Exploring shared risks through public-private partnerships in public health programs: a mixed method

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

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

This study uses a mixed-method approach utilizing both qualitative and quantitative domains to explore the NTP, provide details of PPPs, and focus on more features and models to explain effective PPPs, respectively. To share risks, this study attempts to clarify the PPP process and explain its integration within a universal healthcare system.

For the qualitative approach, the fundamental roles of public and private institutions that are significantly attributed to maintaining the relationships among themselves were identified, as shown in Table 3.

Table 3 summarizes the roles and functions of major institutions associated with the success of the NTP. Previously, the government financed and regulated the healthcare system; however, the private sector may now interfere and regulate the healthcare system.

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

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

Among the 15 MoH initiatives, almost half (47%) are process-based measures, while the rest are either structure- or outcomes-based measures (33% and 20%, respectively).

Based on the analysis, there is a new trend of healthcare prioritizing and implementing, which has yielded in unclear results for addressing the challenges faced by PPPs. Table 5 summarises the priorities and challenges in healthcare based on the answers of experts involved directly in implementing the health transformation. The aim of this group was to provide reliable, comparable qualitative data about the future of PPPs, based on thematic analysis.

The 13 participants believed that the SHCS exhibits a need for more trustworthiness between the public and private sectors to achieve success. Second, they presumed that the technology and patient-centeredness domains are key issues in successful partnerships. Having less importance than previous factors, healthcare professionals’ competence and flexibility within the healthcare system were identified as obstacles that PPPs may face.

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

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

A trust-based model can dynamically facilitate the demands of patients and the activities provided depending on the proposed reimbursement system [40]. Under the NTP, the PPP program clearly shapes the values towards health services and their financing arrangements. For public primary healthcare services, the development of medical technology is slow, unlike for private primary healthcare services. Contrarily, secondary private healthcare services lack advanced technology. Nowadays, providing effective public services and addressing the risk balance are basic requirements measured by third parties and regulatory institutions [41]. There are also intangible rewards at play, such as the healthcare reputation of the institution or physician/specialist at hand. As patient-centeredness is one of the six domains for any effective healthcare system, the SHCS should incorporate the voice of the patient in its overriding goals [17, 42]. In this study, the domain that had the most difficulty in incorporating PPPs was flexibility. Organizational flexibility refers to institutions enabling patients to process their treatments without complications, as a potential management strategy [43]. Thus, the goals must include ensuring adequate and continuous usability of the facility over time, providing amenities, and supporting/creating high-quality services.

As public investment in infrastructure continues to decrease, private participation is required to address the existing and expanding deficit in medical services, especially for chronic cases, patient behaviour, and treatment mechanisms [35]. Despite great progress in PHC services, PPPs may be more successful in secondary healthcare services due to high demand from the population.

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

This paper explores shared risks through PPPs in public health programs, and suggests models for public health policy makers when implementing the NTP. The most appropriate model to gradually implement the NTP is through concession based on primary and secondary treatment. Additionally, CCHI, CBAHI, and SHC should take more active roles in regulating the SHCS. Finally, to ensure effective healthcare system, relationships between public and privet sectors should be tightened based on utilizing high technology including the voice of the patient, increasing competency, and ensuring flexibility.