Public-Private Partnerships in the Healthcare Sector and Sustainability: Managerial Insights from a Systematic Literature Review

Abstract

This article aims to critically understand the current state of the art of Public-Private Partnerships (PPPs) in the health sector and to highlight implications useful for implementing sustainability-oriented PPPs. By employing text mining to analyze the sampled articles, we identify the main themes distinguishing healthcare PPPs and sustainability. We critically discuss the narrative underlying the results achieved in terms of emerging topics: governance, managerial tools, barriers, advantages/disadvantages, and big data. Finally, we propose a literature-driven framework on PPP management that identifies implications – systemic approach, technical managerial skills, governance balance, operational instruments – that can facilitate the development of sustainability-oriented PPPs in the healthcare sector.

Keywords

public-private partnership healthcare sustainability management

Introduction

Health protection and sustainability are two closely related aspects that healthcare organizations should not manage separately (Borgonovi et al., 2018; Mehra & Sharma, 2021). This area is of particular relevance to society, reflecting the growing interest of citizens who are also patients and taxpayers in the public health system.

Considering the complexity of governance in healthcare organizations, we seek to critically understand the relevant topics of a particular governance configuration, namely Public-Private Partnerships (PPPs), to highlight some managerial implications that may be useful for implementing sustainability-oriented PPPs. To achieve this, we employ a literature review methodology to identify the main aspects of this promising relationship.

Numerous configurations of health systems are possible. In fact, from the combination of the three pivotal dimensions that characterize health systems (financing, health service delivery, and regulation), it is possible to obtain several distinct types of health systems that fall between two main extremes: a state health system and a private health system (Wendt et al., 2009). As a result, we can consider three modes of healthcare delivery: (a) mainly private providers (US), (b) public and private providers (Bismarck Model countries: e.g., Germany, France), (c) mainly public providers with a reduced private sector (Beveridge Model countries: e.g., Italy, U.K., Sweden, Canada).

Due to the COVID-19 pandemic, both public and private healthcare sectors are growing in the healthcare market. Examining the relative benefits of the public versus private healthcare sectors, proponents of private healthcare systems argue for advantages such as profit and efficiency maximization; they believe that the competitive market model can improve efficiency, quality, consumer choice, responsiveness, transparency, and accountability (Kaabi et al., 2022). Evidence suggests different results, however. Hollingsworth (2008) showed that “public provision is potentially more efficient than private provision.” According to Lee et al. (2009), non-profit hospitals are more efficient than for-profit hospitals in the United States.

Indeed, the countries with the best healthcare provide free or universal healthcare. Countries such as Sweden, New Zealand, Spain, Portugal, Japan, Italy, Ireland, Germany, France, Australia, Canada, and South Korea provide healthcare following the principles of non-profit public administration (Foreign Countries with Universal Health Care, 2011). These countries regard healthcare as a social rather than an economic good and provide “universal care,” which means that healthcare must be accessible to all residents (Martin et al., 2018).

Among other things, for-profit healthcare aggravates the problem of access to healthcare, creates unfair competition for non-profit organizations, and exerts undue influence on public policies related to healthcare, using its economic power (Institute of Medicine, 1986).

Many low- and middle-income countries (LMICs) with less “evolved” health systems have recently reformed their health systems to promote universal access to healthcare, improve the quality of health services, and increase equity in healthcare financing (Han, 2012).

Many national healthcare systems are focusing particular attention on quality and the efficiency of healthcare spending. Institutions and citizens strongly advocate that public healthcare systems should promote and support only sustainable proposals.. Meanwhile, the concept of sustainability has become fundamental in modern society; for many people, sustainability is a keyvalue, and in some markets, they play a very active role in developing standards for measuring sustainability (Rawhouser et al., 2018).

Traditionally, sustainability is understood as a concept that can be categorized into three dimensions: economic, environmental, and social sustainability (Lozano, 2008; Purvis et al., 2018).

Economic sustainability refers to the ability to generate income and employment under conditions of eco-efficiency in a way that lasts over time, ensuring the rational use of available resources with minimal reliance on non-renewable resources (Ciegis et al., 2009; Spangenberg, 2005). Environmental sustainability refers to the ability to safeguard biodiversity and the integrity of ecosystems, preserving both the reproducibility and quality of available natural resources over time (Arora et al., 2018; Pepe et al., 2018). Social sustainability, on the other hand, is achieved to the extent that access to all services that qualify as basic (health, security, education) is ensured equitably for present and future generations (Boyer et al., 2016; Rogers et al., 2012).

Since the early 2000s, issues concerning social challenges or ecological dilemmas have become familiar to many, leading to increased demand for public involvement. This has resulted in sustainability emerging as a way of assessing the quality of public choices and public governance, particularly with regard to local governments (Chiarini & Vagnoni, 2016).

