assignment 3-2

RESEARCH ARTICLE Open Access

Exploring shared risks through public- private partnerships in public health programs: a mixed method Wadi B. Alonazi

Abstract

Background: The natural assimilation of the process through which health partners sustain long-term relationships is a key issue in maintaining social well-being, reducing health risk factors, and sustaining public health programs. One global initiative in building effective healthcare systems is public-private partnerships (PPPs). This study elucidates the proposed key performance indicators initiated by the Ministry of Health of Saudi Arabia based on the projections of the government, known as Vision 2030, from the perspective of health risk factors.

Methods: Through an inductive content analysis, this study assessed primary and secondary data in relation to the Saudi National Transformation Program (NTP). To identify the institutions that played a role in formulating the new Saudi Healthcare System, health policies, regulations, and reports published between 1996 and 2016 were categorized. After ranking the risk factors, the investigator selected 13 healthcare professionals in four focus group interviews to insightfully explore the challenges that the NTP faces from a health risk perspective. Thus, the study employed qualitative data gathered through focus group interviews with key figures as well as data extracted from written sources to identify distinct but interrelated partnerships practiced within risk management.

Results: A methodological overview of NTP priority and implementation offered practical guidance in the healthcare context. The five critical factors in maintaining successful and sustainable PPPs were (1) trustworthiness, (2) technological capability, (3) patient-centeredness, (4) competence, and (5) flexibility. Concession on primary and secondary healthcare services might be a good option based on the literature review and considering its popularity in other countries. A high outcome-based risk of PPPs was found as the most commonly shared perspective in risk management.

Conclusions: Although the impact of the NTP rise has yet to be explored, its potential for challenging health consequences requires consideration and substantial regulatory action. This study contributes to the emerging critical analysis on local health initiatives by highlighting how integration may only be possible with a more radical conceptualization of national health governance.

Keywords: Public-private partnerships, Vision 2030, Risk shared, Saudi national transformation program, Public health programs

Correspondence: [email protected] Health Administration Department, College of Business Administration, King Saud University, PO Box 71115, Riyadh 11587, Saudi Arabia

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Alonazi BMC Public Health (2017) 17:571 DOI 10.1186/s12889-017-4489-z

Background For decades, the Ministry of Health (MoH) of Saudi Arabia (SA) has substantially financed and delivered 60% of the Saudi Healthcare System (SHCS), although other semi-governmental agencies and private sector actors have had their equal share of influence. Except for three landmark events—launch of the Council of Cooperative Health Insurance (CCHI) in 1999, Saudi Central Board for Health Accreditation Institutions (CBAHI) in 2005, and Saudi Health Council (SHC) in 2009—the SHCS has not changed significantly in terms of major financing and regulation [1–3]. The Saudi constitution emphasizes effective and accountable healthcare provisions for the entire population through universal access to basic healthcare services. Although the government subsidizes the public healthcare system, the system’s performance level has not yet shown promise, especially competent medical specialization [4]. Various forces have chal- lenged the government to improve the quality of care, but there is a reluctance to dramatically intervene in SHCS components. Apparently, Saudi healthcare leaders have already decided to improve the system, bearing some risks [5]. The Saudi Arabian government proposed a National

Transformation Program (NTP) in 2016 due to leadership succession, a drop in oil prices, and rapid medical devel- opment and practice. The NTP requires that each public institution improve its performance by gradual cooper- ation between public and private partnerships, known as public-private partnerships (PPPs) [6]. Thus, the MoH ini- tiated 15 key performance indicators (KPIs) to meet this objective. While the MoH liaises with some private sector entities to treat individual cases locally, the private sector may not offer comprehensive treatment without financial support from a third party or self-payment. Such cases in- dicate inequality in the delivery of treatments, such as fi- nancial concession and disease management, indicating that the poor cannot access necessary treatments due to lack of financing. Under the NTP, primary and secondary healthcare organizations, whether public or private, must cooperate to provide basic healthcare services within a PPP framework. Unfortunately, much of the inequality in the SHCS may persist in non-hospital provisions, especially social services [7]. Therefore, PPPs have re- ceived significant attention in the healthcare system, and organizing and funding the system are only a small part of the research agenda that still need to be deter- mined [8, 9]. Simply, the policy towards PPPs should be effective, comprehensive, and implemented over the course of time with deadlines [10]. This study, through a holistic approach, sheds light on the proposed KPIs initiated by the MoH, in which health risks are mini- mized and the system performs efficiently based on the NTP through engaging PPPs.

