Public–private partnerships for hospitals Martin McKee,a Nigel Edwards,b & Rifat Atun c

Abstract While some forms of public–private partnerships are a feature of hospital construction and operation in all countries with mixed economies, there is increasing interest in a model in which a public authority contracts with a private company to design, build and operate an entire hospital. Drawing on the experience of countries such as Australia, Spain, and the United Kingdom, this paper reviews the experience with variants of this model. Although experience is still very limited and rigorous evaluations lacking, four issues have emerged: cost, quality, flexibility and complexity. New facilities have, in general, been more expensive than they would have been if procured using traditional methods. Compared with the traditional system, new facilities are more likely to be built on time and within budget, but this seems often to be at the expense of compromises on quality. The need to minimize the risk to the parties means that it is very difficult to “future-proof” facilities in a rapidly changing world. Finally, such projects are extremely, and in some cases prohibitively, complex. While it is premature to say whether the problems experienced relate to the underlying model or to their implementation, it does seem that a public–private partnership further complicates the already difficult task of building and operating a hospital.

Bulletin of the World Health Organization 2006;84:890-896.

ميكن االطالع عىل امللخص بالعربية يف صفحة Voir page 894 le résumé en français. En la página 895 figura un resumen en español. .895

Background construction of a health facility and the and Ouchi,8 with Preker et al.9 applying ongoing provision of its non-clinical it to health care. Arguing that the public The delivery of health care in almost (and in some cases clinical) services sector is intrinsically less efficient and sfre every country involves some form of within a public system of provision. sponsive than the private sector, Preker et public–private partnership. In countries Private provision of essential public al. propose a matrix with one axis defined where care is delivered mainly through services has a long tradition, especially by the degree of contestability involved the public system, many inputs, such as in major infrastructure projects in the in providing a service (i.e. ease of market pharmaceuticals and support services, transport sector and in the provision entry), while the other is defined by the ease are sourced from the private sector. In of utilities. The private sector played a with which the outcomes of the service can countries with predominantly privately crucial role in developing these services be measured. owned facilities, the state influences in the 19th century but, in the post-war Where there is low contestability their configuration through regulations period, many were taken into public and problems of measurement then a and financial incentives. In hospitals, the ownership because of market failure.2 service should be provided within a situation is further complicated because Privatization of public services becf managerial hierarchy; conversely where of the many functions provided by such came more widespread in the 1980s with measurement is straightforward and institutions: the training of health proff the emergence of a neoliberal consensus provision is highly contestable it should fessionals and research and development, that sought to reduce the role of the be purchased from the private sector. for example, are activities that are publf state.3 In the health sector, however, Supporters of this approach have striven 1 licly funded to varying degrees. comprehensive privatization was refj to reduce barriers to market entry and to However, even the concept of a jected because of the existence of market enhance the ability to measure quality. public–private dichotomy is problemaf failure.4 Instead, various quasi-market Yet the basic premise is not borne out atic. States often limit the scope of prifv solutions were developed, typically the by the evidence.10 Australian research vate contractors to decide where to place separation of purchasers and providers showed that, after adjusting for case mix, facilities. Furthermore, there is a differef within the public sector.5 The logical public hospitals are more efficient than ence between for-profit corporations next step was to move the delivery of those that are privately operated,11 possf that operate hospitals as one business health care out of the public sector. This sibly due to the more intensive managefm among many and not-for-profit organizf was seen as a means to increase value for ment of patients in private hospitals.12 zations (including religious foundations) money, innovation, and responsiveness A systematic review identified 149 that exist solely to provide health care. to users.6 comparisons of for-profit and not-for- This paper will examine one particular The conceptual underpinning of this profit health facilities (of various types) type of public–private partnership — the approach was developed by Williamson7 undertaken over the past two decades in

a European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England. Correspondence to this author ([email protected]). b Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England. c Imperial College London, South Kensington Campus, London, England. Ref. No. 06-030015 (Submitted: 3 March 2006 – Final revised version received: 8 June 2006 – Accepted: 5 July 2006)

