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\title{Rethinking Public-Private Partnerships (PPPs) in Healthcare: Integrating Social Impact into the Working Model}
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\begin{document}

             \author[1]{Odhiambo  David}

             \affil[1]{  Jomo Kenyatta University of Agriculture and Technology}

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\date{\small \em Received: 11 December 2018 Accepted: 4 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


Introduction-Public-Private Partnerships (PPPs) are collaborations between the public and private sector organizations i.e. for profit, not for profit, faith-based or NGOs. These engagements can be in the form of institutional arrangements ranging from simple collaboration, joint venture programs, direct contract lease and concessions among others (Mwageni, December 2006).PPPs are forged with to meet a common need which either entity alone cannot be able to realize (Thadani, 2014). In most cases, they are designed to take advantage of the strengths of both parties in a structured arrangement i.e. better managerial competencies in the private sector and huge resource pool in the public sector to realize a common goal.The benefits attributed to PPP's include improved physical access to services in under-served areas, efficiency in the use of health resources by leveraging technical and managerial competencies of the private sector, prevent impoverishment of the uninsured & marginalized individuals, equity in access to services not available in the public sector, improved health infrastructure, regulatory and oversight on health standards (Bjorkman, 2015). These benefits double as the partners' aspirations in such arrangements especially within the confines that health is a social need that falls within the premise of governments to ensure access while private entities have an interest for their business success.