Public- private partnership According to the World Bank, PPP is ‘a long-term contract between a private party and a government entity, for providing a public asset or service, in which the private party bears significant risk and management responsibility, and remuneration is linked to performance’ [11]. This form of partnership involves a wide range of activities that vary based on the extent of involvement and the unexplored risks taken by both public and private parties [12]. The SHCS has been practicing individual re- ferrals to many national and international health institu- tions through its ‘direct-payment’ system, which exceed $16 billion for approximately 2000 overseas cases and 60,000 local cases annually; however, the NTP may exceed 20 million cases [13]. To maintain its economic growth, the government has

set aside roughly $10 billion to invest in PPPs, primarily by encouraging private sector investment and participa- tion at all levels of healthcare provision. To optimize the efficiency of the private sector and effectiveness of the public sector, the NTP proposed that the MoH transform the healthcare system gradually and in stages while employing PPPs. These stages are based on a stewardship model in which the private sector takes more of a partner- ship role in certain aspects of the process to accomplish the mission of a project, whereas the public sector assesses the process based on certain KPIs. Consequently, there is high risk to both parties in terms of finance and opera- tions. Using a partnership taxonomy based on the appro- priate structure, process, and outcomes model, the healthcare system may inclusively identify three types of PPPs, as illustrated in Table 1 [14]. In this study, shared risk is defined as the structured

cooperation between public and private sectors to share clinical and non-clinical consequences for individuals [15]. Normally, a risk is shared on three levels: public, private, and patients [16]. This taxonomy focuses on facilitating the levels of risks within common types of PPPs, characterized by a close working partnership be- tween public and private institutions. Risk ranking management at the national level requires ranking risks according to defined standards. Such standards usually take the form of healthcare system performance, especially performance in eliminating disease burdens. The standards also contribute to specifying the level of performance from

Table 1 Common risk ranking within the PPP framework

Risk Ranking Structure Process Outcomes

Low DBFo bOo/OM boT

Intermediate BLT/L BTO bOoT/bLOT/bLTM

High LDO LORT/JV Concession

Note: D Design, B Build, F Finance, o Own, b Buy, O Operate, M Maintenance, T Transfer, L Lease, JV Joint venture, and R Rehabilitate

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each party, although they also consider risk occurrence, severity, and error detection [17]. Table 1 allows the reader to rank the evidence on the

structure, process, and outcome levels in a hierarchy by identifying ‘input’ as a legal structured risk, ‘process’ as an intermediate process risk, and ‘concession’ as a high outcomes risk. This taxonomy modifies both parties by means of varying channels. First, ineffective communica- tion and absence of leadership in complex organizations may reduce their overall performance and keep the orga- nizations from accomplishing their goals; therefore, to be effective, organizations may collaborate in the form of partnerships [18]. Due to increased complexity, the need to collaborate is especially relevant to organizations that work with emerging technologies. These technolo- gies are at the forefront of knowledge, and various sec- tors need to share knowledge to develop technologically [19]. Another business-point reason why organizations form PPPs is that a group of organizations is better poised to overcome market deficiencies than a single organization, especially in medical technology [19–21]. Potentially, shared risk can fit within public and pri-

vate institutions [22]. If the notion of a private provision, is to run ‘low risk’ services and that of a public provision is to run services with ‘substantial risk’, how can the share of risk be equal? Although this approach has been implemented widely, governments have relied heavily on private industry to provide supplies and services for many healthcare activities, from infrastructure to hospital performance measurement. The private sector is underuti- lized in providing healthcare services; however, the risk may be shared in SHCS through major healthcare indica- tors shown in Table 2 [13, 23].

