【探索】卓远译文医院PPP四大模式探索

Public Private Partnerships (PPP) are used for differing reasons across a range of industries. PPPs in the water sector have successfully mobilized private operators to turn around failing public companies and expand access to water services. In the building sector, PPPs have transferred responsibility of construction and estates management to private companies, leaving government departments to focus on their core activities (Grimsey and Lewis 2004). Increasingly policymakers are exploring PPPs as a means to improve their public hospitals. However, the performance goals and policy context for hospitals differ considerably from those in which PPP models evolved (Grimsey and Lewis 2005; Brinkerhoff and Brinkerhoff 2011). Discussions about PPPs in the health care sector are often hampered by confusion about what the term means, with multiple models grouped without distinction on the umbrella PPP term (Field and Peck 2003). Lacking a clear vocabulary, health policymakers find it difficult to sort out what these “imported” models offer and it is difficult to understand which models are likely to address the performance problems for which a specific PPP is contemplated (Ng and Loosemore 2007). 

We review the PPP models most frequently applied in other sectors, and increasingly in hospitals, and use configuration analysisi to group them into categories with analytically important distinctions among them. We propose a typology of hospital PPPs to permit clearer communication and more sound analysis. Clearer specification of their characteristic mechanisms also illuminates the problems that each PPP type has been “built” to address. Establishing analytically meaningful categories allows researchers to compare “like with like”. We hope that this typology will support much needed evaluative research in this field.

Typology

• In the first model, “services” are the core of the partnership. In order to improve the quality and/or efficiency of hospital services provision, a private organization is brought in to operate and deliver publicly-funded hospital services, usually within the existing infrastructure of the government (La Forgia and Harding 2009).The facility may be built by government explicitly in preparation for this model of service PPP.
  

• The second model involves a public agency contracting a private entity to finance, design, build and operate a hospital facility within which a public service is run. We refer to this as the “facilities and finance” model. It is popularly referred to as the PFI model, coming from the name of the “Private Finance Initiative” program which first applied the model in the UK (McKee et al. 2006, Edwards 2005).
  

• Under the third model, a private organization establishes capacity to provide hospital services under sustained public or social insurance reimbursement. We refer to this as the “combined” model, since the public sector “buys” hospital services combined with the underlying facilities and related finance. There are two variants under this model, which merit distinction. In one variant, a public agency tenders to have a private organization build a new facility and provide services; in the second, the private organization takes over an existing facility and services. The former has been applied to add capacity and assure operator “ownership” in the facility construction (Global Health Group 2010, Sekhri et al. 2011). The latter is often more politically controversial, but has the potential to harness the private sector to take over existing failing facilities and turn them around, as has been the case in Germany (Roeder 2012, Coelho and O’Farrell 2009).

• Under the fourth model, public agencies do not buy services but rather allocate public hospital real estate for a private service provider to develop services “co-located” within the public facility. The private organization makes payments to the public agency, as well as providing in-kind services. Most often the objective of this kind of partnership is to capture the value of the real assets, and to tap the private operator’s services and expertise for the benefit of public patients. (Nikolic and Maikisch 2006, Project Equity 1999).

Conclusion

Building upon the typology presented here, we expect that differing models of PPP will be suited to application in a variety of situations depending upon the specific facility and system need; the public and private capacity to fund the PPP; the governmental capacity to contract and oversee; private capacity to implement, and the legal and healthcare system infrastructure in which the PPP is applied. To fully understand the tradeoffs between differing models, and the context appropriate to each, a more compete analysis of experiences within each model is needed. Only at this point will it be possible to define success for each PPP type, and to both build and test a model of the criteria that will make a PPP likely to succeed or fail. The typology presented here is an advance towards this goal.