The currently adopted models of economic and social development, mostly based on the so-called “greed economy” (Striani, 2020), put the availability of natural resources at risk and consequently threaten the health and prosperity of human societies (Fiksel et al., 2012). Part of the environmental damage and related degradation is due to the health industry, and this has become more evident in recent years (Hensher & McGain, 2020). The healthcare sector, according to a 2019 estimate, produces about 4.4% of total global greenhouse gas emissions, while healthcare spending accounts for about 10% of global economic output (Karliner et al., 2020). Therefore, introducing sustainability issues into healthcare systems, in addition to reducing environmental impact, can become crucial for managing resources, improving cost-effectiveness, and pursuing continuous improvement of healthcare services (Marimuthu et al., 2016, highlighting social and economic impacts.

The COVID-19 pandemic underscored the drastic difficulties that healthcare institutions face in responding to growing demand for care, lack of medical equipment, and shortage of health workers (Sun et al., 2021), exacerbating the already existing tensions over the sustainability of healthcare systems.

Particularly in light of the 17th Sustainable Development Goal of the UN Agenda 2030, public-private partnerships (PPPs) are attracting serious attention (Gharaee et al., 2019; Thadani, 2014), given their potential durable forms of cooperation between the public and private sectors based on sharing risks, costs, benefits, resources, and responsibilities, aimed at providing public infrastructure or services (H. Wang et al., 2018). PPPs are not always appropriate, and they are a complex instrument. Therefore, considering the diffusion of partnerships (Bendell et al., 2010) and the renewed focus on them, an in-depth analysis of the needs and objectives of a PPP as a starting point for any PPP project, considering its opportunities and criticalities, becomes indispensable.

For example, some of the factors that should be considered when designing governance and coordination structures for implementing a partnership include the business incentives and support structures required to maintain the alignment of interests of the partners involved (Onyoin & Bovis, 2022).

There is a clear need for further research on the topic of partnerships (in relation to, for example, the political perspectives of PPP boundary management, the organizational interests of intermediary organizations, and the effectiveness of PPPs). Such research could contribute to the debate on corporate engagement in society and the benefits of PPPs for partners and society (Stadtler, 2015) as well as for sustainability.

Moreover, the negative pandemic downturn might accelerate the introduction of decisive actions aimed at guaranteeing greater sustainability of health systems (Auener, 2020), including exploration of partnerships as a solution to increase their resilience (Ranjbari, 2021; H. Wang et al., 2022). Indeed, the healthcare system is one of the most discussed sectors where the PPP instrument might be applied (N. Wang & Ma, 2021). Generally, healthcare institutions’ collaboration with the private sector originates from the growing awareness that such forms of cooperation, if properly implemented, can both mitigate the impacts that public health management has on public finances and utilize the specific technical expertise of private actors to improve the quality of healthcare offered (Schomaker, 2017).

This article analyzes the current state of the art on relevant aspects of PPPs in the health sector and highlights several managerial implications that could be useful for implementing sustainability-oriented PPPs. In doing so, we do not focus on any particular dimension of sustainability. Since this is a preliminary theoretical study, it is appropriate to disregard the type of effect that PPPs produce. This allows us to investigate the relationships between PPPs and sustainability, across the latter’s specific dimensions. . Furthermore, sustainability is considered with regard to both PPPs and the healthcare services they provide. Similarly, we investigate PPS and sustainability independent of the type of healthcare system.

Our inquiry proceeds as follows. We begin by outlining the applied methodology and then turn to examining the results. Next, we discuss the findings in greater depth and conclude with lessons and steps for further investigation.

Sampling and Analyzing Articles

Our analysis is structured as a literature review that uses a mixed-methods approach to data analysis where both quantitative and qualitative tools work together to highlight the main aspects of the ongoing debate. As a first step, we employed a co-word semantic network (Callon et al., 1991) to identify the pattern of discourse, revealing the association among words, and then, the hidden sub-topics nested in the general macro-theme explored. The second step undertook a more in-depth and explanatory qualitative analysis of the articles based on the topics clustered in the first quantitative step. This two-step hybrid methodology can reduce the subjectivity of identification of relevant aspects, preserving the qualities of a typical literature review where the crucial points are expanded, interpreted, and commented on. Similar utilization of such a promising combination can be found in research on other topics (see Lima et al., 2021). To the best of our knowledge, it is the first time that it has been applied to review the topic at hand.

