segunda-feira, 8 de julho de 2013

PUBLIC/PRIVATE INTERFACE FOR SUSTAINABLE INFRASTRUCTURE




ASSESSMENT TASK THREE - MAJOR INDIVIDUAL ASSIGNME





ALEX DANIEL SALOMAO DA CRUZ ROCHA
ID: 1796097





LCM 703 PUBLIC / PRIVATE INTERFACE FOR SUSTAINABLE INFRASTRUCTURE
MBM 703 BUSINESS ISSUES IN PUBLIC PROJECTS


MR. TERRY LANDELLS










24 MAY 2013

Table of Contents

Executive Summary................................................................................................................................................ 4
Introduction................................................................................................................................................................ 6
Public Private Partnerships in the Health Sector............................................................... 8
Health System in Brazil............................................................................................................................................. 8
PPPs in Brazil................................................................................................................................................................. 8
The Suburban Hospital in Salvador: Brazil’s first healthcare PPP................. 10
Rationale....................................................................................................................................................................... 10
Transaction.................................................................................................................................................................. 10
Issues................................................................................................................................................................................ 11
Framework to evaluate The Suburban Hospital PPP....................................................... 12
Accountability and Transparency..................................................................................................................... 13
Stakeholders Engagement..................................................................................................................................... 14
Risk Sharing.................................................................................................................................................................. 15
Costs and Quality...................................................................................................................................................... 15
Equitable Access to quality health services for the poor people..................................................... 16
Evaluating The Suburban Hospital in Salvador................................................................... 17
Recommendations...................................................................................................................................................... 18
Conclusion.................................................................................................................................................................... 20
References................................................................................................................................................................... 21













 

 





Executive Summary



Currently, many countries around the world have formal programs of Public Private Partnership (PPP), which has been used not only as alternative to fiscal restrictions, but also as a means to improve the quality and efficiency of public services. Savas (2000) suggests that the rationale for embracing PPP arrangements includes both ideological and pragmatic perspectives. Ideological refers to the superior capacity of the private sector in providing better services, while pragmatic argues that these arrangements are ways of borrowing expertise, funding, and innovation from the private sector to address complex public policy problems.
In fact, the success of various PPP projects in many countries, has been leading other nations to encourage PPP procurements for infrastructure projects, instead of using traditional methods to achieve such benefits, being their experience extremely favourable for new projects.
However, due to the complexity of these new milieus, where challenges are constantly changing and becoming more complicated, continuous improvements seem mandatory as a means to achieve the optimum balance between diverse interests of multi stakeholders and therefore guarantee viability and long-term sustainability of PPP projects.
In countries such as UK and Australia for instance, where the programs are more consistent, there seems increasingly adoption of concepts into innovative initiatives, in which the new challenges refer to the reduction of costs and deadlines in the bidding process, the standardization of contracts, the dissemination of good practices, and also the establishment of competencies in project management in the public sector.
In Brazil, the use of PPPs is relatively a new phenomenon. Only in 2002, through the union of every segments of the Brazilian society in collaborative governance alliances, the country took its first step toward Public Private Partnership infrastructure projects in essential sectors of the economy. Since then, Brazil has developed various PPP infrastructure projects as an inevitable requisite for its economic and social development.
The purpose of this report is to analyse a PPP project in healthcare in Brazil, with specific reference to the Hospital do Subúrbio in Salvador, the state of Bahia, providing a framework to enable an effective evaluation of the project, identifying and analysing its strengths, weaknesses and areas of improvement.
The framework to evaluate The Hospital do Subúrbio PPP includes:
·         Accountability and Transparency
·         Equitable Access
·         Stakeholders Engagement
·         Cost and Quality
·         Risk Sharing
The strengths of the PPP are:
-       Effective monitoring of services
-       High quality
The weaknesses of the PPP are:
-       Low staff commitment
-       Insufficient community involvement
-       Inefficient assessment of political and social risks
Areas of improvement are:
-       Incentives
-       Government support