890 Bulletin of the World Health Organization | November 2006, 84 (11) Special Theme – Contracting and Health Services Martin McKee et al. Privately financed hospitals the USA. Of these studies, 88 concluded Franchising is an alternative model, of high cost legal, financial and other that non-profit facilities performed bettf where a private company takes over technical advice — the process remains ter with respect to cost, outcomes of management of an existing public daunting for parties on both sides of the care, access and social mission, 43 studies hospital. This approach has been tried transaction. found no difference, and 18 reported in Sweden17 (including the sale of a In theory, the British PFI model for-profit facilities to be better.13 public hospital to a private company) should contain the cost to the health and in Italy. A unique model has been authority by transferring risk to the Public–private partnerships developed in the Alzira Hospital, in contractors. But in practice, the corpf Valencia, Spain, which is managed by a porate bonds used to finance PFI deals to build and run hospitals private consortium that accepts responsf are typically awarded BBB+ status by The model in which a public authority sibility for the health care for a defined financial rating agencies, just above contracts with a private company to population in return for an annual per junk bond status, while government build or run a hospital is, inevitably, capita payment. bonds are considered less risky, and for seen mainly in countries with national There is still relatively little experf many European governments attract health services. Various models have rience with these models of hospital AAA ratings.19 The consequence of this been developed (Table 1). Australia has provision, and governments have yet to low rating is that the cost of borrowing the most diverse range of models, with undertake rigorous evaluations. Thus money is higher than it would be for differing versions in several states.14 The the merits of these models compared governments. A particular problem arises Private Finance Initiative (PFI) in the with the traditional model of provision with the way that the risks of constructf United Kingdom is a design, build, remain highly contentious but it is tion are bundled with those associated finance and operate (DBFO) model. It already possible to identify several key with the operation of services. Whereas has been the primary means of financing issues that have emerged. These are cost, construction risks may be high and quite major capital investments in the health, quality, flexibility and complexity. real, the operation of services carries a education and prison sectors during the much lower risk, not least because hospf past two decades. While this arrangemf Key issues pitals are financially backed by governfm ment provided a source of much needed ment — i.e. the government is a single new finance, a great deal of this funding Cost payer, meaning that income streams to was “off-balance-sheet” financing and There are significant costs not only for hospitals are less at risk than in markets did not appear in the government books the firms bidding for a public–private with multiple payers. However, some as new borrowing. This arrangement enaf partnership, but also for the health-care contend that several of the risks factored abled the government to remain within provider. Prospective bidders incur large into PFI business cases are unlikely or targets set for public sector borrowing. costs in developing their tenders, and notional and appear to be an accountif Moves by the British Office for National losing contenders must find a way of ing device designed to favour private Statistics to redefine such expenditure are recouping their expenditure from subsf procurement in cost comparisons with likely, at a stroke, to remove one of the sequent contracts. A sequence of losif its public alternative.20 The reason for main reasons justification for pursuing ing bids by a leading British company this may have been a very strong signal the DBFO model.15 involved in PFI deals led to fears of from government that schemes relying In the British model, a company — insolvency.18 Although the PFI profc on public funding rather than PFI were usually in the construction sector — will cess has been simplified by the use of very unlikely to succeed. create a “special purpose vehicle” to bid model contracts and other measures to The low risk once construction for a contract with a health authority to reduce the very high level of complexity is complete has allowed advantageous build and provide non-clinical services to — and thus the need for large amounts refinancing of projects at lower interest a hospital. The successful contractor will enter into three types of subcontract: one with banks to finance the project; one Table 1. Models of public–private partnership in hospital provision with a construction company to build the hospital; and one with a facilities Model Description management company to manage it over Franchising Public authority contracts a private company to manage the lifetime of the contract, typically 30 existing hospital years. Over the lifetime of the contract, DBFO (design, build, finance, Private consortium designs facilities based on public the health-care provider undertakes to operate) authority’s specified requirements, builds the facility, pay a defined amount from its revenues finances the capital cost and operates their facilities and the contractor undertakes to mainft BOO (build, own, operate) Public authority purchases services for fixed period (say tain the fabric of the hospital in good 30 years) after which ownership remains with private order and (depending on the agreemf provider ment) manage facilities. Similar models BOOT (build, own, operate, Public authority purchases services for fixed period after have been adopted, although on a very transfer) which ownership reverts to public authority much smaller scale, in Canada, Portugal BOLB (buy, own, lease back) Private contractor builds hospital; facility is leased back and Spain. It is also being introduced in and managed by public authority Ireland and, while not yet used to finance Alzira model Private contractor builds and operates hospital, with hospitals, is used for procurement of contract to provide care for a defined population other infrastructure in Greece.16