Healthcare economics Based on the population’s socioeconomic indicators, health economics is an essential principle governing the performance of health organizations [24]. The trad- itional role of public institutions is developing public

health and social welfare through not-for-profit health organizations, while private institutions aim to increase profit but through less risky performance [25]. Saudi Arabia’s economy is heavily based on its natural oil re- serves; therefore, the budget is normally associated with increases or decreases in oil prices in the fossil fuel market. From the end of 2015 and all through 2016, there has been a substantial decrease in crude oil revenue worldwide. Consequently, this has led to a significant decrease in government funds allocated to the MoH budget in 2016, as compared with 2015 (−34.5%). As the MoH intends to propose serious steps to reen-

gineer the SHCS through the NTP, the proposed initia- tive aims to reduce costs by, on one hand, sharing risks between public and private institutions and, on the other hand, engaging community-driven approaches within the healthcare system [26, 27]. The current Saudi system is under significant pressure, primarily because of the inappropriate utilization of the rising proportion of provincial budgets and, secondarily, because of the below-intermediate quality of care provided to the population versus high government expenditure [28, 29]. Due to high costs, emerging advanced technologies are prevalent indicators of public economic growth; however, in Saudi Arabia, such technologies are rarely available within the private sector [30].

Regulating the healthcare system One central component of any effective healthcare sys- tem is its policies. Administrative efforts underpin the movement of health institutions and gradually govern patient flow. Therefore, any health inequality is attribut- able, at least in part, to administrative deficiencies [31]. Surveying a given situation requires epidemiological ana- lysis to identify risk factors for particular diseases, such as infectious diseases, and targets for health regulations. Measurability has become a key determinant of health outcomes, and such KPIs are leading factors in either weakening or strengthening the SHCS. Political and organizational approaches to policy analysis estimate the policy itself as a decision-making process rather than focusing on health output [32]. Measuring patient be- haviours and endorsing ineffective health awareness and misled ideologies in medicine were two common themes within a primarily publicly funded system [33–35]. Even so, effective regulation and government support were the key elements of national health progress [36]. This study reports on details of how the surrounding risks might affect PPPs.

Methods This study uses a mixed-method approach utilizing both qualitative and quantitative domains to explore the NTP, provide details of PPPs, and focus on more features and

Table 2 Major health demographic indicators in 2016

Indicator Data

Total population (million) 31.00

Citizens (million) 20.00

Mortality rate under 5 (per 1000) 15.20

Population growth (annual %) 2.11

Birth rate, crude (per 1000 people) 22.00

Death rate, crude (per 1000 people) 4.00

Life expectancy at birth, total (years) 74.00

Total fertility rate (births per woman) 3.00

Fertility rate (births per 1000 women aged 15–19 years) 18.00

Urban population (% of total) 84.00

Alonazi BMC Public Health (2017) 17:571 Page 3 of 7

models to explain effective PPPs, respectively. To share risks, this study attempts to clarify the PPP process and explain its integration within a universal healthcare system.

Procedure Initially, this study organized common health policies issued by the relevant agencies between 1996 and 2016 based on risk factors associated with the role of each institution, that is, on the primary and secondary levels. For the qualitative approach, this study analysed semi- structured interviews while employing focus group. First, the author reviewed major health policies and

reports issued in the decades after 1996. This included articles issued by the CCHI, CBAHI, and the SHC. Moreover, the study analysed the initiative proposed by the MoH to meet Vision 2030 through the NTP. This stage involved identifying the role and implication of each public and private institution. Then, the risk was ranked subjectively based on the risk level faced by the components of the healthcare system. The study describes the major domains based on expert reviews that may streamline the transformation within the SHCS. The inter- view went through two stages. Initially, all participants were asked about major domains that the SHCS may need to meet future challenges. The four focus group interviews enabled the development of relationships among the sam- ple. Finally, each group rationally ranked these domains, highlighting their implications and impact on the SHCS. Thus, triangulation assures that this study captures the different levels and dimensions of the PPPs as the relation- ship among key constructs can be identified and empiric- ally documented. By discussing the role of public and private institu-

tions, the aim of the review was to look for patterns ra- ther than test or confirm a hypothesis. The focus was on gaining insight and familiarity regarding the PPP areas for a more rigorous investigation while utilizing a mixed-research methodology. After obtaining ethical ap- proval, the researcher approached a workshop supported by the MoH to prepare for the inauguration of Vision 2030. The participants were interviewed collectively to determine several domains that may govern the SHCS. Then, individually, each member was assigned a rank for each domain, indicating its priority. To ensure validity, the potential homogenous sample indicated that the collection of new data did not shed any further light on the subject under investigation.

Sample Known of their conceptual and practical knowledge of the PPPs, the purposive sample consists of 13 healthcare professionals belonging mainly to the most representa- tive segments of the SHCS workforce and those who

have effectively participated in continuous workshops held by the MoH. The researcher selected this sample mainly due to the participants’ respective leadership roles in developing MoH initiatives. These initiatives were planned by the MoH and a panel of 30 experts pro- posed different methods in addressing Vision 2030.

