At the Intersection of Health, Health Care and Policy

Cite this article as: Neelam Sekhri, Richard Feachem and Angela Ni

Public-Private Integrated Partnerships Demonstrate The Potential To Improve Downloaded from Health Care Access, Quality, And Efficiency Health Affairs 30, no.8 (2011):1498-1507 doi: 10.1377/hlthaff.2010.0461 http://content.healthaffairs.org/ The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/30/8/1498

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Not for commercial use or unauthorized distribution Global Health Financing

By Neelam Sekhri, Richard Feachem, and Angela Ni doi: 10.1377/hlthaff.2010.0461 HEALTH AFFAIRS 30, NO. 8 (2011): 1498–1507 ©2011 Project HOPE— Public-Private Integrated The People-to-People Health Foundation, Inc. Partnerships Demonstrate The Potential To Improve Health Care Access, Quality, And Efficiency Downloaded from

Neelam Sekhri (nsekhri@ hcredesign.com) is senior vice ABSTRACT Around the world, publicly owned and run health services face president of global access and challenges. In poor countries in particular, health services are alliances at Napo http://content.healthaffairs.org/ Pharmaceuticals, in San characterized by such problems as inadequate infrastructure and Francisco, California. equipment, frequent shortages of medicines and supplies, and low quality Richard Feachem is professor of care. Increasingly, both developed- and developing-country of global health at the University of California, San governments are embracing public-private partnerships to harness private Francisco. financing and expertise to achieve public policy goals. An innovative form

Angela Ni is a health care of these partnerships is the public-private integrated partnership, which consultant in Beijing, China. goes a step further than more common hospital building and maintenance arrangements, by combining infrastructure renewal with delivery of clinical services. We describe the benefits and risks inherent in

such integrated partnerships and present three case studies that by demonstrate innovative design. We conclude that these partnerships have Health Affairs the potential to improve access, quality, and efficiency in health care. More such partnerships should be launched and rigorously evaluated, and their lessons should be widely shared to guide policy makers in the effective use of this model. on May 1, 2016 by HW Team

ealth care is the world’s largest ing them to do better what they have failed to do industry and produces 9.8 per- well in the past. Although more money is defi- cent of the world’s gross domes- nitely needed in many countries,8 nations as tic product.1 Yet health systems wealthy as the United Kingdom and the United in many countries, regardless of States have found that money alone will not solve theirH level of income, are frequently described as the problems of medical services that are incon- “in crisis.” The problems are particularly acute sistent in quality and inefficiently delivered in for publicly operated health services. In many neglected facilities.9 There are exceptions, such low-income countries in particular, health ser- as the Department of Veterans Affairs and many vices are provided in crumbling facilities that are major US teaching hospitals.Yet governments at lacking basic sanitation, water, electricity, and all income levels find it difficult to finance capital functioning equipment and that experience fre- spending through tax revenues; have a poor quent shortages of medicines and supplies. Low- track record of managing infrastructure proj- quality services are inevitable.2–5 Similar prob- ects; and are challenged by the complexities in- lems occur at many public facilities in wealthy herent in providing health services.6,10 countries.6,7 Of course, the picture is more dire in Most countries have engaged private capital, developing countries. expertise, and innovation to strengthen public To address these problems, a common re- services in other sectors. However, investments sponse has been to spend more money on poorly in the health care sector in many countries have functioning government-run services, encourag- lagged behind this trend.

1498 Health Affairs August 2011 30:8 This situation is beginning to change as the continuum, the risks and rewards for both public-private partnerships in health become partners are greater. The integrated partnership more popular. Australia, Canada, and the United model, well along the continuum, is most appro- Kingdom have accessed private capital and priate in situations where the policy goal is to management for hospitals and have seen meas- mobilize private capital to fundamentally im- urable benefits such as facilities completed on prove quality, access, and efficiency in health time and budget, and well-maintained buildings services delivery. with functioning equipment. The United King- An integrated partnership consists of the dom has invested almost $21 billion in health government and a private partner—usually a facilities through private finance initiatives consortium of health providers and financiers. 11,12 and public-private partnerships since 1997. These entities enter into a long-term agreement, Downloaded from These models have their critics,13 but studies in which the partner accesses private capital and show they have achieved average savings of expertise to build or renovate health facilities, 17 percent compared to public-sector options.10,14 and also agrees to deliver services to a broad In Mexico, for example, the public-private part- segment of the population in those facilities over nership approach led to construction and open- an extended period. The detailed contract is ing of a hospital in thirty-six months, compared structured around a defined project and specifies