Introduction



It is more and more evident that the success of implementing PPP projects in many countries has been leading others nations to encourage PPP procurements for infrastructure projects, instead of using traditional methods, as a means to promote economic and social development in diverse sectors of the economy; some sectors showing higher priorities (Sen1999).
In health, the increasingly costs of delivering services has been a significant issue for the state. Thus, PPP seems a universal adopted mechanism to reduce costs while increasing health services quality and capacity of the system, by investing in infrastructures.
In Brazil, health services have been rising considerably. The country has found in PPPs not only a solution for mitigate public issues, but also a way to provide equitable access to good quality health, benefiting the community, and at the same time enabling return to the private sector, in win-win-win arrangements.
This report analyses the PPP of the Hospital do Subúrbio in Salvador, capital of the state of Bahia in Brazil. The main objective here is to build a framework to evaluate this PPP project, identifying issues that affected the development and maintenance of its effectiveness and providing critical analysis of strengths, weaknesses and areas of improvement. In despite of the Hospital do Subúrbio PPP being considered one of the world’s most innovative projects by KPMG in its “Infrastructure 100: World Cities Edition” report (Infrastructure 100: world cities edition 2012), issues still need to be addressed, such as low staff commitment, insufficient community involvement, and inefficient assessment of political and social risks.
This report explores the importance of effective PPP projects in promoting health services in Brazil, approaching some relevant features for the achievement of effectiveness. It also develops a framework that may effectively evaluate the Hospital do Subúrbio PPP, providing some detail of this completed project.
While the literature explores various elements on evaluations of PPP projects, this report then focus on some key features to evaluate this particular social infrastructure PPP. Finally, this report addresses the issues based on the presented framework, identifying and analysing strengths and weaknesses of this project, pointing some recommendations for improvement when appropriate.


















Public Private Partnerships in the Health Sector



The increasingly costs of delivering health services has forced the public sector to look at alternative mechanisms in order to reduce cost while increase efficiency of services. PPP rises as a solution to contain this growing health care costs and government budget constraints (Blanken & Dewuful 2010).
In fact, successful PPP projects developed in many countries around the world has led other nations to encourage PPP procurements for social infrastructure projects, instead of using traditional methods, motivated by the potential to transfer risks and some revenues to the private sector, as a means to create efficiency and control costs in the health public sector (Blanken & Dewuful 2010). Notwithstanding, due to high complexity, it is unclear to what degree PPP arrangements are capable to respond to changing demands in health sector.

Health System in Brazil


Brazil has a Unified Health System (Unified Health System 2013). Created in 1989 from the merger of two state systems, one for those in formal work and the other for everyone else, it is exceptional in Latin America, which by and large continues with the two-tier public system Brazil abandoned. The 1988 constitution declared health care to be the right of the citizen and its provision the duty of the state (Law 11.079/2004 establishing general rules for bidding and contracting for public-private partnership 2004). However, there is a big gap between the aspirations of the Government and the reality. Funding is inadequate and varies wildly from place to place, affecting mostly poor people living in remote rural areas or violent urban slums where the service is lacking.

PPPs in Brazil


In the past decade, Brazil in a very successful initiative, brought together business, labour and civil society organizations to advise the government on its economic policy, resulting in a considerable development for the nation, evidencing the power of collaborative governance alliances (Landells 2013).
As private organizations play an increasingly role in the global economy, public-private collaborative alliances have been strongly defended by credible experts and institutions as essential for the global community welfare. The private sector, because it is motivated by something other than good public policy, is prepared to make tougher decisions and act more quickly to get outcomes (Bovis 2010).
In recent years, Brazil has developing various PPP infrastructure projects as an inevitable requisite for the economic and social development of the country. In 2002, the society finally understood the importance of reviewing its investment policy, started involving businesses, labours and civic leaders to advise on economic aspects in order to promote the engagement of business in the development of the nation (Nobre et al. 2012). By the union of every segments of the Brazilian society in collaborative governance alliances, the country took its first steps toward Public Private Partnership infrastructure projects in essential sectors of the economy.
After having executed concession agreements for the construction of several large infrastructure projects, the Federal Government also transferred the management of many others to the private sector. Besides, it has recently launched the first part of its Investment Program in Logistics, which provides for the application of approximately US$ 67bn in the renovation and construction of federal motorways and railways (PPP Brazil 2013). Furthermore, since 2010, states and municipalities have also engaged on a variety of infrastructure projects in diverse sectors of the economy, including the health sector.





