Mount Carmel Institute of Business Intelligence The Feasibility of Healthcare Public Private Partnerships in Zimbabwe by Nixjoen Mandaza Mapesa Mount Carmel Institute of Business Intelligence 2017 Abstract The Feasibility of Healthcare Public Private Partnerships in Zimbabwe by Nixjoen Mandaza Mapesa DBA, Walden University, 2016 MBL, Bindura University of Science Education, 2014 MBA, Frankfurt School of Finance and Management, 2006 MBChB, University of Zimbabwe, 1993 Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Masters in Business Intelligence Mount Carmel Institute of Business Intelligence May 2017 Abstract Public-private partnerships are increasingly seen as playing a critical role in improving the performance of health systems worldwide, by bringing together the best characteristics of the public and private sectors to improve efficiency, quality, innovation, and health impact of both private and public systems. While partnerships can be an effective force toward achieving these results, they are not a magic solution to the many problems that now face health systems in Zimbabwe and around the world. Zimbabwe has been characterised by a continuous deterioration in existing public infrastructure due to the continued economic meltdown and lack of funding. The Government has taken a policy position to adopt public-private sector partnerships (PPP), under which the private sector would partner Government to deliver infrastructure. This study focuses on the feasibility of healthcare PPP through drawing lessons from some previous projects involving PPP in Zimbabwe and in other countries, and notes that there is a potential for PPP to transform healthcare in Zimbabwe. For this to happen, several critical issues must be addressed as a prerequisite. These issues generally centre on financing challenges, policy and institutional framework, risk analysis and management, expertise on PPP, and inculcating a culture of infrastructure maintenance. The study recommends a speedy finalisation of the already initiated policy and institutional framework process to govern PPP in Zimbabwe, which would also include putting measures in place centred on risk analysis and management during the process, issues on financing and issues on the mobilisation and incentivising of the private sector to participate in the process. The Feasibility of Healthcare Public Private Partnerships in Zimbabwe by Nixjoen Mandaza Mapesa DBA, Walden University, 2016 MBL, Bindura University of Science Education, 2014 MBA, Frankfurt School of Finance and Management, 2006 MBChB, University of Zimbabwe, 1993 Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Masters in Business Intelligence Mount Carmel Institute of Business Intelligence May 2017 Dedication To my children, Kudakwashe Brandon, Abraham Joshua Mpho, and Zoe Makatendeka. Acknowledgments It has been through the support of others that I have been able to complete this dissertation. To the faculty at Mount Carmel Institute of Business Intelligence, thank you for affording me the opportunity to advance my academic aspirations. Professor Gunduza, I will forever remain indebted to your exceptional mentorship and wise counsel. To my extended family, I express my gratitude for your unwavering support. To my children, Kudakwashe, Abraham, and Zoe, each one of you deserves a special thank you—for your love and understanding—but wondering why dad still has to go through all this. I did this especially for you my children. I hope that I have shown you by example the importance of education. No matter what direction your future holds, never stop learning. Always remember dad loves you, but God loves you more. To all those who have contributed to the successful completion of this dissertation—too many to mention—I say thank you. To my Lord and personal Saviour—Jesus Christ, you have always been there for me and with me, and I know you will always forever be. Table of Contents List of Tables................................................................................................................... v List of Figures ................................................................................................................ vi CHAPTER 1: INTRODUCTION TO THE STUDY ........................................................ 1 1.1 Introduction ......................................................................................................... 1 1.2 Background of the Research ................................................................................. 1 1.3 Problem Statement ............................................................................................... 4 1.4 Objectives of the study ......................................................................................... 5 1.5 Research Questions .............................................................................................. 5 1.6 Research Philosophy ............................................................................................ 6 1.7 Significance of the Study ..................................................................................... 7 1.8 Assumptions, Limitations, and Delimitations ....................................................... 8 1.8.1 Assumptions ................................................................................................8 1.8.2 Limitations ..................................................................................................9 1.8.3 Delimitations ...............................................................................................9 1.9 Definition of Terms .............................................................................................. 9 1.10 Summary and Transition .................................................................................. 10 CHAPTER 2: LITERATURE REVIEW ........................................................................ 11 2.1 Introduction ....................................................................................................... 11 2.2 Public-Private Partnership .................................................................................. 11 2.2.1 Overview................................................................................................... 11 2.2.2 History of PPPs ......................................................................................... 15 i 2.2.3 Definition of Public-Private Partnership .................................................... 15 2.2.4 The Benefits of Public-Private Partnerships ............................................... 18 2.2.5 Disadvantages of PPPs .............................................................................. 21 2.2.6 The Different Forms of PPPs ..................................................................... 22 2.2.7 Classification by Degree of Risk Transfer.................................................. 25 2.2.8 The Key Process Phases of PPPs ............................................................... 26 2.2.9 The Typical Financial Structure of a PPP................................................... 28 2.3 PPP in Developing Countries ............................................................................. 29 2.4 PPPs in the Healthcare Sector ............................................................................ 32 2.4.1 The Range of PPPs in the Health Sector .................................................... 32 2.4.2 What Makes Health PPPs Different? ......................................................... 34 2.5 PPP in Africa ..................................................................................................... 36 2.6 PPP in Zimbabwe ............................................................................................... 