to fifty-seven months for a similar publicly man- financial, operational, and clinical standards http://content.healthaffairs.org/ aged project.15 Brazil has also benefited from that the private partner must meet.18 private-sector management of public facilities.16 The government retains its role as the ultimate Some countries are taking the next step, by payer of health care. In some arrangements the bringing the private sector in for both infrastruc- government makes no payments to the private ture renewal and delivery of clinical services17,18 partner until facilities are completed and through public-private integrated partnerships, delivery of care begins.18 This can be two to four also known as “integrated partnerships.” Ap- years from the time the contract is signed, pro- proximately 80 percent of hospitals’ annual viding an incentive for timely opening of new costs are for clinical and ancillary services. Thus, facilities that meet agreed-upon standards. The these integrated partnerships are opportunities government is also responsible for safeguarding for higher efficiency gains than is the case with the public interest by setting and overseeing public-private partnerships that focus solely on quality and performance standards. by infrastructure.17,19 Facilities developed through this model are Health Affairs In this article we describe the integrated part- intended to serve the same population as the nership model in greater detail, highlighting public facilities they replace, including provid- both its potential benefits and risks.We describe ing access for the poor. The government may how the model differs from other public-private also use the arrangement to expand outreach partnership arrangements, provide examples of to underserved populations by targeting new ser- integrated partnerships in various countries, vices to rural areas and urban slums. Financially, on May 1, 2016 by HW Team and examine lessons from both failed and suc- the facilities must deliver value for money for cessful arrangements. both the government and patients. Integrated partnerships should be cost- neutral at the point of service, with patients pay- What Is An Integrated Partnership? ing the same or less out of pocket under the new The goal of any partnership with the private sec- arrangement. Ideally, as in the examples de- tor is to actively enlist private capital, both hu- scribed in this article show, they are “cost- man and financial, to help governments fulfill neutrality squared” in that they also deliver their responsibilities for providing equitable ac- higher quality, and often a higher volume of cess to high-quality public services. As Andrew services in new facilities at the same or less cost Smith, the United Kingdom’s chief secretary of to the government than the services in the old the treasury, noted, “Partnerships enable the facilities.21 public sector to benefit from commercial dyna- Integrated partnerships share certain features mism, innovation and efficiencies, harnessed that distinguish them from other models along through the introduction of private sector invest- the continuum. These partnerships provide an ors who contribute their own capital, skills, and end-to-end “bundled” solution, in which the pri- experience.”10(p5) vate partner is actively involved in designing, Choices of how to involve the private sector financing, building, and maintaining health fa- depend on the public policy goals and the level of cilities and delivering clinical services in those risk and potential reward expected. Appendix facilities (see Appendix Exhibit 2).20 The com- Exhibit 1 shows a continuum of public-private prehensive functions of these partnerships dif- partnership arrangements.20 As one moves along ferentiate them from private finance initiatives

August 2011 30:8 Health Affairs 1499 Global Health Financing

or other public-private partnerships, which do with service standards and assist the government not include clinical services.21 with its new role of contract management, an Unlike short-term contracting, integrated independent monitoring and evaluation body partnerships feature long-term investments is often created. The private provider’s payment and shared risks, resulting in mutual commit- is contingent on achieving and maintaining ment to successful outcomes. Return on invest- national or international health services accredi- ment comes over time based on performance, tation using agencies such as the Joint Commis- which makes it harder for either party to walk sion.24 This is particularly important in develop- away from the partnership. The private partner is ing countries, where public oversight of care can paid based on outputs at specified performance be weak.