The Suburban Hospital in Salvador: Brazil’s first healthcare PPP



 “Brazil’s first public-private partnership (PPP) in health dramatically improved health services for Salvador’s community, establishing a new paradigm of quality into the Health Care Network in Brazil”.
Brazil: Hospital do Subúrbio 2013

Rationale



Brazil is a country with widely diverging income levels, where the access to quality healthcare is unfortunately very unfair. People with high-income levels have the privilege to access private hospitals, while those with low incomes, that is, the majority of the population, must rely on public hospitals, which are often poorly equipped and serviced, as well as overcrowded. With the objective to reduce social inequalities in health (Sen 1999) by ensuring that all its population had access to high quality health services, the government of Bahia embraced this PPP project.
As Brazil’s first healthcare public-private partnership (PPP), the Hospital do Subúrbio effectively made an impact, improving emergency hospital services for more than one million people living in an extremely underserved district in Salvador, the capital of the state of Bahia. According to Bahia Hospital - better access to Healthcare for Poor (2013) the district where was built, presents ranks much lower than the state and national average on the Human Development Index (PPP Development stage-establishing principles 2012). Although not initially planned as a PPP project, the state government looked at the private sector as a partner to supply equipment and carry out all services and maintenance.

 

Transaction



Prodal Health SA, consortium composed by Promedica, a leading Brazilian regional healthcare company, and Dalkia, a French company specializing in facilities management and non-medical services, won the bid. The concessionaire is responsible for equipping, maintaining and operating both clinical and non-clinical services at the hospital for a term of ten years. The short time was set because the construction was excluded. The construction was conducted by the State, requiring investments of approximately US$ 54 million while Promedica & Dalkia invested US$ 23 million to equip the hospital, being expected more US$ 9 million over the life of the concession (Brazil: Hospital do Subúrbio 2013).
The payment to the consortium is linked to key performance indicators based on quantitative and qualitative expectations, therefore creating incentives for high levels of performance. The agreement established that regular auditing is to be conducted by qualify companies, analysing not only performance indicators, but also financial statements. In auction at BOVESPA, Sao Paulo stock exchange, the consortium requested maximum annual payments of R$ 103.5 million (approximately US$ 52 million), wherein seventy per cent would be volume based, and the rest linked to quality indicators.  As the payment mechanism is the principal means for allocating risks and providing incentives in the PPP contract, it was settled to minimize the state’s credit risk thus increasing interest by the consortium and the possibility of obtaining financing for the project (Brazil: Hospital do Subúrbio 2013). The deal closed in just 90 days from when the contract was awarded until the project reached financial agreement. The results evidence not only the quality of services, but also the constraints of the project.

Issues



The issues identified in this social infrastructure PPP are: lack of public transport in the area; high rates of absenteeism; and overcrowding which are associated to the low staff commitment, insufficient community involvement, and inefficient assessment of political and social risks.
As the number of patients is higher than expected, the public sector is under pressure imposed by both, the community that calls for more and more beds; and the consortium, which added beds but wants to negotiate a higher payment. Besides, concerns about quality have been raised around the facility’s low capacity, by which the principal of equitable access to quality health services for poor people is directly affected. Moreover, the lack of public transport in the area evidences a public controversy in achieving social goals.

Framework to evaluate The Suburban Hospital PPP


According to Wettenhall (cited in Hodge & Greve 2005), public-private partnerships are based on win-win-win arrangements by which the public sector, the private sector and the community are simultaneously benefited in a synergistic interaction. Thus, there are many concerns around the achievement of effective public-private partnerships.  Trafford and Proctor (2006) suggest that indentifying critical features that may impact these multi-sector alliances is crucial to achieve long-term sustainability.
In order to consolidate benefic and successful public-private partnerships, expectations, risks and responsibilities need to be mutually agreed and clearly specified in advance. Additionally it is critical that the contractual arrangements are complete and effective, preserving good relationships between partners, communication efficiency, goals and value alignment and continuous adjustment for mutual benefits. Furthermore, Bresnen (2007) states that diversity may be an important factor to recognize differentiation as a tool to reach efficiency and adaptability. Moreover, affordability and value for money, project design, compliancy of rules and limits, risk sharing, communication, transparency, legality, monitoring, and political support may be key elements that may compose PPP’s frameworks of good practices (Public-Private Partnerships: In Pursuit of Risk Sharing and Value for Money 2008).
Formulating arguments around PPP effectiveness or good practice, as well as determining the appropriateness of partnerships are not easy tasks, as they can vary considerably across sectors (Rosenau 2000). The holistic understanding of contextual factors on a case-by-case basis may be paramount in identifying and addressing issues therefore helping overcome a number of challenges, especially in the Health Sector.
PPPs in health distinguish from others for their social nature, by which expectations are strongly defined in terms of outcomes for specific groups or communities.
According to Buse and Walt (2000) there are key elements that must be in place when developing PPPs in health, such as transparency and accountability, common understanding, risk and responsibility sharing, and clear definition of expectations.

