues relating to
the various groups are described in the discussion section.
The most widespread opinion among scholars in the field is that, despite the
increasing diffusion and adoption of PPP solutions in health care worldwide, some
elements need to be carefully evaluated, such as

– How the effectiveness of PPP projects depends on several factors, such as: the
role of the partners (and in particular the regulating role of the public sector),
the regulatory framework, the contract arrangements, and the involvement of
stakeholders. Are these elements taken into due consideration before starting a
PPP?
– PPP benefits. In order for the PPP to be beneficial for all stakeholders, it is
important to: carry out rigorous risk analysis and optimal risk allocation; achieve
synergies through improved integration of design, construction, operation, and
maintenance; and focus on whole-life costing and long-term performance
management.
– Public interest. Due to the number of actors involved, the interests of various
stakeholders need to be carefully considered. Undoubtedly, the most important
of them is public interest. Is public interest the main driver of a PPP, or is it
mainly driven by the interests of the private sector or politicians?
– The actual efficiency of PPPs. Is a PPP really the best solution? Or are other
better cost-saving solutions available to the health care sector?
– PPP partners. As partners in a PPP will work together for a long time, the
selection process of the private partners is crucial. A transparent and fair
selection process is required in which all proposals from potential partners are
objectively evaluated. However, the selection process is often guided by eco-
nomic reasoning, with the financial contribution of the partners being the main
selection criteria.
 Torchia et al.: PPPs in the health care sector 23

The research lines identified in this review of the literature need to be further explored.
Despite the increasing attention PPPs are gaining in the health sector worldwide, some
questions remain unanswered. Future research should provide more empirical results
on the actual effectiveness, efficiency and convenience of PPPs as solutions for public
health care system problems.

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