The analysis is based on a systematic literature review, which relies on “a review of clearly formulated questions” using systematic methods for identification and selection purposes (Moher et al., 2009). To this end, we follow the research stages of the PRISMA protocol, considering only peer-reviewed articles published in international journals, the so-called “white” literature (Borghesi & Morone, 2023). That is, we avoid gray literature since it is not always subject to rigorous peer review processes and checks (Borghesi & Morone, 2023; Mahood et al., 2013). For keywords, we made checks with similar terms (with no significant variations) and opted to use the most generic in order to have a large basis as the starting point of the analysis.

The sample has been constructed following the typical steps of a literature review process (Snyder, 2019; Tranfield et al., 2003), ensuring an appropriate and rigorous identification. The main steps are summarized below.

Keyword Search Process

First, we employed the Web of Science and Scopus search engines to identify bibliographic references to be considered in the sample. To identify the keywords, we adopted a balanced approach that combines the need to to make the search relatively complete and to produce a search precise enough to identify only more important results more important (De Matteis et al., 2022). This balance between comprehensiveness and precision allowed us to both increase the opportunity to collect the most important articles as well as those of intermediate relevance while avoiding less relevant works (Table 1).

Table 1.

Keywords Selection Matrix.

Keywords definition	Comprehensiveness	Precision	Balanced criterion
Advantage	Increases the possibility to find all articles on the subject, without missing relevant papers	Increases the possibility to find the most relevant articles on the topic, reducing the collection of irrelevant results	Increases the possibility of finding the most relevant articles on the topic, also collecting articles with intermediate relevance and avoiding the collection of irrelevant results
Disadvantage	Risk of collecting irrelevant papers	Risk of not identifying relevant papers	Risk of classifying many papers as intermediately relevant, spending deciding if they should be included in the sample

Source. De Matteis et al. (2022).

Applying the balanced criterion, we identified the three keywords: “public-private partnerships,” “healthcare management,” and “sustainability.” “Sustainability” is a broad term that goes in the direction of comprehensiveness, while “healthcare management” narrows the focus of research to a more precise field. Meanwhile, the term “public-private partnerships” allowed identification of all articles focusing on this particular type of service provision. The search period was limited to 2000 to 2021. At the end of this initial phase, the search process generated 370 articles.

Data Cleaning

Second, 81 duplicates in the initial sample were removed. Of 289 articles remaining, approximately 68% were identified by the Web of Science search.

Skim and Scan

As a third step, we scraped the abstracts and conclusions of these 289 articles has been scraped, generating a second sample of 69 articles. Finally, following Eloranta and Turunen (2015), we conducted a completeness test using the systematic literature review focused on public-private partnerships present in Ali et al. (2020). Comparing our set to the references in the Ali et al. review (107 articles), we added one article, producing a final sample 70 articles (Supplemental Appendix 1).

After this preliminary process, a quantitative analysis mapped the different topics, followed by and, a qualitative analysis to probe major themes. Figure 1 summarizes the differentsteps of the analysis.

Figure 2 reports the publication dates of the articles in the final sample, while the countries of the authors appear in Figure 3.

Interestingly, it is possible to observe a trend of increasing publications (Figure 2), marking the growing attention toward the theme around the world (Figure 3). Indeed, the number of publications from 2016 to 2021 is nearly six times higher than the appearing between 2010 and 2015.

As Figure 3 indicates, the authors of these publications are from numerous countries: Italy (17), UK (12), USA (5), Canada (4), Portugal (4), Saudi Arabia (4), UAE (4), Poland (3), Spain (3), China (2), Malaysia (2), Sweden (2), Bangladesh (1), Czech republic (1), Denmark (1), French (1), Germany (1), Ghana (1), Indonesia (1), Iran (1), Kazakhstan (1), Netherlands (1), Pakistan (1), Romania (1), Scotland (1), South Africa (1), Switzerland (1), Thailand (1), Taiwan (1), Ukraine (1). (The number of countries is larger than the number of publications, since scholars from multiple locations may coauthor a single publication. As is evident, a number of scholars are from Italy (17) and UK (12). Nonetheless, scholars from both “developed” and “developing” countries focused on the theme.

Results

In what follows, we report the results of the quantitative analysis based on semantic analysis and thematic clustering ” and the related qualitative narrative analysis of emerging topics . We begin with two observations.

On the one hand, it is clear that text mining analyses can be applied to manage thousands of articles, where manual checking and visual examination are not feasible or extremely time-consuming. On the other hand, the main trend in systematic literature review studies is to apply quantitative techniques even with fewer items, varying from 30 (e.g., Rotaris et al., 2022) to about 100 (e.g., Lima et al., 2021). Our “mixed strategy” is intermediate. We applied automated procedures to identify clusters in a more “neutral, detached way than might take place with manual classification manually). At the same time, we qualitatively analyzed the content of the identified clusters. Since we ultimately demonstrate that the two strategies produce similar conclusions, we propose one strategy as a robustness check of the other. The name assigned to each cluster derives from this kind of exercise: not only have we assigned names based on the content of the cluster, but we also have double-checked the content of the articles with the number of times the word appears within each cluster.