To evaluate the Suburban Hospital PPP five key features are considered relevant to this particular project:

-       Transparency and Accountability
-       Stakeholders engagement
-       Risk sharing
-       Costs and Quality
-       Equitable access

Accountability and Transparency 



Rosenau (2000) suggests that it is difficult to define which of the parties involved in PPPs is more accountable or that policies and regulations increases or decreases accountability, especially regarding social sensitive projects such as healthcare, where the public sector is seen as the rescuer when projects fail.
Notwithstanding, ensuring accountability in healthcare PPPs is fundamental, therefore the public sector needs to be well informed about potential partners and their proposals, and the private sector have to be held accountable to the community by providing complete and equal information. Furthermore, if PPPs are to improve performance (Flinders 2005), partners need to be accountable to each other as well as transparent.
Reports of performance indicators by the public sector in Brazil, is not a common practice. Thus to ask the private sector to adhere to this idea, it is necessary that the state also release information to the public, so the society can form concrete opinions about the public sector actions. However, in many developing countries, including Brazil, the communication between the government and the community is ineffective and not well supported, for the fact that some information may indicate significant room for improvement. Besides, corruption and frauds has been affecting the accountability and transparency of many public sector initiatives in Brazil (Changing the rules of the game: a diagnosis of corruption in Brazil 2011).

 

Stakeholders Engagement



Kwak et al. (2009) suggest that good stakeholder communications is essential to ensure that people close to the project have the opportunity to have their views considered before decisions are made. Innovative approaches to communications and stakeholders’ management can help PPP projects achieving sustainable outcomes. Furthermore, early engagement with stakeholders creates opportunities to build relationships, understand concerns, mitigate issues, and involve those who will be most affected by the PPP project. Yet, the outcomes of PPPs in health are difficult to predict, as they are dependent on the way the internal stakeholders interpret policies and how the community react to them (Rosenau 2000).
For a better understanding of the tensions and pressures involved in PPPs, cultural perspectives and stakeholder analysis need to be considered. According to Flinders (2005) organizations that share value with their stakeholders and involve them in their strategic decisions, could gain unmeasurable benefits. Bresnen (2007) mentions stakeholders as partners, with different perceptions, thoughts and feelings, who can encourage knowledge sharing to generate both economic and social values. Besides, social capital may also be regarded, as it may clarify the level of synergy as well as identify weaknesses or strengths of relationships and interpersonal connections. Moreover, breakdowns in the relationship between the parties involved in PPPs may represent a high strategic risk for the project (Kwak et al 2009). In healthcare PPP projects, internal stakeholders commitment to public good and external stakeholders involvement in planning and monitoring of services seem essential considerations in such social and political sensitive projects (Rosenau 200).

Risk Sharing



English (cited in Hodge & Greve 2005) suggests that social infrastructure PPPs are usually considered safe for the private sector, based on the idea that the state is always prepared to interfere in these projects to protect them to fail, as in some cases the costs for replacing the consortium, in social sensitive PPPs, can be higher than political costs. Indeed, in healthcare PPPs there is a great chance of public sector intervention, including financial renegotiation (Akintove & Beck 2008), requiring a deliberate risk analysis to guarantee their viability.
Hence, the anticipation of the government support, regardless contractual arrangements, may promote unrealistic bids, assuming that the risks, not specified in the proposal, will be absorbed by the public sector (Hodge & Greve 2007). Thus, PPPs in health call for effective appreciation of risks in order to find the proper balance of its stakeholders’ interests.
In fact, risk sharing is often pointed as one of the major benefits in PPPs, but if inappropriate managed it can result in insufficient risks transferred to the sector that can better deal with them, therefore affecting PPPs outcomes (Flinders 2005).