Bulletin of the World Health Organization | November 2006, 84 (11) 891 Special Theme – Contracting and Health Services Privately financed hospitals Martin McKee et al. rates, with significant benefits to the PFI record of maintaining its buildings, with compares the cost of a privately financed consortia. Such activities have attracted money meant for maintenance often befi initiative with a public sector option, this unfavourable comment from the British ing reallocated to provide services. PFI comparison is not always straightforward, National Audit Office.21 Belatedly, the contracts ensure that money is put aside with the Assistant Auditor-General from British Treasury required that new contf to properly maintain buildings. These the United Kingdom National Audit tracts should incorporate provisions to charges have also focused attention on Office describing this process as “pseudo- share these profits between the contractf the costs of maintaining and operating scientific mumbo-jumbo.”24 tor and the public authority.22 buildings. The legacy of buildings that Although this section has examined The enormous size of some British are expensive to run, clean, heat and in detail the evidence from the United PFI hospital projects has also been a cause repair is a significant problem to the Kingdom, similar conclusions have been of concern. Where this is the case, it may extent that some hospitals constructed reached in an economic assessment of reduce the level of competition between in the 1960s and 1970s have already the P3 hospital financing scheme in bidders as there are a relatively small numbf reached the end of their useful life. Canada, which shares many features ber of construction companies capable of Public–private partnerships can create with the PFI model, including the secf undertaking very large projects and the an incentive for those involved in the crecy that shrouds contracts.25 bidding costs can pose a significant barrf construction of buildings to pay more The costs involved in public–private rier to market entry. One factor behind attention to these issues. partnerships have frequently been undf the increasing size of projects may be that It is difficult to make accurate cost derestimated. Box 1 provides examples consortia have been unwilling to assume comparisons between the costs of PFI of several projects that have encountered the risk of modifying existing buildings. procurement and more conventional serious financial problems.26–28 Building a hospital around existing buildif methods. Pollock et al. have argued ings and services increases the risks and that privately funded initiatives are Quality complexity of construction. Because a PFI significantly more expensive than the In any procurement exercise, when contract is set up to deliver a single project, conventional government funded arrf problems arise there are trade-offs betf there is an incentive to load as much into a rangements for a variety of reasons, tween three variables: cost, time and scheme as possible since additional capital including the higher cost of financing quality. Traditionally, the priority has may not be available in the future. Thus, the associated with lower credit ratings.23 been to meet the specifications agreed risks facing both parties are compounded They also note the requirement for privf in the initial contract, with a reluctant as the schemes become very much more vate companies to make sufficient profit acceptance that the project may go over complex, less financially viable, and the to return to their shareholders. While the time or budget. For example, in the ability to adapt flexibly to rapid changes British government disputes the argumf United Kingdom in 2001, 76% of PFI in the health-care environment is limited, ments against PFI, its case is weakened by projects were delivered on time and 79% as we discuss later in this article. the lack of transparency that surrounds within budget, compared with 30% The cost of annual charges for buildif these projects, which are deemed to be on time and 27% within budget using ings constructed under public–private commercially confidential. Comparison conventional procurement. With cost partnership arrangements may be between the two procurement models is and time seeming to be fixed in the PFI higher than the cost associated with also made more difficult by the need to model, concerns arise about the quality hospitals built and run using conventf take a life-cycle view to accommodate the of projects, with many of the hospitals tional procurement methods. Some of trade-offs between higher initial capital built using this model experiencing signf this additional cost may be justified as cost and lower long-term operating costs. nificant problems (Table 2).29,30 the National Health Service (NHS) in Although the decision to proceed with a It is important to distinguish betf the United Kingdom has had a poor project should be based on a process that tween problems inherent in the PFI