Quantitative Approach: Semantic Analysis and Thematic Clustering

We relied on the abstracts of the 70 articles as proxies of the main elements each article examined. By employing a bag of word approach, we tokenize words included in each abstract, obtaining 7,711 words. We removed the “private-partnerships,” “ppp,” “health-care,” and “sustainability” keywords included in the creation of the sample, since they can generate bias in separating and clustering differing themes (see Lima et al., 2021 for a similar approach).

Based on the semantic network constructed, we cluster co-occurrent words to identify topics, employing the weighted modularity clustering method in order to account for the intensity (i.e., the link weights) of connects. This is the mainstream method for text clustering (Blondel et al., 2008). The results of this topic identification exercise appear in the word clouds of Figure 4. The size of each word is weighted by its vertex strength, a proxy of the relevance of each word. That is, the more times the word appears, the larger its size.

Varying clusters of topics emerge. We can summarize the main elements by visually scanning the content of each word-cloud. Here we report the words included with quotation marks): topic 1, Governance, included “governance,” “government,” “policy” as words that might highlight the relationship among partners in the implementations of partnerships; topic 2, named Management, given the occurrence and the higher centrality of this word, frequently in combination with words such as efficiency, control, and others tapping managerial issues in the PPP; topic 3, Barriers, included that word and others related to potential “social,” “environmental,” “coordination,” and “organization” constraints or problems. In re-arranging the different themes, we merge the third and fourth sub-topics in a broader category named “Advantages and Disadvantages,” since elements such as the “quality” of “services” and “performance” represent crucial indicators of the success or the failure of the PPP managerial structure. The final topic 5, Data, is included the presence of this word and the potential added value and “benefits” that the use of (big) “data” might generate.

Obviously, this is a preliminary screening process that might suggest to the researcher the main lines defining the subtopic of the research. As in Lima et al. (2021), we integrate this information with a narrative analysis of the articles to outline the actual content of each topic. Having showed in broad terms evident in the sampled articles’ discussion, we turn next to article content.

Qualitative Approach: Narrative Analysis of the Emerging Topics

We used a manual content analysis method to process and analyse the sampled articles (Miles & Huberman, 1994), applying a qualitative systematic review approach (Siddaway et al.,2019). Following Hsieh and Shannon (2005), we adopted three strategies (conventional, direct and summative) to analyse the content of the sampled articles: one author manually coded the information from each article coded using an Excel file, and the other authors checked the coding. All authors reviewed the Excel file and met regularly to discuss and resolve any discrepancies. The information in the file included a number of descriptive statistics (e.g., authors, year of publication, title, journal name) to which the abstract was added. During the data coding process, we focused as well on the “narrative integration of qualitative content” suggested by Rojon et al. (2021), also called “thematic analysis” (Tranfield et al., 2003). Specifically, the authors read and analyzed the 70 articles in the sample in order to categorize them into the five topics previously identified using the semantic analysis.

Consequently, the following analysis of the sampled articles follows the clustering in Figure 4.

Topic 1: Governance

Governance is a particularly important element for PPPs, as for all hybrid organizations that involve the coexistence of often quite different partners (Kumar Hota et al., 2023). Clearly, the establishment of a stable governance structure is a prerequisite for the longevity of a PPP and it contributes to the sustainability of the PPP and the health services it provides.

Since the health sector is one of the most difficult to govern, the involvement of private actors might strengthen the role of health policymakers through the creation of a governance system in which private or civil society actors horizontaly influence the political/governmental component (Fanelli et al., 2020). At the same time, it should be emphasized that influence from private parties may expose policy makers to the risk of weakening as a result of possible interference from private stakeholders. Furthermore, in the context of social infrastructure governance, the use of the private sector through the partnership instrument is only one of the factors that shape the success of broader strategies aimed at redefining the health care delivery model (Hussain & McKellar, 2020).

As Monaghan et al. (2001) state, such success factors can be divided into two categories: (a) partners’ characteristics and (b) partnership process elements. Considering the first set of factors, mutual trust between the partners and compatible organizational cultures require intensive and extensive management commitment for partnership development. The second category of critical factors includes sharing of goals and information, clear specification of each partner’s roles, and the feasibility of the expected timeline for achieving the set goals.