levels and is accountable for meeting quality Downloaded from standards. The government shifts to the private partner the risk for construction delays, cost Examples Across The Economic overruns, inadequate or poorly trained staff, Spectrum and inefficient care that fails to meet agreed- There are many ways to structure an integrated upon benchmarks. The government retains the partnership based on the unique circumstances risk for payment of services and for ensuring that of the country, project, or community. We se-

good access and quality are provided for the lected the three cases described below because http://content.healthaffairs.org/ people served. they highlight how the model has been adapted In integrated partnerships, the government across a range of income levels. They represent retains ownership of assets. This feature also innovations in design that may be useful for fu- distinguishes integrated partnerships from pri- ture applications. Exhibit 1 summarizes their key vatization, in which public assets are sold to the features. private sector. Lesotho: A New Hospital And Clinic Net- work Lesotho is a land-locked country sur- rounded by the Republic of South Africa. In Why Consider An Integrated 2008 the Lesotho Ministry of Finance and Devel- Partnership? opment Planning awarded a contract to Tšepong The potential benefits of well-structured inte- Ltd. to replace Lesotho’s only tertiary hospital,

grated partnerships are that they can provide Queen Elizabeth II Hospital. The hospital was by greater stability in capital and operational public 100 years old, was in bad repair, consumed in- Health Affairs budgets, improve equity of access, and improve creasing amounts of government funds, and de- quality. Bringing in private capital spreads livered poor and deteriorating services. government payments for infrastructure over Tšepong, a consortium of community groups, the useful life of a facility, instead of requiring funders, and providers led by the South African a large up-front investment. Importantly, the health care group Netcare, is responsible for co- government’s repayment includes maintenance financing, building, maintaining, and delivering on May 1, 2016 by HW Team over the life cycle of the asset, estimated at 30– services in a new 425-bed national referral hos- 35 percent of costs, which is often underreserved pital linked to three primary care clinics and a as a result of constraints in annual public budget- gateway clinic, located adjacent to the hospital to ing processes.10,22 triage patients. The hospital will serve as the Stability in operational budgets is achieved main clinical teaching facility for a range through payment methods that put the private of health professionals. Capital costs of US provider at risk for budget overruns and that $120 million were financed through commercial make payment contingent on outputs meeting loans by the Development Bank of South Africa defined performance standards.23 Common and equity investors (66 percent) and the methods for provider payment include capita- government (34 percent).25–27 tion or global budgets, which shift financial risk The integrated partnership aims for better for care to the private partner. Although these than “cost-neutrality squared,” meaning that it methods can be used in publicly run services, the is actually structured to expand the volume of formal contractual agreement creates a level of services provided while holding the operating accountability in cost management that is other- budget at current levels. Specifically, the wise hard to enforce when the government is government has negotiated a commitment from both the purchaser and the provider of care. the partnership to accommodate a 24 percent Finally, integrated partnerships can result in increase in outpatient visits and a 21 percent systemic quality improvements because they in- increase in inpatient visits. Patients pay the same clude explicit agreements on performance mon- out-of-pocket payments at the new facilities as at itoring that specify measurable, internationally the existing ones. recognized standards. To guarantee compliance The project is designed to enhance economic

1500 Health Affairs August 2011 30:8 Exhibit 1

Examples Of Integrated Partnerships In Three Countries

Feature Lesotho Turks and Caicos Islands Valencia, Spain Rationale for using a PPIP Improve systemwide Repatriate treatment Reduce costs; introduce efficiency, quality, and overseas; increase access; innovation in care delivery access; promote economic improve quality development and local ownership Facilities constructed/refurbished Teaching hospital: 425 beds, 1 Two integrated hospital University hospital: 300 beds; gateway clinic, 3 filter facilities: 13 surgery suites; 22 clinics Grand Turk: 20 beds emergency beds; 22 ICU Downloaded from Will also reengineer Lesotho’s Provendiacles: 40 beds beds; 65 outpatient rooms; drug supply system Primary care clinics, specialty 7 PICU beds outpatient, dental clinics in 46 primary care clinics hospital complex 4 integrated health centers Services delivered Full range of clinical services Full range of clinical services Full range of clinical services, including primary care, with limited tertiary care; including primary care, inpatient care, maternity includes primary care, inpatient care, surgery, care, neonatal and pediatric inpatient care, maternity outpatient care, intensive http://content.healthaffairs.org/ ICU, emergency care, care, emergency care, care, radiology, lab dialysis, lab, radiology, diagnostics and imaging, medical transport, medical dentistry, dialysis, equipment pathology, and blood bank; does not include outpatient pharmacy Residents/patients served Contracted visits annually Full care for 35,000 residents Full care for 250,000 more than 20% above (with the exception of some residents; if residents current numbers for same primary care services on choose to go elsewhere, price: 310,000 outpatients, outlying islands) Alzira pays 100% of costs 20,000 inpatients of care; if patients from other areas go to Alzira,