Box 1. Public–private partnerships facing financial problems Alzira Hospital, Valencia, Spain 26 In 1999 a consortium consisting of an insurance company, banks and construction companies was awarded a contract by the regional government of Valencia to construct a hospital to replace an obsolete facility. The hospital achieved high levels on standard measures of performance but was afflicted by poor labour relations. It became clear that the contract was financially unsustainable and in 2002 a refinancing deal was arranged, providing a substantial financial injection. The hospital is now working well. Paddington Health Campus, London, England 27 A private financing initiative approach was chosen as the mechanism to consolidate several world-class teaching hospitals on a single site in west London. In 2000 an Outline Business Case estimated a cost of £300 million with completion by 2006. When the scheme eventually collapsed the budget had risen to £894 million, with completion projected by 2013. Preparation of the failed project cost £15 million. The official report highlighted the extreme complexity of the project, unclear lines of accountability and a failure by central government to clarify whether it actually supported the scheme. La Trobe Regional Hospital, Melbourne, Australia 28 La Trobe Regional Hospital was built by a private company to replace older public hospitals, having entered into a confidential contract with the government of the state of Victoria to provide hospital services for 20 years. In 1999 the hospital lost AUS$ 6 million and was projecting ongoing losses. The Victorian health minister reported that the scale of losses was such that the hospital could no longer guarantee its standard of care. In 2000 the company was released from its contract in return for an agreement to drop legal action against the government. It sold the facility to the government for AUS$ 6.6 million (about half of its estimated valued) and made an additional payment of AUS$ 1 million.

892 Bulletin of the World Health Organization | November 2006, 84 (11) Special Theme – Contracting and Health Services Martin McKee et al. Privately financed hospitals

Table 2. Quality problems experienced with United Kingdom private finance initiative (PFI) hospital schemes