Data analysis Data relevant to the research questions were obtained mainly through major resources, such as the rules and regulations issued by the MoH, Council of Ministers memos, and guidelines enforced by public and private organizations. The process of identifying statements that support and describe the function of the institu- tions was developed based on the roles and implica- tions involved. Furthermore, the functions were based on the regular impact on providers and categorized into different levels. For the quantitative approach, major do- mains were formulated according to four experts’ responses. Credibility and transferability were used to infer trust-

worthiness and to reduce the effect of investigator bias. One way to achieve this was to seek domain agreement in the first stage with the second stage among experts. Again, in the second stage, findings had been transferred to the focus group. This may increase the trustworthi- ness of the most probable interpretations.

Results For the qualitative approach, the fundamental roles of public and private institutions that are significantly attrib- uted to maintaining the relationships among themselves were identified, as shown in Table 3. Table 3 summarizes the roles and functions of major

institutions associated with the success of the NTP. Previously, the government financed and regulated the healthcare system; however, the private sector may now interfere and regulate the healthcare system. An aspect of PPP is to identify public and private sectors

that can collaborate to improve the SHCS in the future. Table 4 presents a cohort analysis of the major indicators of both public and private sectors (2011–2016).

Table 3 Roles and functions of major institutions attributed to the success of the NTP

Institution Mission Implication Institution Type

Public Private

CBAHI Enforcing quality High Restricted Unrestricted

CCHI Financing roles High Unrestricted Restricted

SHC Regulating/ coordinating

Law Restricted Unrestricted

Note: Public institutions aim to reduce risk by improving the quality of care, incurring financial support from the government, and coordinating with the SHC to refer patients.

Alonazi BMC Public Health (2017) 17:571 Page 4 of 7

The MoH has recently proposed rigid KPIs to instil PPPs gradually by the end of 2030, as shown in Fig. 1. The proposal promotes a strong health economy at both preventive and curative levels, and the spread of KPIs will massively impact the health labour market and skills needed to develop social welfare. Although the full potential of improving health through such KPIs is yet to be discovered, the proposed model is developing policy and supporting research to make people healthy for life and work in a rapidly technologically developing society by 2030. Among the 15 MoH initiatives, almost half (47%) are

process-based measures, while the rest are either structure- or outcomes-based measures (33% and 20%, respectively). Based on the analysis, there is a new trend of health-

care prioritizing and implementing, which has yielded in unclear results for addressing the challenges faced by PPPs. Table 5 summarises the priorities and challenges in healthcare based on the answers of experts involved directly in implementing the health transformation. The aim of this group was to provide reliable, comparable qualitative data about the future of PPPs, based on the- matic analysis. The 13 participants believed that the SHCS exhibits a

need for more trustworthiness between the public and private sectors to achieve success. Second, they pre- sumed that the technology and patient-centeredness domains are key issues in successful partnerships. Having less importance than previous factors, health- care professionals’ competence and flexibility within the healthcare system were identified as obstacles that PPPs may face.

Discussion The purpose of a health model is to decrease potential personal and organizational risk factors associated with implementing the NTP. The integration of health reports and indicators may lead to a better understanding of healthcare priorities in coming decades [37]. Organizationally, there are some concerns regarding

the progress of quality culture within the majority of the primary and minority of the secondary healthcare ser- vices, the proposed model may yield to both regulatory and economic obstacles unless the implementation phases guarantee an injection of capital [1–3, 36]. Risk is normally associated with both regulation and financing of the SHCS. Based on the results, in order to gradually introduce the role of the private sector and retain the finances of the public sector, it is imperative to consider ‘concession’ as one of the most suitable risk-shared indicators while delivering the SHCS through PPPs, especially in the case of primary and secondary health- care services [38]. This is a widely practiced process, especially in the United Kingdom and Australia. Thus, the CCHI, CBAHI, and the SHC should no longer play small roles in the healthcare system but instead employ insightful curative health services while building disease- management and drug-regulation mechanisms [39]. Indeed, the MoH may also still operate in a regulative position, but only with limited influence in operation and maintenance. Thus, the 15 MoH initiatives will measure the outcomes of each provision, and reim- bursements could be based on performance. To form a mutual strong attribution of PPPs, public and private sectors should set preliminary trust of relationships, es- pecially in reimbursement. A trust-based model can dynamically facilitate the

demands of patients and the activities provided de- pending on the proposed reimbursement system [40]. Under the NTP, the PPP program clearly shapes the values towards health services and their financing ar- rangements. For public primary healthcare services, the development of medical technology is slow, unlike for private primary healthcare services. Contrarily,