government pays 80% of by costs. Health Affairs Consortia ownership structure Tšepong Ltd.: Interhealth Canada UTE-Ribera Adeslas Netcare: 40% (insurance company): 51% Excel Health Ribera Health (building (Basotho doctors): 20% societies): 45% Afri’nnai (Basotho doctors Lubasa (construction in South Africa): 20% company): 4% on May 1, 2016 by HW Team Women Investment Group: 10% Lesotho Chamber of Commerce: 10% Capital cost US$120 million US$124 million €61 million (US$82 million) (€68 million [US$92 million] more will be invested during life of contract) Payment terms Unitary payment for capital Unitary payment for building Single capitated payment of investment and maintaining facilities €607 per resident in 2009 Annual global budget for Per capita payment for (US$819) (includes capital clinical services based on clinical services negotiated costs) negotiated volumes annually based on medical Annual increases in operating price index and additional budget based on medical services cost inflation for publicly Profit margin capped at 10% operated hospitals in area Profit margin capped at 7.5% Length of contract 18 years 25 years; renewable to 15 years; renewable to 30 years 20 years Date became operational 2010–11 2010 1999

SOURCES See Notes 18 24, 25, 26, 28, 29, and 30 in text. NOTES PPIP is public-private integrated partnership. ICU is intensive care unit. PICU is pediatric intensive care unit.

August 2011 30:8 Health Affairs 1501 Global Health Financing

development by requiring local participation health care costs are lower because expensive and investment. Local businesses, women’s overseas referrals have been replaced by less- groups, and physicians currently own 40 percent expensive on-island services, yet overall patient of Tšepong. This ownership share is expected payments remain unchanged. Accreditation by to grow to 60 percent in the future. The Accreditation Canada28 is required after two government believes that the new facilities will years of operation. Failure to obtain accredita- help retain current staff and provide opportuni- tion or its subsequent loss is a cause for termi- ties for Basotho (as the people of Lesotho are nation of the contract. known) doctors and nurses who have left the Spain: Integrated Care In A Health Dis- country to return and practice in Lesotho. trict In 1997 the regional government of

Accreditation and ongoing monitoring are Valencia, Spain, launched its first integrated Downloaded from important features of the integrated partnership partnership in the Alzira district. The partner- that will have a systemic effect on quality. The ship was between the Valencia government and provider is required to obtain independent UTE-Ribera, a consortium led by Adeslas, a accreditation by the Council for Health Service health insurer and provider. The fifteen-year Accreditation of Southern Africa. Failure to be contract, which could be extended to twenty accredited or loss of accreditation provides years, includes development and management

grounds for termination of the contract. In ad- of a full range of services from prevention http://content.healthaffairs.org/ dition, an independent contract management through tertiary care for the 250,000 residents company appointed by the government will pro- of the Alzira district. The integrated health sys- vide quality oversight through quarterly audits. tem includes a 300-bed university hospital, a The company will recommend financial penal- district health network of four health centers, ties for Tšepong in the event of failure to meet and forty-six primary care units. The initial performance standards. capital costs were US$82 million, with an addi- The refurbished primary care clinics became tional US$92 million committed for improve- operational as of mid-2010. The hospital is on ments over the contract period.21,27,29,30 track to serve patients in late 2011. “Cost-neutrality squared” was exceeded be- Turks And Caicos Islands: National cause the capitation payment to the provider Health Reform The Turks and Caicos Islands was benchmarked at 25 percent less than the