PFI development Problems 29,30

Cumberland Infirmary, Carlisle • Use of cheap components necessitating regular refitting • Maintenance costs 50% higher than projections. • Poor drainage and plumbing; and limited signage • Patients leaving the cardiology department must go through five sets of swing doors, even though most are in wheelchairs Durham District General Hospital • Pathology laboratory flooded three times in first 18 months, twice with raw sewage • Poor ventilation and air filtration • Fixtures and fittings are of poor quality; lightweight storage cupboards unable to take the weight of routine equipment Bishop Auckland Hospital • Opening delayed by 2 months for modifications • Generator and core electrical systems had to be redesigned immediately after opening Norfolk & Norwich Hospital • Negative pressure rooms were not properly operational for 2 years • Air ducting found to be lying in unconnected lengths • No ventilation in the kitchens so staff work in 30 °C temperatures (with 44 °C being recorded) • Delivery loading bays inefficient Hereford Hospital • Boiler house opened with no water treatment plant • Doors too heavy for the opening restraints • Three lifts had to be refitted within 12 months of operation Seacroft Hospital, Leeds • Mental health facility found to have breached “every section of the fire safety code” process and more general shortcomings given rise to several buildings that lack overall system has very little flexibility to in the mechanisms for the planning and natural light and have other undesirable adapt to the new circumstances. procurement of new hospitals. It is possf features. These shortcomings need not Incorporating flexibility into the sible that some of the issues with PFI are necessarily be a feature of public–private original design is possible without addfi a more general feature of the design and partnerships; rather they are a reflection ing costs for constructors or operators build model used in the United Kingdf of underdeveloped skills and an imbalfa but it does impose additional design dom, where public authorities, under ance of power and knowledge between costs. There are few incentives for consf pressure to outsource key activities, have client and contractor. sortia to build in flexible design solutions run down their architecture and plannf since the cost of future modifications fall ning departments. Instead of providing Flexibility on the client. As noted previously, the the contractor with detailed drawings, a The delivery of health care is changing “big bang” nature of most public–private broad specification, which the contractf rapidly, partly in response to altered partnerships makes it more difficult to tor can then interpret, is agreed. This demands on health-care systems, such adopt the modular approach to develfo approach has led to a series of failures in as shifting patterns of disease and risif opment that would provide more flexif several public sectors,31 but also in private 32 ing public expectations, and also in ibility, although only issues that can be sector procurement where firms have response to the opportunities offered anticipated will be addressed. also been under pressure to outsource by new technology.33 By contrast, the core functions. The expertise on the clief quest to minimize the risk to which the Complexity ent side of the PFI process is relatively parties to public–private contracts are Although the use of public–private partnf underdeveloped compared with PFI exposed has meant that the contracts are nerships has been effective when used consortia bidding teams. Whereas few health authorities will have undertaken a often specified in very great detail, with to finance transport infrastructure (but large penalties for introducing changes. even here there have been some high proff large capital development, the consortia 35,36 will have done several. This lack of flexibility has meant that file failures), this success has yet to be A related issue is the bundling of the configuration of some hospitals repeated in the health sector. The chalfl design with the rest of the PFI process. has been out of date by the time they lenges of implementing a public–private Although taking responsibility for design are opened. The problem is not unique partnership have been greatest in the case has some advantages for the consortia in to public–private partnerships but the of major teaching hospitals. These institf terms of being able to control the risks rigidity of contracts makes the solution tutions accept a wide range of referrals and costs of construction, design featf more complex. In England, the difficulty and provide services for various types of tures that benefit the user of the building of inflexible contracts has become more patients. As such, these projects involve rather than the operator may be less likely acute as new policies, especially in health, many different types of stakeholders. to be incorporated. Design elements that have created a much less stable environmf They also require the active participation might create a more therapeutic environmf ment. For example, there is currently a of universities and research funders. The ment or an improved work setting for deliberate intention to shift care away difficulties in reaching agreement with staff are not always implemented. The from hospitals.34 What would once have all of these stakeholders, combined with pressure to reduce building costs has been variable costs are now fixed, sothe the high costs of the projects, have led

Bulletin of the World Health Organization | November 2006, 84 (11) 893 Special Theme – Contracting and Health Services Privately financed hospitals Martin McKee et al. to the collapse of a major teaching hosfp more later to prevent the project from characterized by ideology rather than pital (the Paddington Health Campus) collapsing. evidence, with a reluctance to undertake development in west London (Box 1).37 One positive finding is that, comfp evaluations. In the United Kingdom one Failure results in very large losses in pared with the traditional system, new of the leading critics of the PFI has been terms of fees and prepayments. These facilities are more likely to be built subject to vociferous personal attacks by experiences raise questions as to whether on time and within budget; but these some politicians.39 this model can be simplified sufficiently gains seem often to be at the expense It is impossible to say whether to be used for very complex projects. of quality. The need to minimize the the model underlying public–private risk to the parties means that it is very partnerships is flawed or whether the Conclusion difficult to “future-proof” facilities in a difficulties with such endeavours are The delivery of hospital care inevitably rapidly changing world. Finally, while the result of mistakes in its execution. involves many partnerships between the the processes involved in procuring One plausible interpretation is that the public and private sectors. Here, we have standard general hospitals are now well additional complexity of public–private examined the situation where public established, the complexity involved is partnerships makes all but the most authorities contract with the private increasing, especially with very large straightforward projects just too difficf sector to run — and sometimes to build projects. cult. Uncertainty surrounding the role — a hospital. Major capital procurement is very and value of public–private partnersf The theoretical justification for privf difficult in any sector. Examples from ships in health care needs urgent resolutf vate financing of public facilities, altf the defence sector offer many cautionaf tion. O though debated, has come to be widely ary tales and there are striking parallels accepted. However the practical results between the difficulties being faced by Acknowledgements seem not to have lived up to what was those procuring a major teaching hospf We are grateful to Mick Brundle of Ove expected from privately funded ventf pital and the current procurement of Arup for advice on architectural issues. tures. The new facilities have, in general, two planned British aircraft carriers.38 been more expensive than they would However, public–private partnerships to Competing interests: Nigel Edwards have been if procured using traditional procure hospital services do seem especf is employed by an organization that recf methods and where the public sector cially difficult. ceives subscriptions from organizations does achieve a good deal from a privately Unfortunately, the debate on the undertaking PFI projects. funded development, it may have to pay merits of different approaches has been