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction} 
\section[{ublic-Private}]{ublic-Private}\par
Partnerships (PPPs) are collaborations between the public and private sector organizations i.e. for profit, not for profit, faith-based or NGOs. These engagements can be in the form of institutional arrangements ranging from simple collaboration, joint venture programs, direct contract lease and concessions among others \hyperref[b7]{(Mwageni, December 2006)}.\par
PPPs are forged with to meet a common need which either entity alone cannot be able to realize \hyperref[b8]{(Thadani, 2014)}. In most cases, they are designed to take advantage of the strengths of both parties in a structured arrangement i.e. better managerial competencies in the private sector and huge resource pool in the public sector to realize a common goal.\par
The benefits attributed to PPP's include improved physical access to services in under-served areas, efficiency in the use of health resources by leveraging technical and managerial competencies of the private sector, prevent impoverishment of the uninsured\& marginalized individuals, equity in access to services not available in the public sector, improved health infrastructure, regulatory and oversight on health standards \hyperref[b4]{(Bjorkman, 2015)}. These benefits double as the partners' aspirations in such arrangements especially within the confines that health is a social need that falls within the premise of governments to ensure access while private entities have an interest for their business success.\par
The key factors that drive governments to establish PPPs as argued by the Africa Health Forum Finance and Capacity and Results are: i. The desire to improve the operation and performance of public health services and facilities and to expand access to improved quality services ii. An opportunity to leverage private investment for the benefit of public services iii. The desire to formalize arrangements with non-profit partners who deliver a substantial share of public services iv. An increase in the potential partners for governments as the private healthcare sector matures (Africa Health Forum: Finance and Capacity for Results, 2013).\par
With these in sight, it's critical to assess the different models of engagement in PPP currently being employed and propose new models which would bridge the gap and fuel the transition to UHC since this is an ever desired most elusive target. 
\section[{II. Public-Private Partnership Models in Healthcare}]{II. Public-Private Partnership Models in Healthcare}\par
There are three main working PPP models in place which include: i. Health services-only model where a private entity is given the mandate to operate and deliver publicly funded services to citizens in public facilities. ii. Facility finance model in which a public agency contracts a private organization to design, build, and finance and operate a health program/facility. Health services within such a facility are mostly provided by the government iii. Combined facility finance and health services model where a private entity builds or leases a facility and delivers free or subsidized healthcare services to a specific population as per the agreement.\par
(Independent Evaluation Group: World Bank Group, 2016). The same model is confirmed to be a common case in facility-based PPPs as presented by PwC and Institute of Global Health Sciences in their Healthcare public-private partnerships series No. 4 (Abuzaineh, January 2018). This commonality confirms that most PPPs in health are limited to the provision of healthcare services and specifically with ensuring access through either facility development, service provision or financing of the same programs. The success of PPPs in healthcare to this stage are instrumental in shaping the next steps to be taken and this is affirmed by the discussions presented in the Africa Health Forum report (Africa Health Forum: Finance and Capacity for Results, 2013).\par
The Africa Health Forum report further presented categories of PPP models with key examples on where they have been successful;  
\section[{Proposals on PPP}]{Proposals on PPP}\par
In the new wave of action towards UHC, there is a need to reassess the structures and models that have been adopted in PPPs for health and revamp the offerings for impact. In this new approach, private sector players should assess their offerings in light of their social impact on the communities in which they intend to operate. However, these should not be confused for Corporate-social responsibility (CSR) activities as they constitute the core business being conducted by the different partners in such an arrangement. PPPs with social impact is at the core of the post-industrial revolution as postulated by Karl Marx even though it may not come in the form of revolutions as defined by him (Anthony \hyperref[b2]{Giddens, 2012)}.\par
Initiative for PPPs should not be constrained to emanate from the public sector but should be driven from any party that identifies a need area which would be served better through a PPP. In so doing, any party will have the responsibility of researching on the healthcare needs and emerging concerns, designing interventions and proposing partnerships to ensure there is efficiency in the delivery of the same services with maximum impact. With such a shift in focus, instead of private health insurance companies focusing extensively on better ways of offering covers for medical care to cushion clients from burdensome healthcare costs, they will restructure to have offerings on health promotion programs and support for the determinants of health such as nutrition.\par
The upcoming avenues for massive PPP engagement are in the global health sphere and include: i. Healthcare financing: With financial constraints that are limiting the ability of governments to cater to the healthcare needs of their citizenry. There is a need to find new frontiers for funding. Organizations such asGAVI, Co-Impact Lab, etc. are coming with new ways of mobilizing funds for interventions with impact and these should be benchmarks for healthcare financing as well. With most countries in the global south working towards structuring or restructuring their national health insurance schemes, PPPs should be focused on modalities of having comprehensive revenue management models which would ensure all facets of care are serviced i.e. preventive, health-promoting, curative, rehabilitative, palliative and infrastructural needs. This concept is currently under development and review by our team at Ryculture to come up with a Comprehensive Community-Based Health Insurance Scheme.\par
ii. Immunization: there have been a re-emergence of outbreaks of disease which have been managed through vaccinations in the past such as the measlescase in the USA due to belief systems as witnessed with members of the Orthodox Church.\par
Cases have also been witnessed as a result of lack of access to facilities in some developing countries.\par