Costs and Quality



The quality of public services in Brazil is traditionally very poor. Many hospitals provide low quality services, where lack of accountability, inadequate supervision of staff, inadequacy of equipment, lack of drugs and materials, and excess of bureaucracy, are clearly evident. On the other hand, private hospitals in Brazil are known for excellent quality but unfortunately they serve only the minority.
Health care costs in Brazil are abusive. Although some improvement can be expected due to recent regulations enforcement (Public-Private Partnership 2013), health services costs are associated with technology improvements and population growth. Thus, some relief from increasing costs may rely on efficiency improvements brought by PPP projects, by which quality needs to be also guaranteed. In fact, providing quality services and offering cost advantages are not only objectives of PPPs in health, but also challenges in achieving value for money (McKee et al. 2006).
Notwithstanding, governments increasingly use PPP’s to pursue value for money. A PPP project achieves value for money when it costs less than the best realistic proposal in providing the same services (Infrastructure Australia 2008).
According to Trafford & Proctor (2006) an effective assess of value for money depends on simultaneous considerations of qualitative and quantitative aspects, not independently. Qualitative aspects are related to operations requirements, service delivery, and project management, while quantitative aspects involve costs that can be measured using Public Sector Comparator (Quiggin 2004).

Equitable Access to quality health services for the poor people



There is a broad understanding that governments are to provide health services to poor people that cannot pay for them. Poverty in Brazil is common and there are wide disparities in both income and health among the wealthiest and poorest parts of the society. Promoting equitable access is one of the biggest challenges for PPPs in health, since the private sector concentrated in maximizing profit is normally less concerned with issues of equitable access for poor people (Mills 1998). In PPPs projects maximizing profit means cost reduction, which may affect performance and quality (McKee et al. 2006). Notwithstanding, when establishing a PPP in health, the concerns remain not in the profit maximization by the private sector, but whether the minimum standard of quality will be maintained. In long-term equitable access can change value for money considerations (Rosenau 2000), therefore affecting viability of the project. Moreover, not providing equitable access in healthcare PPPs may also affect the reputation of the project. According to Benoit & Pang (cited in Tricia et al. 2007), projects’ reputation is usually threatened when it is held accountable for an undesirable event.


Evaluating The Suburban Hospital in Salvador


Based on the evaluation framework developed and justified above, this section critiques the Hospital do Subúrbio PPP in Brazil, pointing strengths and weaknesses of the project as well as evidences some areas of improvement. 
Despite the fact that the Hospital do Subúrbio PPP was chosen as one of the world’s most innovative projects (Infrastructure 100: world cities edition 2012), perfection is not the right word to describe this initiative. With the objective of providing equitable access to quality health services for the poor people from the local community in Salvador, in Brazil, this PPP has been facing some issues such as innumerous complaints from the patients regarding the difficult access to the Hospital due to the lack of public transport in the area; high rates of absenteeism; and overcrowding.
Although corruption and fraud are considered to be constraints on government’s activities in Brazil (Changing the rules of the game: a diagnosis of corruption in Brazil 2011), surprisingly transparency and accountability are pointed as strengths of this PPP, while, controversially, stakeholders’ engagement seems weak. Procedures have been executed in open manner, and monitoring of services shows efficiency by assessing performance to benchmarking against best practices. However, external stakeholders could be more involved in planning, and internal stakeholders could be more committed in promoting equitable access to quality health services for the local community, by helping to speed up treatment and reduce the length of stays, clearly affected by the high rates of absenteeism. Further, it also calls for more government support, as the lack of public transport in the area has been recognized as the main cause of absenteeism and difficult access. Consequently, the Brazilian society started questioning the Government about the real intention of this PPP, since without public transport, the poor people, who do not have own vehicle, are unable to access the hospital, raising doubts about equity and access considerations in this project. Hence, social, political and reputational risks appear to be poorly explored.
In fact, the holistic appreciation of risks, highly recommended for this type of PPP, seems inefficient, considering the social and political sensitivity of the project, wherein only financial risks appear to be taken into account, even thought ignoring operating costs in the case of increasing demand. It is worth mentioning that this analysis, made by a proud Brazilian, does not consider the possibility of hidden risks in order to reduce bid’s price which follows the principle that the public sector cannot allow this type of project to fail, regardless their contractual responsibilities.