Résumé Partenariats public/privé en faveur des hôpitaux Si dans tous les pays à économie mixte, on fait couramment appel avaient été obtenus selon des méthodes classiques. Ils ont aussi à certaines formes de partenariats public/privé pour construire et une plus grande probabilité d’être construits dans les délais et les exploiter des hôpitaux, un modèle de partenariat dans lequel une limites budgétaires prévus, mais ce résultat semble obtenu au prix autorité publique passe des contrats avec une entreprise privée de certains compromis avec la qualité. La nécessité de minimiser pour concevoir, construire et exploiter un hôpital entier, suscite les risques pour les parties implique une grande difficulté pour de plus en plus d’intérêt. En s’appuyant sur l’expérience acquise réaliser des établissements «capables d’affronter l’avenir» dans dans des pays comme l’Australie, l’Espagne et le Royaume-Uni, le un monde en évolution rapide. Enfin, ces projets sont extrêmement présent article analyse les résultats obtenus avec des variantes de complexes et dans certains cas atteignent un niveau de complexité ce modèle. Même si l’expérience disponible est encore très limitée prohibitif. Bien qu’il soit prématuré pour dire si les problèmes et si l’on manque d’évaluations rigoureuses de cette expérience, rencontrés proviennent du modèle sous-jacent ou de sa mise en quatre aspects ressortent en tant que critères de comparaison œuvre, il semble qu’un partenariat public/privé complique la tâche importants : le coût, la qualité, la flexibilité et la complexité. Les déjà difficile de construire et d’exploiter un hôpital. nouveaux établissements ont en général coûté plus cher que s’ils

894 Bulletin of the World Health Organization | November 2006, 84 (11) Special Theme – Contracting and Health Services Martin McKee et al. Privately financed hospitals

Resumen Alianzas publicoprivadas para los hospitales Aunque en todos los países con economías mixtas surgen ciertas métodos tradicionales. En comparación con el sistema habitual, formas de colaboración publicoprivada a la hora de construir y los nuevos servicios suelen construirse respetando los plazos y el gestionar hospitales, cada vez suscita más interés la opción de que presupuesto, pero ello se logra a menudo a expensas de la calidad. una autoridad pública contrate a una empresa privada para diseñar, La necesidad de reducir al mínimo el riesgo para las partes significa construir y dirigir todo un hospital. A partir de la experiencia de que es muy difícil crear servicios «a prueba de acontecimientos países como Australia, España y el Reino Unido, en este artículo futuros» en un mundo en rápida transformación. Por último, esos se analiza la experiencia adquirida con diversas variantes de ese proyectos son extremadamente, si no prohibitivamente, complejos. sistema. Aunque la experiencia es todavía muy limitada y no se Aunque sería prematuro afirmar que los problemas surgidos están han hecho evaluaciones rigurosas, han aflorado cuatro factores: relacionados con el sistema empleado o con su ejecución, parece costo, calidad, flexibilidad y complejidad. Los nuevos servicios han que la colaboración publicoprivada complica aún más la ya de por sido en general más costosos que si se hubieran empleado los sí difícil tarea de construir y dirigir un hospital.