In the latter, PPPs with community pharmacies which are relatively more accessible to the public even in remote communities can help support the access to vaccines if structured to serve this gap, especially where geographical access has been a constraining factor. A partnership in this context would make the pharmacists serve a social need in the community while at the same time aiding governments in the provision of immunization services. iii. Telemedicine: technology is becoming a part of our everyday lives even in the poorest of communities there is access to a mobile phone. This presents a great avenue to promote health where resource constraints have been an impediment. With a mobile phone patients can be able to secure consultations from qualified practitioners, access verified prescriptions, etc. However, for this to work, government policies, regulatory and structural interventions will be crucial in supporting the private sector in adopting such arrangements. Currently, this is taking root in Rwanda through the adoption of Babyl services which offers general practitioner consulting, prescription and referral systems via phone (Babylon Health Rwanda, 2019) and Japan \hyperref[b6]{(Kyodo, 2019)}.\par
IV. 
\section[{Conclusion}]{Conclusion}\par
PPPs have helped ensure essential services which would otherwise not be provided by the public sector or the private sector alone are made available in an efficient manner to the public. This has been instrumental in promoting healthcare access especially in the low and middle-income countries (LMIC) as depicted by case analysis by the Africa Health Forum. However, in order to realize the goal of achieving UHC, we need to rethink our models for PPP with focus on the most pressing challenges, the available resources and the value we are bound to obtain from concerted investment in health through PPPs with a social conscience.\begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.059691011235955056\textwidth}P{0.09829119850187266\textwidth}P{0.004377340823970037\textwidth}P{0.004377340823970037\textwidth}P{0.3195458801498127\textwidth}P{0.000795880149812734\textwidth}P{0.10386235955056179\textwidth}P{0.24154962546816477\textwidth}P{0.017509363295880147\textwidth}}
\tabcellsep \multicolumn{2}{l}{Category}\tabcellsep \tabcellsep \multicolumn{3}{l}{Private sector responsibility}\tabcellsep Public sector responsibility\\
\multicolumn{4}{l}{Public Health Services PPP}\tabcellsep \multicolumn{3}{l}{? Management of services under contract}\tabcellsep ? Contracts a private sector entity for the\\
e.g.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{?Provision of either clinical and nonclinical}\tabcellsep provision of public services\\
-\tabcellsep \multicolumn{3}{l}{Performance-Based}\tabcellsep services\tabcellsep \tabcellsep ? Pays for, monitors and regulates services\\
\tabcellsep \multicolumn{2}{l}{Financing (PBF)}\tabcellsep \tabcellsep ?Provision\tabcellsep of\tabcellsep healthcare\tabcellsep products,\tabcellsep \& contract compliance by the private entity\\
-\tabcellsep \multicolumn{2}{l}{Riders for Health}\tabcellsep \tabcellsep \multicolumn{3}{l}{especially pharmaceuticals, at agreed}\tabcellsep ? May engage with development partners for\\
\tabcellsep \multicolumn{2}{l}{(Transport)}\tabcellsep \tabcellsep rates\tabcellsep \tabcellsep the project\\
-\tabcellsep \multicolumn{2}{l}{Food Fortification}\tabcellsep \tabcellsep \multicolumn{3}{l}{?Employment of staff and manage new}\\
\tabcellsep \multicolumn{2}{l}{(Salt Iodization)}\tabcellsep \tabcellsep \multicolumn{3}{l}{capital investment, depending on the}\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep contract\tabcellsep \\
\multicolumn{4}{l}{Hospital Services PPP e.g.}\tabcellsep \multicolumn{3}{l}{?Manage public hospital as per the}\tabcellsep ? Contract a private firm for the provision of\\
-\tabcellsep Brazil:\tabcellsep Sao\tabcellsep Paulo\tabcellsep contract\tabcellsep \tabcellsep public hospital services\\
\tabcellsep Hospitals.\tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{? Provide clinical and nonclinical services}\tabcellsep ? Pays for, monitors and regulates services\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{?Employ all staff and be responsible for}\tabcellsep rendered by the private operator as per the\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{new capital investment as defined in the}\tabcellsep contract terms\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep contract\tabcellsep \tabcellsep ? May engage development partners\\
\multicolumn{4}{l}{Facilities-finance PPP e.g.}\tabcellsep \multicolumn{3}{l}{? To finance, construct, and own a new}\tabcellsep ? Manage a privately developed hospital and\\
-\tabcellsep \multicolumn{3}{l}{United Kingdom: Private}\tabcellsep \multicolumn{3}{l}{public health facility then lease it back to}\tabcellsep make lease payments to the private\\
\tabcellsep \multicolumn{2}{l}{Finance Initiative}\tabcellsep \tabcellsep \multicolumn{2}{l}{the government}\tabcellsep developer\\
\multicolumn{4}{l}{Combined Facilities and}\tabcellsep \multicolumn{3}{l}{? To finance, construct, and operate a new}\tabcellsep ? Reimburse private operator for capital\\
\multicolumn{3}{l}{Services PPP e.g.}\tabcellsep \tabcellsep \multicolumn{2}{l}{public hospital}\tabcellsep investment and recurrent costs for the\\
-\tabcellsep Lesotho:\tabcellsep \tabcellsep Queen'\tabcellsep \multicolumn{3}{l}{-To provide clinical or non-clinical services}\tabcellsep services provided;\\
\tabcellsep Mamohato\tabcellsep \multicolumn{2}{l}{Memorial}\tabcellsep or both\tabcellsep \tabcellsep -Provide relevant public premises such as\\
\tabcellsep \multicolumn{3}{l}{Hospital and Clinics}\tabcellsep \tabcellsep \tabcellsep land\\
\multicolumn{3}{l}{Co-location PPP e.g.}\tabcellsep \tabcellsep \multicolumn{3}{l}{? Operate a private section or department}\tabcellsep ? Manage public section for public patients\\
-\tabcellsep \multicolumn{3}{l}{South Africa: Pelonomi \&}\tabcellsep \multicolumn{3}{l}{of the public facility}\tabcellsep -Manage relationship with the private unit\\
\tabcellsep \multicolumn{3}{l}{Universitas Hospitals}\tabcellsep \multicolumn{3}{l}{? Fulfillpayment and service access}\tabcellsep such as sharing of overhead costs and\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{conditions as agreed in the contract;}\tabcellsep equipment\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \multicolumn{3}{l}{-Maintain public land or building used}\tabcellsep ? Supervise the fulfillment of patient access\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep and other conditions as agreed on in the\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep contract\\
\tabcellsep III.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_0}Table 1}\end{figure}
 		 		\backmatter  			  				\begin{bibitemlist}{1}
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\end{document}