According to Caldwell et al. (2017), generation of estimable social value is based upon relational coordination (resulting from mutual knowledge and alignment of goals among partners) and the value associated with the working environment. Indeed, each component of the partnership has a distinct organizational culture and managerial approach that clearly are reflected in the dynamics underlying the cooperation. Cappellaro and Longo (2011) consider clear regulation of the workforce as one of the major governance issues, balancing contractual arrangements and organizational cultures. It follows that the commitment of both public and private management to harmonize their respective cultures is an essential condition for ensuring the quality of joint activity and preventing cultural differences from undermining the strength of the partnership (Mannion et al., 2011). On the other hand, sharing of goals and actions among the partners, together with a regular and mutual flow of information, is a prerequisite for building the climate of mutual trust that Padma et al. (2017) find necessary to enhance PPP performance and commitment among the parties involved. Similarly, mutual trust is a basic condition for limiting the risk of opportunistic behavior and reducing transaction costs, thus helping ensure long-term public-private relations.

Doś (2017) emphasizes the desirability of integrating appropriate governance mechanisms into the negotiation and management phases of the partnership agreement, reducing transaction costs, monitoring financial efficiency, managing conflicts, safeguarding the quality of health care, and achieving environmentally and socially relevant outcomes. Torchia and Calabrò (2018)argue as well that the structural complexity of the partnership model requires specific attention to the risks associated with the uncertainty characterizing healthcare, and which often is excluded from economic assessments of PPP development. Focusing on epidemiological risks, Baxter and Casady (2020) note that although PPPs may not be the solution to all sustainability problems in health care, a proactive approach to implementing them could pave the way for global partnerships that can increase the resilience of health systems against borderless epidemics.

An analysis of scholarship on governance aspects reveals some of the difficulties in bringing together the varying goals, logics, and managerial approaches of PPP partners. It might be useful to clearly delineate the playing field of governance in terms of common goals to be achieved through a partnership and the responsibilities of each partner pursuing these goals.

Topic 2: Managerial Tools

The literature sampled makes it possible to highlight managerial tools that may be useful for the functioning and sustainability of PPPs in healthcare.

Over time, public management increasingly has viewed collaboration with the private sector as a solution to help ensure the timeliness of and flexibility in delivery of health services (Field & Peck, 2003). Focusing on PPPs, attention needs to be placed on both the implementation of measures that motivate the private actor to participate (Yang et al., 2020) and the critical factors that can shape their success. According to Alonazi (2017), accountability of stakeholders, patient-centeredness, and competence and flexibility of health care providers are key issues for successful and sustainable public-private partnerships. For Pereira et al. (2021), ensuring the success of the partnership model in healthcare means defining, from the outset, a set of indicators for evaluating the performance of the parties involved in order to monitor the quality of the service provided and the degree to which contractual objectives are met.

Public accountability also plays a crucial function the sustainability of PPPs. Cappellaro and Ricci (2017) identify different configurations of partnerships, each marked by its own accountability profile: as the degree of resource sharing (of, e.g., technologies, information, protocols) among partners increases, (the financial performance monitoring systems used by the public sector become more analytical, thus contributing to the improvement of public accountability and, ultimately, to the consolidation of PPP sustainability. Moreover, attention to the economic and financial soundness of the partnership is necessary. For instance, concerns about financial stability, economic performance, and social issues (see the Alzira case), might bring back to direct public management of health services (Comendeiro-Maaløea et al., 2019)

In any case, the implementation of profitable and sustainable-oriented health partnerships passes through the development of an appropriate culture and knowledge of sustainability, equally weighting the three fundamental pillars (Borgonovi et al., 2018). Health managers must consider all key skills, directing management strategies toward a complete sustainable organizational framework (Ramirez et al., 2013). Likewise, healthcare managers must ensure a proper balance of the environmental, economic and social issues, typically unlike the actual dynamics where social aspects are overweighted at the expense of the other two factors (Conte et al., 2018).

Effective pursuit of sustainability in healthcare organizations postulates the development of management documents from which a greater balance in the treatment of the economic, social and environmental dimensions of sustainability can be inferred. Of particular interest would be the adoption of tools for planning, managing and reporting sustainability implemented by PPPs, accompanied by appropriate outcome indicators.

Topic 3: Barriers

According to Al-Hanawi et al. (2020), it is possible to identify a number of barriers that can potentially undermine the fruitful development and sustainability of PPPs in healthcare.

Technological: The shortage of professionals with adequate skills and experience in the activation of partnership projects, together with the inability of private operators to fully address investment challenges related to healthcare partnerships, limits the use and diffusion of PPPs.

Political: One of the major conditions hindering the concretization of partnership agreements is decision-makers’ lack of knowledge of the partnership instrument, which they in some cases likento a privatization process.

Economic: Among them, high transaction costs are one of the most important limiting factors for PPP implementation. Additional types of economic barriers to the establishment of PPP arrangements have been identified by both Al-Hanawi et al. (2020) and other authors.