ملخص رشاكات القطاع العام مع الخاص يف املستشفيات رغم أن بعض أشكال رشكات القطاع العام والخاص تعد مبثابة ظاهرة مميزة املرافق الجديدة يف غالب األحيان تبنى يف الوقت املحدد لها، وضمن امليزانية لبناء وتشغيل املستشفيات يف جميع البلدان ذات النظام االقتصادي املشرتك، املحددة لها، ولكن ذلك يف غالب األحيان يكون عىل حساب نقصٍ يف الجودة. فإن االهتامم يتزايد بنموذج تتعاقد فيه السلطات العامة مع رشكة خاصة ومتس الحاجة إىل التقليل وإىل أقىص حد ممكن من األخطار التي قد يتعرض لتصميم وبناء وتشغيل املستشفى بكامله. وباالعتامد عىل الخربات املكتسبة لها الطرفان الرشيكان، وهذا يعني أن من الصعوبة البالغة املوافقة عىل يف بعض البلدان مثل النمسا وأسبانيا وبريطانيا، تراجع هذه املقالة الخربات تصميماملرافق بشكل مالئم للمستقبل يف عامل رسيع التغري. وأخرياً فإن املستفادة من مختلف هذه النامذج. ومع أن الخربات املستفادة التزال مثل هذه التوقعات يف غاية التعقيد وقد تكون باعثة عىل اإلحباط. ومن محدودة جداً وأن التقييم الصارم مفقود حالياً، فقد الحت لنا أربع قضايا املبكر القول بأن املشكالت اآلن متعلقة بالنموذج الذي نجري دراساتنا حوله رئيسية هي التكاليف والجودة واملرونة والتعقيد. وميكن القول بشكل عام أو بطرق تنفيذه، ويبدو أن الرشاكة بني القطاع العام والخاص ستؤدي إىل أن املرافق الجديدة تتسم بأنها أكرث غالءً من تلك التي تستعمل الطرق املزيد من التعقيد يف املهام الصعبة التي تواجهها عمليات بناء وتشغيل التقليدية. وإذا قارنا بني املرافق الجديدة وبني النظام التقليدي نجد أن املستشفيات.

References 1. McKee M, Healy J, editors. Hospitals in a changing Europe. Buckingham: 15. Atun RA, McKee M. Is the private finance initiative dead? BMJ 2005; Open University Press; 2002. 331:792-3. 2. Crompton G. “Good Business for the Nation”: the railway nationalisation 16. Lethbridge J. European works councils and the healthcare sector. London: issue, 1921-47. J Transport Hist 1999;20:141-59. PSIRU; 2004. 3. Savoie DJ. Thatcher, Reagan and Mulroney: in search of a new bureaucracy. 17. Sveman E, Essinger K. Procurement of health care services in Sweden in Pittsburgh, PA: University of Pittsburgh Press; 1994. general, and the example of procurement of acute care in the Stockholm 4. Arrow KJ. Uncertainty and the welfare economics of medical care. Am Econ Region. In: European integration and health care systems: a challenge for Rev 1963;53:941-73. social policy. Stockholm: Swedish Federation of County Councils; 2001. 5. Le Grand J, Bartlett W. Quasi-markets and social policy. London: Palgrave, 18. News BBC. Jarvis to sell PFI bidding unit. Available from: http://news.bbc. Macmillan; 1993. co.uk/1/hi/business/3738716.stm 6. Kikeri S, Nellis J, Shirley M. Privatization: the lessons of experience. World 19. Treasury MH. OGC guidance on certain financing issues in PFI contracts. Bank/ IBRD: Washington DC; 1992. Available from: http://www.hm-treasury.gov.uk/media//6066B/PPP_ 7. Williamson OE. Markets and hierarchies: analysis and antitrust implications. GuidanceonCertainFinancing.pdf New York: The Free Press; 1975. 20. Gaffney D, Pollock AM, Price D, Shaoul J. The private finance initiative: PFI in 8. Ouchi WG. Markets, bureaucracies, and clans. Admin Sci Quarterly 1980; the NHS. Is there an economic case? BMJ 1999;319:116-9. 25:129-41. 21. National Audit Office Report (HC 78, 2005-06).The refinancing of the Norfolk 9. Preker AS, Harding A, Travis P. “Make or buy” decisions in the production of and Norwich PFI Hospital. London: NAO; 2005. health care goods and services: new insights from institutional economics 22. UNISON. Refinancing: profiting from public services.London: UNISON; 2001. and organizational theory. Bull World Health Organ 2000;78:779-90. 23. Pollock AM, Dunnigan M, Gaffney D, Macfarlane A, Majeed FA, on behalf 10. Tittenbrun J. Private versus public enterprise: in search of the economic of the NHS Consultants’ Association, Radical Statistics Health Group, and rationale for privatisation. London: Janus; 1996. the NHS Support Federation. What happens when the private sector plans 11. Duckett SJ, Jackson TJ. The new health insurance rebate: an inefficient way hospital services for the NHS: three case studies under the private finance of assisting public hospitals. Med J Aust 2000;172:439-42. initiative. BMJ 1997;314:1266-71 12. Robertson IK, Richardson JR. Coronary angiography and coronary artery 24. Anon. PFI/PPP conference (news). National Audit Office Focus. Available revascularisation rates in public and private hospital patients after acute from: http://www.nao.org.uk/guidance/focus12.pdf myocardial infarction. Med J Aust 2000;173:291-5. 25. Auerbach L. Issues raised by public–private partnerships in Ontario’s hospital 13. Vaillancourt Rosenau P, Linder SH. Two decades of research comparing sector. Ottawa: Canadian Health Coalition; 2002. for-profit and nonprofit provider performance in the United States.Soc Sci 26. Lethbridge J. Public health section relations and deregulation in Europe. Quaterly 2003;84:219-41. London: Public Services International Research Unit; 2003. Available from: 14. Bloom A. Hospital co-locations: private sector participation in the hospital http://www.epsu.org/IMG/pdf/Public_health_sect_and_deregul.pdf sector. In: Bloom A (editor) Health reform in Australia and New Zealand. Melbourne: Oxford University Press; 2000.