Table 4 Health indicators based on PPP provisions

Provisions 2011 2012 2013 2014 2015 2016

Public hospitals 246 251 259 268 270 275

Private hospitals 130 137 136 141 145 147

Public PHC 2109 2259 2259 2281 2282 2300

Private PHC 1987 2168 2249 2408 2670 2710

Structure 1. New Financial Resources 2. Efficiency 3. Governance 4. Risk

Management 5. Privitization

Process 1. IT Development 2. Training 3. Supportive

Staff 4. Access 5. Check-

ups 6. Less waiting-

time 7. Health

Administration

Outcomes 1. Public Health 2. Quality of Life 3. Safety Culture

Fig. 1 Summarizes the 15 initiatives proposed by MoH along with the structure, process, and outcomes model

Alonazi BMC Public Health (2017) 17:571 Page 5 of 7

secondary private healthcare services lack advanced tech- nology. Nowadays, providing effective public services and addressing the risk balance are basic requirements mea- sured by third parties and regulatory institutions [41]. There are also intangible rewards at play, such as the healthcare reputation of the institution or physician/ specialist at hand. As patient-centeredness is one of the six domains for any effective healthcare system, the SHCS should incorporate the voice of the patient in its overrid- ing goals [17, 42]. In this study, the domain that had the most difficulty in incorporating PPPs was flexibility. Organizational flexibility refers to institutions enabling pa- tients to process their treatments without complications, as a potential management strategy [43]. Thus, the goals must include ensuring adequate and continuous usability of the facility over time, providing amenities, and support- ing/creating high-quality services. As public investment in infrastructure continues to

decrease, private participation is required to address the existing and expanding deficit in medical services, especially for chronic cases, patient behaviour, and treatment mechanisms [35]. Despite great progress in PHC services, PPPs may be more successful in second- ary healthcare services due to high demand from the population. This study has some limitations including understating

the exact roles of both public and private sectors. This study has not tackled the nature of information shared between the PPPs and NTP. Thus, additional means of improving healthcare, especially when introducing private roles in healthcare services, may yield inequalities in cases with high costs [27]. There have been some concerns in building effective PPPs attributable to the period of trans- formation during which the study occurred. Additionally, the current NTP has not yet addressed the reimbursement system. For future research studies, concentrating on the possible impact of each initiative may be helpful in under- standing and measuring the effective achievement of each domain of the program.

Conclusions This paper explores shared risks through PPPs in public health programs, and suggests models for public health policy makers when implementing the NTP. The most

appropriate model to gradually implement the NTP is through concession based on primary and secondary treatment. Additionally, CCHI, CBAHI, and SHC should take more active roles in regulating the SHCS. Finally, to ensure effective healthcare system, relationships between public and privet sectors should be tightened based on utilizing high technology including the voice of the pa- tient, increasing competency, and ensuring flexibility.

Abbreviations CCHI: Council of Cooperative Health Insurance; KPIs: Key Performance Indicators; MoH: Ministry of Health; PHC: Primary Healthcare Center; PPPs: Public-Private Partnerships; SA: Saudi Arabia; CBAHI: Saudi Central for Health Accreditation Institutions; SHC: Saudi Health Council; SHCS: Saudi Healthcare System; NTP: Saudi National Transformation Program

Acknowledgement Not applicable.

Funding This paper is supported by the Research Center at the College of Business Administration and the Deanship of Scientific Research at King Saud University.

Availability of data and materials The data that support the findings of this study are not publicly available. Those interested in the data can contact the author for further information.

Authors’ contributions Not applicable.

Competing interests The author declares that he has no competing interests.

Consent for publication Not applicable.

Ethics approval and consent to participate All ethical approvals were obtained prior to data collection from the Saudi Society of Health Administration (SSHA) on 1 November, 2016. The SSHA liaised directly with the potential sample and all participants verbally agreed to take part in this study; thus, the investigator did not provide a consent form.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Received: 8 February 2017 Accepted: 1 June 2017

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