As mention above, this project has been regarded as very successful, however problems with increased demand have been raising debates around quality. The Government, worried about the maintenance of quality, has been making contractual adjustments to increase payments for the private sector, but it may affect the expected value for money. The private sector, on the other hand, having its payment associated to performance indicators, started showing discontentment around political support and inappropriate risk assessment, thus threaten the long-term sustainability of the partnership.
Indeed, despite some issues, the Hospital do Subúrbio PPP can be referred as innovative, since its financial arrangements include payments to the private partner that is linked to key performance indicators, based on quantitative and qualitative targets, therefore creating incentives for high levels of performance. As a means to guarantee long-term viability for the partnership, these arrangements has been focused on the possibility of obtaining financing for the project by minimizing the government’s credit risk, which directly benefits the private sector.
Finally, joint initiatives have been implemented to address these issues, indicating that the partners involved in this first healthcare PPP in Brazil, are becoming gradually more aware of the importance of commitment and mutual support to build an ideal public-private partnership, where, public and private interests are transformed into benefits and opportunities to achieve public outcomes.

Recommendations


Based on the analysis above it is recommended that a horizontal communication plan takes place in order to stimulate staff in promoting equitable access to quality healthcare for the community, by sharing with their managers, issues that could affect their commitment to the project. Besides, a formal external communication plan is also recommended, as it may help addressing reputational threats for the project as well as assist managing issues around equity and access considerations. . Managers, on the other hand, may have to concentrate in finding the best means of linking public values to the public interest. Benoit (1995) states that when an organization’s reputation is threatened, whether or not the accusations are true is irrelevant, as the public perception is all that is needed to damage its image, calling for urgent actions.
Moreover, due to increasing concerns around contractual adjustments, the parties may focus on improving their relationships, as a weak interconnection may represent high strategic risk for the project (Landells 2013).
Further, managing stakeholders participation and involvement may help clarifying the level of synergy as well as identifying weaknesses or strengths of relationships and interpersonal connections. According to Landells (2013) organizations that share value with their stakeholders and involve them in their strategic decisions, could gain unmeasurable benefits, by encouraging knowledge sharing to generate both economic and social values.

Moreover, rigorous process of risk identification, assessment, analysis, and mitigation are recommended to allow a more effective risk allocation of this PPP. Thus, when risks are understood and their consequences are measured, decisions can be made to allocate risks (Flinders 2005) in a manner that minimizes costs, promotes project goals, and ultimately aligns stakeholders with the needs and objectives of the partnership (Hodge & Greve 2007). Furthermore, based on the proposition that optimal risk sharing with the private partner delivers better value for money for the public sector and ultimately for the end user, the aim is not maximize risk transfer but optimize it (Delmon 2009).






Conclusion


Public Private Partnership is gradually becoming a universal, adopted form of procurement to improve performance of health systems worldwide, wherein the public and private sectors collaborate to deliver better health services, improving efficiency, quality, and innovation of public health networks.
According to (PPP Development stage-establishing principles 2012), countries with differing government and legislative frameworks sign an impressive number of common features associated with successful implementation of PPP programs, however there is no defined solution to address many issues in the health system in Brazil and around the world.
If PPPs in health are to facilitate the improvement of health services, providing equitable access for the poor people, stakeholder engagement is one of the first priorities as it may bring in unmeasurable benefits from different perspectives.
Moreover, a holistic and continuous appreciation of risks in healthcare PPPs due to its complex milieus, is extremely important, as it can reduce the probabilities of unexpected financial, social and political crisis that could negatively affect long-term outcomes.

Finally, a lot of work still need to be done, not only in Brazil but worldwide, to improve the accountability and transparency, the regulatory framework, and the mutual trust in healthcare PPPs projects to enable governments, by these type of procurement, accommodate problems of access and equity, quality improvement and cost containment.

 

 


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