Bulletin of the World Health Organization | November 2006, 84 (11) 895 Special Theme – Contracting and Health Services Privately financed hospitals Martin McKee et al.

27. National Audit Office. The Paddingtion Health Campus scheme: report by the 33. McKee M, Healy J. The role of the hospital in a changing environment. Bull Comptroller and Auditor General. HC 1045. London: The Stationery Office; World Health Organ 2000;78:803-10. 2006. Available from: http://www.nao.org.uk/publications/nao_reports/05- 34. Department of Health. England. Your health, your care, your say. Available 06/05061045.pdf from: http://www.dh.gov.uk/NewsHome/YourHealthYourCareYourSay/fs/en 28. Parliament of Australia Senate Community Affairs Committee. The interface 35. Monbiot G. Captive state: the corporate takeover of Britain. London: Pan, between private and public hospitals. In: Healing our hospitals: a report 2001. on public hospital funding. Canberra: Commonwealth of Australia; 2000. 36. National Audit Office.The Channel Tunnel rail link. Report by the Available from: http://www.aph.gov.au/SEnate/committee/clac_ctte/ Comptroller and Auditor General. HC 302. London: The Stationery Office; completed_inquiries/1999-02/pubhosp/report/c06.pdf 2001. 29. Parliament UK. House of Commons questions 26 Jan 2006. Available from: 37. Vince N, Niven B. Lessons learned from the Paddington Health Campus http://www.publications.parliament.uk/pa/cm200506/cmhansrd/cm060126/ project: final report to the NWLSHA from the Independent Review Panel. debtext/60126-32.htm London: North West London Strategic Health Authority; 2005. 30. Hencke D. Private-finance hospital “putting lives at risk”. Guardian 17 June 38. House of Commons Defence Select Committee. Future carrier and joint 2005. Available from: http://politics.guardian.co.uk/publicservices/story/ combat aircraft programmes: second report, 21 December 2005. London: 0,11032,1508413,00.html UK Parliament; 2005. 31. Glancey C. Anatomy of a disaster. Guardian. 1 March 2004 Available from: 39. Carvel J. PFI critic demands retraction after “sloppy research” accusation by http://www.guardian.co.uk/arts/critic/feature/0,1159694,00.html MPs. Guardian 1 June 2002. Available from: http://society.guardian.co.uk/ 32. Chapman JC. Collapse of the Ramsgate walkway. Structural Engineer 1998; privatefinance/story/0,8150,725882,00.html 76:1-10.

896 Bulletin of the World Health Organization | November 2006, 84 (11)