are a British overseas territory located about Valencia health ministry’s budget for public fa- by 650 miles east of Miami, Florida. In 2008 the cilities in neighboring districts, and there were Health Affairs government of the Turks and Caicos Islands no out-of-pocket patient payments. Profit mar- finalized a twenty-five-year contract with a con- gins were capped at 7.5 percent. In this arrange- sortium led by Interhealth Canada. The agree- ment, money follows patients: UTE-Ribera must ment was to build two new health complexes pay the ministry 100 percent of treatment costs with a total of sixty beds and deliver a full range for Alzira residents who choose to seek care in of integrated health services. The clinical ser- other districts. This ensures choice for patients on May 1, 2016 by HW Team vices agreement is a separate contract that is and competition among providers. renewable every five years, to allow competitive The integrated system, in operation for a de- benchmarking. cade, has generated considerable outcome data The integrated partnership provided the foun- showing that it provides high-quality services dation for a complete restructuring of the is- at 25 percent lower cost than public facilities lands’ health system, which also includes a (Exhibit 2). In patient surveys and performance national health insurance plan to provide sus- measures, the hospital consistently ranks among tainable financing and a health regulatory au- Spain’s top twenty hospitals. The model has pos- thority to monitor quality. The consortium itively affected the performance of Valencia’s independently secured capital funding of public hospitals as well. For example, the use US$124 million. The hospitals were completed of ambulatory surgery pioneered by Alzira is ahead of schedule in January 2010, and services now widespread, and the rate of cesarean sec- began in April of that year. tions for low-risk deliveries has been dramati- The government’s repayments for construc- cally reduced.31 As a result, use of the model tion, equipment, and maintenance began only has expanded to include four other health dis- when the facilities were completed. Payment for tricts in Valencia and the Madrid region. clinical services, based on capitation, began Common Elements These three examples when the hospitals were operational. Profit mar- share the following innovative elements. First, gins on clinical services have been capped at less efficiency gains in health services delivery were than 10 percent.18,21,27 achieved through contracting for more and The integrated partnership exceeded “cost- higher-quality services at the same price, as neutrality squared.” The government’s overall was done in Lesotho and the Turks and Caicos

1502 Health Affairs August 2011 30:8 Exhibit 2

Key Performance Indicators In The Alzira District Of Valencia, Spain, 2009 Indicator Performance Cost €607 per capita, almost 25% less than comparable public hospitals Surgeries per day 6.6 per operating theater, compared to 5.4 per operating theater in public facilities Average length-of-stay 4.76 days, compared to 5.22 days in comparable public hospitals Waiting lists None: outpatient visits generally occur within 2 weeks; elective surgeries occur within 90 days Access Outpatient and elective surgeries from 8:00 a.m. to 9:00 p.m., compared to public hospitals that do not provide clinical services after 3:00 p.m. Patient satisfaction 87% satisfied with services; 95% loyal to hospital Downloaded from Staff compensation Productivity and performance incentives for all staff; doctors earn 25% more than in public hospitals Technology First to have integrated computerized medical history; system has been used as model for expansion to public facilities

SOURCES See Notes 26, 27, 29, and 31 in text.

Islands, or the same level of services at a lower dence on where they work best, how they should http://content.healthaffairs.org/ cost, as in Spain. The government received more be structured, and the myriad details that must value for its money, patient fees remained the be managed to ensure success. Although some same, and quality improved. integrated partnerships have failed, evaluation Second, integrated care models, linking pre- of these is limited. An exception is Australia, ventive, primary, secondary, and tertiary care, where Abby Bloom and Annette Schmiede ana- were introduced. There is growing evidence that lyzed the partnership efforts. During the 1990s integrated delivery achieves better outcomes at a Australia implemented seven integrated partner- lower cost than other models.32–34 The partner- ships as part of a multisectoral effort to improve ship in Spain evolved from a stand-alone hospital public services within severely constrained to an integrated system because this was essen- budgets.35 Of these, two had reverted to public tial to ensure financial viability while addressing management by 2004, and several others were 29 population health needs. In Valencia and the struggling. The authors cited several factors con- by Turks and Caicos Islands, capitation payments tributing to the partnerships’ difficulties.35 Health Affairs avoided perverse incentives to maximize pay- First, the parties were unable to agree on meth- ment through expensive hospital care. ods for negotiating annual operating budgets. Third, provider payments were linked to meet- Second, lack of data and transparency of pub- ing internationally recognized quality and per- lic-sector costs made it difficult to establish “fair formance standards, validated by independent value” in pricing for contracted services and ac- bodies. In developing countries, this is not gen- counting for changes in volume over time. on May 1, 2016 by HW Team erally true of public hospitals, and introducing Third, contracts with few demand-side con- standards has positive effects on the entire trols resulted in too much risk being transfered health system. to private operators, which made the contracts unsustainable. It was evident that both the public and private partners were inexperienced in Managing The Risks long-term contracting. Multiple and often con- In addition to the integrated partnerships de- flicting objectives, clash of cultures, and insuffi- scribed in this article, similar arrangements cient understanding of the incentives and needs exist in Australia, Brazil, Canada, the Gambia, of the other party were common across the Germany, Mexico, Portugal, Romania, and Australian integrated partnership projects. South Africa.27,28 Similar models are being Bloom and Schmiede pointed out that some considered in Egypt, India, Malawi, Namibia, problems might have been resolved over time. Uzbekistan, and Zambia. Variations exist in But the political environment that supported Brazil, Germany, and Slovakia, ranging from partnerships with the private sector had minimal capital investment by the private part- changed, which left little political commitment ner to joint ventures with both public and private to continuing with the model. This scenario shared equity.16,19,27 was also observed in Portugal, where a con- To achieve the full rewards of integrated part- servative government embarked on an ambitious nerships, governments must actively manage integrated partnership program that was cur- their associated risks. Experience with inte- tailed when a socialist government came into grated partnerships in health is still limited, power.36,37 and it will take more applications to gather evi- Empirical evidence from models that have