Regulatory: A well-delineated and stable regulatory framework is essential. Where specific legislation on the partnership instrument is lacking, one may see uneven and fragmented implementation of partnership projects (Greve et al., 2022).

Environmental: The context in which public and private partners operate influences the effective implementation of partnerships. Lack of managerial experience in the public health sector may result in partnerships with the private sector that are of little benefit in terms of innovation and management efficiency. Likewise, additional barriers can be found in the resistance of the health workforce (Khan & Puthussery, 2019) and the lack of transparency and accountability.

Social: In the process of implementing a partnership, it is necessary for both stakeholders to pay attention to the cultural, religious, and professional characteristics of their respective partners (Alves et al., 2021).

Such barriers evidently can affect the sustainability of PPPs and the health services they provide, and different dimensions of sustainability(for example, economic and social barriers).

It should be noted that some authors point out barriers related to issues such as the effectiveness and efficiency of health partnerships or optimal risk management. These difficulties, in practical terms, may discourage partners from embarking on some forms of public-private cooperation considering that, while evidence of the actual effectiveness and efficiency of partnerships is still limited (Torchia et al., 2015), the success of the partnership initiative also depends on the risk management model employed (Hasim et al., 2016). An underlying theme in most of the barriers identified is the lack of qualified health professionals and management training. This points to the need for some countries to revise their approach in training health managers, either by separating the management pathway from the clinical pathway when these two types of training paths overlap-or by expanding the use of partnerships to address the lack of incentives for health professionals (Chang & Besel, 2020).

Topic 4. Advantages and Disadvantages

A growing body of scholarship focuses attention on the advantages and disadvantages potentially arising from the implementation of PPPs, which impact the sustainability of partnerships and the health services they provide. In what follows, we disentangle two faces of the same coin.

Advantages of PPPs include:

the ability of partnerships to profitably combine the strengths that usually characterize the private sector (technical knowledge and skills, managerial efficiency, entrepreneurial spirit) with the functions vested in the public sector, thus arriving at positive results in terms of both employment and social infrastructure development (Roehrich et al., 2014);

the achievement of better clinical performance in health facilities in developing countries (McIntosh et al., 2015);

the improvement of health care quality in terms of reducing waiting times for access to public health services (Caballer-Tarazona & Vivas-Consuelo, 2016) as well as lengths of stay and bed occupancy (Sadeghi et al., 2016);

the contribution to pharmaceutical research and development investments (Kostyak et al., 2017);

the risk sharing between the public and private sectors, leading to higher efficiency in the implementation of healthcare infrastructure (Almalki & Al-Hanawi, 2018);

the possibility of mastering economic problems and constraints (Łakomy-Zinowik & Horváthová, 2016) through the provision of alternative sources of capital and cost savings in health services (Kosycarz et al., 2019);

the realization of investments in healthcare, including in countries with high public debt (Zakharina et al., 2020);

the achievement of higher levels of efficiency (compared to the traditional hospital management model) in the care of chronic diseases, although such differences in efficiency measures also could be influenced by the characteristics of the operating environment (e.g., the average age of the population served; Franco Miguel et al., 2020);

safeguards for the principles of universality, equity and solidarity in access to health care (Signorelli et al., 2020).

Conversely, among the disadvantages are:

the risk that the development of international partnerships in low- and middle-income countries will cause the relevant governments to abandon their role as guarantors of citizens' health, resulting in weakened social safety nets (Kostyak et al., 2017);

the lack of real competition in the private partner selection process, often attributable to the size of the initial investment that the PPP requires (Caballer-Tarazona & Vivas-Consuelo, 2016);

the lack of flexibility linked to the high level of detail characterizing partnership contracts, which in practice prevents hospitals from adapting health care delivery to the opportunities new technologies provide (Kosycarz et al., 2019);

the presence of sources of social inefficiency, which characterize both partnership-run and publicly run hospitals, with potential for improvement in the adequacy of health care (Ferreira & Marques, 2021).

The literature analyzed shows that such advantages and disadvantages represent possible positive or negative impacts on different spheres of the sustainability of health services such as, for example, the development of social infrastructures, the improvement in the quality of and access to health services, reductions in operational rigidity. At the same time, the analysis underscores functionality and complexity of PPPs, while also referring to the previously mentioned topic of the managerial skills needed to govern a partnership. Indeed, like barriers and potential governance problems, analysis of advantages and disadvantages should take place at the stage of partnership design. At that point, only partners and managers with appropriate skills can increase the likelihood of benefiting from the advantages and limiting the disadvantages related to the implementation of public-private collaborations.

Topic 5. Big Data

The sampled scholarship also shows how the technological innovation that PPPs can bring to data management can contribute to the sustainability of health services. Against a backdrop of growing healthcare spending and concomitant public spending cuts, the search for solutions that help ensure healthcare cost containment has become essential.

