This is an unprecedented time of change for the healthcare sector globally. Demand is rising exponentially as life expectancy increases, and patients are better informed and have higher expectations. The information revolution has also given clinicians better access to evidence-based practice, and scientific and technological innovation that will transform the way health services are delivered.
The United Nations' Sustainable Development Goals (SDGs) set some challenging targets in relation to healthcare. As well as SDG3 – the aim of ensuring healthy lives and the promotion of wellbeing for all at all ages – they also include targets for reducing inequality, improving the resilience and sustainability of services and infrastructure, and economic development. Many of the other SDGs – improving water and sanitation, ending poverty and hunger, and the promotion of inclusive, safe, resilient and sustainable cities will directly enable societies to improve health outcomes and provide healthcare more efficiently to their people.
Unfortunately, many health systems are subject to tough financial constraints and realising the SDGs will call for significant investment. One way of overcoming this challenge could be the use of Public-Private Partnerships (PPPs), but they must be used very carefully. If managed well, PPPs can play an important role in attracting private sector expertise and investment that will help achieve the SDGs.
At their best they can enable change, give patients the best care in an appropriate setting, and make healthcare staff feel valued and fulfilled. But it is crucial that the suitability of PPP for any given programme is carefully assessed; at their worst they can represent poor value for money and lack transparency which could result in worsening inequality.
SDG3 comprises three subgroups: three targets similar to the Millennium Development Goals (ending certain epidemic and communicable diseases, and reducing maternal deaths and infant mortality); three focussed on non-communicable diseases (addressing road traffic accidents, substance abuse and mental illness); and three cross-cutting targets aiming to improve health systems, including universal health coverage.
The first of these categories can have the most easily defined investment needs and measures of success. A reduction in maternal mortality ratio (MMR) to 70 per 100,000 live births (SDG3.1) will require each country to reduce its MMR by two thirds, and no country should have an MMR greater than 140. Some of the world’s lowest income countries have a baseline MMR greater than 420 with the highest levels seen amongst poorer rural communities which have limited access to healthcare services. To address this there is a need for significant investment in infrastructure, technology and staff.
The Saving Mothers Giving Life partnership is one example – a PPP between the governments of Uganda, Zambia, the USA and Norway, clinical institutions and the commercial firm Merck delivered over $10m of capital investment in facilities such as operating theatres to perform safe caesarean sections; and recurring costs associated with staffing and improvements in maternal health networks, leading to reductions in maternal mortality by 53% in target facilities in Zambia, and 45% in target facilities in Uganda.
The key to addressing non-communicable diseases is the introduction of sustainable public health strategies and effective local networks. Low levels of investment and high cultural barriers can therefore make it a difficult match for PPP. In 2003, a PPP between Pakistan’s Ministry of Health and Non-Governmental Organisation Heartfile developed a plan for better integrating efforts to tackle non-communicable diseases and invested in development and communication of the plan and its delivery through local networks. But they found that changes in national governance, health system constraints such as poor regulation of private providers, and incoherent clinical workforce planning impeded its implementation.
Changing health systems is the most difficult task to assess. There is a need for investment in strong health information systems and the generation of robust, relevant measures in the first instance. But improving equality of access calls for a clearly defined set of healthcare policies and strategies for delivering them, so that investment is prioritised in the areas where it will make the most difference.
Where this has been tackled successfully, the programmes are characterised by strong and objective political focus on areas where PPPs will really add value, and a robust partnership between the government and private sector which provides demonstrable value for money. It is crucial that these partnerships are systematically assessed because there is no single “private sector” and the quality of outcomes will depend on many factors, including the simplicity of the project, its suitability for PPP arrangements and the culture and approach of each specific private sector partner.
There are good examples of success: In Ghana, the establishment of a National Health Insurance Scheme which features private as well as public investment resulted in a five-fold increase in access to primary healthcare services between 2003 and 2011. The governments of Mexico and Singapore have taken the same approach and seen similar results.
The need for clarity and evidence-based guidance on implementation has led the United Nations Economic Commission for Europe to sponsor the development of UN Standards on best practice in the implementation of PPP programmes. Starting at a very high level, the Standards will provide governments with recommendations on implementation developed by PPP specialists from government and the private sector. UNECE will also commission “Centres of Excellence” in several sectors which will provide ongoing advice and support to governments considering PPP programmes.
The Sustainable Development Goals represent a shared vision for the world’s population in 2030. PPPs can play a significant role in delivering them, but it is critical that governments ensure that any PPP programme fits within an appropriate policy framework and investment strategy, so that it delivers the best possible value for money. One important feature of successful PPP programmes is the development of strong public sector management skills and governance, and the recent development of PPP management certification programmes will help achieve this end.
Director of Healthcare Projects
Peter is responsible for business development in the healthcare sector for John Laing, a leading international investor in economic and social infrastructure which has delivered more than 20 major healthcare PPP projects and over 40 clinics and primary care facilities.
He has worked on the development of public infrastructure since 1989 and has substantial experience in the successful structuring and delivery of a diverse range of Public-Private Partnerships in the healthcare, water and transportation sectors in the UK, Africa, the Middle East, South East Asia and the Caribbean. Since 2001 he has focussed specifically on healthcare projects, managing the development and delivery of major acute and mental health schemes with a capital value exceeding £2bn.
Peter is a Chartered Civil Engineer and a Fellow of the Institution of Civil Engineers. He is also a Non-Executive Director of the Oxford University Hospitals NHS Trust which operates one of the UK’s leading teaching hospitals, and is leading a project to develop a standard for the implementation of Healthcare PPP projects globally for the United Nations.