August 2011 30:8 Health Affairs 1503 Global Health Financing

failed to deliver35,37 and those that have shown well-managed providers to undertake the risks success point to a number of risks that must be of partnering with governments. Where public managed.38 debt is high or there is political instability, the First, the integrated partnership requires financial case alone will not be strong enough for strong and sustained leadership from senior the private sector to invest the large amounts of champions in the government with sufficient time and money needed to enter into such part- political stature to manage powerful stakehold- nerships. Risk mitigation strategies, such as en- ers. Leaders can expect initially to be vigorously suring a transparent procurement process, or opposed by opposition parties, medical associa- international guarantees (for example, through tions, unions,30 patient groups, international the Multi-Lateral Investment Guarantee Agency

agencies, and major nongovernmental organiza- of the World Bank) may be needed. Downloaded from tions,39 all of which may be skeptical of private- Fifth, investment in planning and expert re- sector involvement in health or have a vested sources is critical. A thorough initial assessment interest in the status quo. Political leadership will help ensure that the project serves health often comes from the treasury, because of the policy goals and does not create excess capacity scale of the investment and that department’s or tie the government to outmoded delivery mod- experience with public-private partnerships in els.37 Investment in expert transaction advisers is

other sectors. Importantly, high-level commit- needed to negotiate long-term contracts that http://content.healthaffairs.org/ ment must be sustained and not change with fairly allocate risks and rewards and to specify the political ideology of the day.35–37 measurable performance standards. To build lo- Second, integrated partnerships create new cal capacity in contracting, many countries have and unfamiliar roles for government. Ministries established agencies to support public-private of health are no longer direct providers of care. partnerships and track their performance.46–49 Instead, they must be regulators, partnership As in other sectors,50 an advantage of accessing managers, and purchasers. To be successful in private capital is that external funders force rigor these roles requires dedicated resources and suf- in the design of public projects, requiring a ro- ficient investment in capacity building. The UK bust business case that ensures sustainability.23,51 Office of Government Commerce recommends Although this scrutiny can be onerous for al- allocating 2 percent of the total cost of a project ready burdened ministries of health, the initial

to provide partnership and contract manage- investment makes it less likely that projects are by ment over the life of an arrangement.39 abandoned midstream; facilities sit empty with- Health Affairs Third, the success of the arrangement is deter- out adequate resources to equip and operate mined by the ability of the public and private them; or services are delivered inefficiently, fail- sectors to forge a partnership that can adapt to ing to meet the needs of the target communities. the inevitable changes that will occur over a Finally, these arrangements may require new multiyear relationship. In clinical services deliv- institutions—in the government or independent ery, this means agreeing at the outset on fair risk bodies—that can develop and monitor perfor- on May 1, 2016 by HW Team allocation and rewards and on methods to set mance standards to demonstrate continued prices and negotiate changes in services and vol- value for investment and achievement of policy umes. Partnerships are not arm’s-length con- objectives. This maintains public confidence in tractual agreements but are more like marriages, the arrangement and ensures that appropriate requiring a high degree of trust and an appreci- course corrections take place as the partnership ation for the incentives and motivations of the evolves. Although the investment in monitoring other party. Partnership protocols, multilateral and oversight mechanisms can be burdensome, agreements, open-book accounting for cost these features can lead to fundamental changes transparency, joint risk management teams, in quality and access well beyond the integrated and shared governance are useful tools.40–45 partnership. Fourth, selection of the right private partner requires greater interaction and discussion with potential bidders during the precontracting Conclusion phases and a more flexible approach to procure- Major improvements in health systems require ment than traditional public processes often al- approaches that must simultaneously address low. Public processes may need modification to not only infrastructure and financing, but reflect practices more common in the private also access, service delivery, and management, sector, such as collaborative specification devel- to achieve better patient outcomes. Many cur- opment and cultural compatibility assessment. rent initiatives offer a piecemeal approach In many lower-income countries, effort will be to strengthening health systems.4,52–54 In con- required to encourage a diverse private market trast, the integrated partnership model is com- that supports high-quality, well-financed, and prehensive and can deliver important benefits,