In this regard, Moro Visconti and Morea (2019) state that when the interaction between public and private partners is based on the use of big data, the ability of healthcare partnerships to create value in health protection increases. The value added of big data is based on the availability of relevant data (e.g., medical, demographic) that feed into health information databases. Such data are exchanged among partnership actors through digital networks and shared databases. As a result, the ability to have continuous data processed in real time improves predictive analytics, reduces risk, and thus increases the sustainability of the health sector through cost reduction and improved quality of care (Moro Visconti & Morea, 2019). At the same time, the introduction through partnerships of big data-based innovations in healthcare still presents open issues related to data variety, quality and sharing (Witjas-Paalberends et al., 2018).

Considering the potentiality of big data, there clearly is a need for further research that more thoroughly evaluates its contribution to the performance of healthcare partnerships.

Discussion

The results of this analysis allow for a systematization of the literature analyzed. This represents a contribution of this study to scholarship on PPPs in the health arena. The proposed framework in Figure 5 summarizes our findings. The framework identifies barriers as conditions necessary for the development of a governance structure, managerial tools, and big data that work synergistically to achieve advantages and avoid disadvantages. The relational arrows between topics are derived from the literature analysis and highlight actionable steps from the planning stage to operation, which can guide PPPs toward sustainability.

Barriers (topic 3) are interpreted as conditions that should be addressed ex ante by influencing “PPP planning.” These include technological, political, economic, regulatory, environmental, and social conditions (Al-Hanawi et al., 2020; Alves et al., 2021; Greve et al., 2022; Khan & Puthussery, 2019) that require careful analysis and evaluation prior to implementation of PPPs aimed at ensuring both their own sustainability and that of the health services provided.

Governance (topic 1), managerial tools (topic 2), and big data (topic 5) can be considered as areas of intervention to be developed during “PPP implementation.” A balanced governance arrangement that fosters fruitful collaboration between public and private partners facilitates the implementation of a durable PPP (Mulyani, 2021), which in turn supports the sustainability of the health services the PPP delivers. That is, good governance is a prerequisite for the sustainability of the PPP itself, enabling it to achieve its goals (Hayllar, 2010). This overall sustainability of the PPP is essential for pursuing other dimensions of sustainability achieved through the various elements enhanced by the partnership.

The use of managerial tools and big data positions the PPP to achieve the goals for which it was initiated, including sustainability (Cappellaro & Ricci, 2017; Moro Visconti & Morea, 2019; Pereira et al., 2021). Ultimately, the appropriate implementation of the governance structure, managerial tools, and big data should lead, on the one hand, to achieving advantages (topic 4) and, on the other hand, to avoiding disadvantages (topic 4), which are interpreted as potential outcomes of “PPP operation.”

Such outcomes also affect the sustainability of health services managed through PPPs. Disadvantages may hinder the sustainability of the entire management process of PPPs and consequently the sustainability of the health services they provide. Conversely, advantages can contribute to the sustainability of PPPs by improving the socio-economic development of the health system. Both disadvantages and advantages of PPPs in health care then affect their sustainability, which in turn influences the sustainability of health care services (among others: Caballer-Tarazona & Vivas-Consuelo, 2016; Ferreira & Marques, 2021; Kosycarz et al., 2019; Signorelli et al., 2020).

Over time, PPPs in the health field have taken on three different configurations depending on whether they had as their primary purpose (Pereira et al., 2021): (a) the construction or renovation of public health infrastructure; (b) the expansion of clinical service delivery capacity; or (c) the integration, in a single partnership model, of both objectives. Indeed, considering the period of our analysis, it is possible to observe that this managerial tool was being debated before the advent of COVID-19. The pandemic outbreak might speed up implementation of this process, given the mutual support required among the public and private actors involved, and thus the need to trust the PPP framework (Casady & Baxter, 2020). In a broader perspective, PPPs would favor the resilience of the system (Hasan et al., 2021), thanks to the symbiotic interaction between the public and the private sectors, unlocking the economic lockdown (Vaslavsky, 2021). From here, it becomes crucial to identify the challenges of preserving and the opportunities to enhance the sustainability of PPP outcomes in a future post-COVID world (Strasser et al., 2021).

Conclusion

From this literature review, we derived several managerial implications that could facilitate sustainable implementation of PPPs.

First is the need to develop a systemic perspective to managing the various elements that define partnership development. Scholarship on health partnerships reveals characteristic features and critical factors, whose numbers and complexity necessitate a systemic approach. It is advisable to consider together all aspects the literature during both the planning and implementation phases of a partnership. Although some aspects may be more relevant than others, all must be considered systemically to avoid the risk of focusing on certain critical elements while neglecting others. This approach allows PPP managers to consider barriers to overcome, interventions to realize, and related outcomes to pursue.