1504 Health Affairs August 2011 30:8 as Spain’s experience illustrates. To gain a full appreciation of the strengths and In trying to fundamentally improve health sys- weaknesses of this model and its applications tems, policy makers are confronted by the ques- requires more projects accompanied by rigorous tion of whether they face a greater risk in con- and independent evaluation. We encourage the tinuing to pursue what has not worked in the international community to strengthen the evi- past, or in trying new approaches. The evidence dence base by supporting integrated partner- shows that integrated partnerships are a new ships and evaluating their performance, to pro- approach that may be relevant across a range vide practical guidance to policy makers on when of country income levels. and how to use this model most effectively. ▪ Downloaded from The Global Health Group at the and the World Bank. The Healthcare Dominic Montagu, Heather Kinlaw, University of California, San Francisco, Redesign Group is a for-profit Mudita Tiwari, and Matthew Loening for is dedicated in part to documenting consultancy assisting public and private their many contributions. They also innovative approaches for private-sector clients in health policy and financing thank Hyun Woo for her assistance with engagement in health systems reform. It played a key role in the the manuscript and the anonymous strengthening. Its work is supported by design of the integrated partnership and reviewers for their suggestions to the Bill & Melinda Gates Foundation, health care reform in the Turks and improve the paper. ExxonMobil, the Rockefeller Foundation, Caicos Islands. The authors thank http://content.healthaffairs.org/ NOTES

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1506 Health Affairs August 2011 30:8 ABOUT THE AUTHORS: NEELAM SEKHRI, RICHARD FEACHEM & ANGELA NI

global access and alliances for Commander of the Order of the Napo Pharmaceuticals, in San British Empire in 2007, has also Francisco. She is also the chief workedfornumerousagenciesand executive officer of the Healthcare organizations throughout the Neelam Sekhri is Redesign Group. Sekhri is a world, including the World Bank senior vice member of the faculty for the andtheWorldHealth Downloaded from president of global Global Health Leadership Forum at Organization. access and the University of California, Feachem is a member of Health alliances for Napo Berkeley, and teaches in the Global Affairs’ Global Advisory Board. His Pharmaceuticals. Health master’sprogramofthe numerous degrees include a Neelam Sekhri, Richard Feachem, University of California, San doctorate of science in medicine and Angela Ni present their study Francisco (UCSF). Sekhri from the University of London in on the use of public-private previously worked at the World 1991 and a doctorate in http://content.healthaffairs.org/ integrated partnerships— Health Organization and for Kaiser environmental health from the arrangements in which the private Permanente. She holds a master’s University of New South Wales. sector partners with governments degree in hospital and health care Feachem and coauthor Sekhri are to upgrade health system administration from the University married. infrastructure and deliver clinical of Minnesota. services. The authors determined that the partnerships have the potential to improve access to and quality and efficiency of care. They recommend that more such partnerships be created and by evaluated for their potential to Angela Ni is a boost health outcomes. health care Health Affairs Sekhri says that she first became Richard Feachem is consultant in professor of global Beijing. aware of such arrangements as a health at UCSF. member of the team that designed Ni was a Fulbright Research andlaunchedtheintegrated Feachem, the former executive Fellow in China and is now partnership in the Turks and director of the Global Fund to working as a health care consultant on May 1, 2016 by HW Team Caicos Islands. She has since Fight AIDS, Tuberculosis and in Beijing. Prior to this, she studied this model in Valencia and Malaria,nowservesasexecutive worked at the Global Health Group elsewhere and has become director of UCSF’s Global Health at UCSF. She has a bachelor’s persuaded of the potential of these Sciences and director of its Global degree in political economy from partnerships to improve quality Health Group. He also is professor the University of California, and access in public health of global health at UCSF and at the Berkeley. facilities globally. University of California, Berkeley. Sekhri is senior vice president of Feachem, who became a Knight

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