A systematic view of the elements the review identified using the proposed framework supports an overview of various dimensions of sustainability. These include analyzing barriers (e.g., economic, environmental, social), monitoring governance aspects (e.g., mechanisms to reduce conflicts and safeguard healthcare service quality), using managerial tools (e.g., accountability documents), leveraging big data (e.g., real-time data processing to improve predictive analytics, reduce risk, and increase sustainability), and considering advantages/disadvantages (e.g., service accessibility, public expenditure inefficiency). In turn, this highlights elements of the environmental, economic, and social sustainability of PPPs and the health services they provide.

Conversely, failing to consider the issues identified in the literature review systematically may undermine the sustainability of healthcare services. For example, regulatory barriers, governance issues, and certain disadvantages may affect the flexibility of a PPP. If not addressed together, they could generate rigidity, undermining the PPP’s sustainability.

The need for systemic management points to the second implication: the opportunity to develop technical managerial skills essential for addressing critical aspects of the partnership. Managerial competence is crucial for the success of PPPs (Torchia et al., 2018), making it desirable for the public sector to invest more in acquiring and retaining these skills (Bloomfield, 2006). Managers should be aware that addressing critical issues in PPP management affects the sustainability of PPPs and the healthcare services they provide.

The third implication is the search for a governance balance that supports the sustainable implementation of PPPs. Beyond building mutual trust among parties, identifying the roles and responsibilities of partners is crucial. Failure to specify these aspects clearly can create governance problems (Buse et al., 2007), while overly stringent definitions can make the partnership scheme rigid and unsuitable for adapting to the dynamic healthcare environment. Partners often exacerbate this rigidity in order to minimize risk by adding details to the partnership contract and providing for penalties in case of changes. Incorporating flexibility during the PPP planning phase could help address technological and epidemiological changes (McKee et al., 2006). Balanced and stable governance helps enable a solid, durable partnership that supports the sustainability of healthcare services.

A fourth and final implication concerns the need to adopt operational instruments to monitor sustainability at different PPP stages (planning, implementation, functioning), contributing to healthcare sustainability. Developing tools to monitor governance balances or internal control and performance management tools could help track the correlation between PPP objectives and results, including sustainability. Monitoring sustainability enables continuous assessment and improvement.

Appropriate attention to the implementation of PPPs can enhance pursuit of the 17th Sustainable Development Goal of the UN Agenda 2030. Public institutions play a crucial role in monitoring the stability and effectiveness of existing partnerships, assessing the feasibility of planned ones, and collaborating with the private sector for post-pandemic recovery (Baxter & Casady, 2020).

In light of these results and reflections, it is important to conduct further empirical research, including questionnaires and interviews, to investigate the skills and viewpoints of public and private managers involved in PPPs. Such research could explore the pros and cons, operational tools, specific skills needed, and the links between PPPs and sustainability, seeking verification of the conceptualizations and framework we have presented.

Supplemental Material

sj-docx-1-aas-10.1177_00953997241275576 – Supplemental material for Public-Private Partnerships in the Healthcare Sector and Sustainability: Managerial Insights from a Systematic Literature Review

Supplemental material, sj-docx-1-aas-10.1177_00953997241275576 for Public-Private Partnerships in the Healthcare Sector and Sustainability: Managerial Insights from a Systematic Literature Review by Fabio De Matteis, Fabrizio Striani, Giovanni Notaristefano and Rocco Caferra in Administration & Society

Footnotes

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Fabio De Matteis

Fabrizio Striani

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Fabio De Matteis, PhD, is an Associate Professor of Public Management at the Ionic Department in “Legal and Economic System of Mediterranean: Society, Environment, Culture”, University of Bari (Italy). He has been teaching and researching on public management issues for many years, and has coordinated a three-year research project (“Multidimensionality, measurement and valorisation of sustainability in public administration”) on sustainability management in local government. Other research areas are accounting, performance, accountability, public-private partnership, planning and control in public sector.

Fabrizio Striani, PhD, is a Research Fellow at the University of Salento (Italy), Department of Innovation Engineering. He coordinated projects on telemedicine and healthcare governance and his current research areas concern performance of public sector organizations and quantitative analysis.

Giovanni Notaristefano, PhD at the Ionic Department in “Legal and Economic System of Mediterranean: Society, Environment, Culture”, University of Bari (Italy). He develops research and publishes in Public Management with specific interest in the topics of public-private partnerships, sustainability management, governance and performance management.

Rocco Caferra, PhD, is a researcher in Political Economy at UnitelmaSapienza University of Rome. His main research interests are related to the field of public economics, with a focus on issues of social, economic and environmental sustainability.

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