39 2.6.1 Historical Perspective ................................................................................ 39 2.6.2 Healthcare in Zimbabwe ............................................................................ 41 2.7 Requisites for Successful PPP ............................................................................ 43 2.8 Transition and Summary .................................................................................... 45 CHAPTER 3: RESEARCH METHODOLOGY............................................................. 46 3.1 Introduction ....................................................................................................... 46 3.2 Research Method ............................................................................................... 46 3.3 Research Design ................................................................................................ 47 3.4 Population and Sampling.................................................................................... 47 ii 3.5 Ethical Research ................................................................................................ 48 3.6 Data Collection .................................................................................................. 48 3.6.1 Instruments................................................................................................ 48 3.6.2 Data Collection Technique ........................................................................ 49 3.6.3 Data Organization Techniques ................................................................... 50 3.7 Data Analysis Technique.................................................................................... 50 3.8 Reliability and Validity ...................................................................................... 51 3.8.1 Reliability ................................................................................................. 51 3.8.2 Validity ..................................................................................................... 52 3.9 Transition and Summary .................................................................................... 54 CHAPTER 4: DATA PRESENTATION AND ANALYSIS .......................................... 55 4.1 Introduction ....................................................................................................... 55 4.2 Presentation of the Findings ............................................................................... 55 4.2.1 Understanding of PPP as Healthcare Development Model ......................... 57 4.2.2 Barriers to PPP Adoption........................................................................... 59 4.2.3 Critical Issues to Address .......................................................................... 63 4.2.4 Chitungwiza Central Hospital Case Study ................................................. 67 4.3 Transition and Summary .................................................................................... 69 CHAPTER 5: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ............. 70 5.1 Introduction ....................................................................................................... 70 5.2 Summary ........................................................................................................... 70 5.3 Conclusion ......................................................................................................... 71 iii 5.4 Recommendations .............................................................................................. 74 5.4.1 Recommendations for Action .................................................................... 74 5.4.2 Recommendations for Further Study ......................................................... 76 References ..................................................................................................................... 78 Appendix A: Consent and Confidentiality Form ............................................................ 87 Appendix B: Interview Questions .................................................................................. 89 Appendix C: Email Invitation ........................................................................................ 90 Appendix D: Approval Form ........................................... Error! Bookmark not defined. Appendix E: Release Form .............................................. Error! Bookmark not defined. iv List of Tables Table 1. Initial coding schema based on research questions ........................................... 57 Table 2. Major themes & subthemes .............................................................................. 57 Table 3. Understanding PPP as a model of healthcare development ............................... 58 Table 4. Barriers to PPP................................................................................................. 61 Table 5. Critical issues to be addressed .......................................................................... 64 v List of Figures Figure 1. Classification of Public-Private Partnerships by type of contract ..................... 23 Figure 2. Examples of PPP contracts categorized by infrastructure asset involved.......... 26 Figure 3. Overview of typical Public-Private Partnership life cycle ................................ 27 Figure 4. Typical financing structure of a Public-Private Partnership project.................. 29 Figure 5. Fields of application for PPP in the healthcare sector ...................................... 33 Figure 6. Categorization of health PPPs by core activity ................................................ 34 vi 1 CHAPTER 1: INTRODUCTION TO THE STUDY 1.1 Introduction The purpose of this study was to develop a perspective on the role of Public Private Partnerships (PPPs) in Zimbabwe through healthcare providers’ perspective. The study, which was in the form of in-depth interviews, sought to determine the underlying challenges of PPPs, and how PPPs in healthcare can be leveraged to improve service delivery and drive quality affordable healthcare. The challenge in Zimbabwean healthcare is to develop and sustain an affordable and easily accessible quality healthcare system. This qualitative study provided information regarding the feasibility of healthcare PPPs in Zimbabwe. 1.2 Background of the Research The vision of the Zimbabwe Ministry of Health and Child Care is to have the highest possible level of health quality of life for all its citizens. The National Health Strategy 2016-2020—Equity and Quality of Health: Leaving No One Behind—sets out the strategic direction for the health sector over the next five years, to attain this vision. The strategy lays out the health agenda for 2016-2020 considering the broader policy context as defined by the Zimbabwe Agenda for Sustainable Socio-Economic Transformation (Zim-Asset) and the Sustainable Development Goals (SDGs). The current challenges of economic growth, worsened by a turbulent global market, mean that the strategy cannot be business as usual as the country needs to find innovative ways of supporting the health sector (Government of Zimbabwe, MOHCC, 2016). At independence in 1980, the new government embarked on an extensive investment in social services that included universal healthcare provision. The 2 strategy centered on the provision of primary health care in communities and was a monumental success in the early 1980s when life expectancy rose by nearly a decade from 54.9 in 1980 to 63 years in 1988. The post 2000 period witnessed a negative trend in the health sector as the Zimbabwean economy plunged. The erosion of Zimbabwe’s health system was indexed by a fall in key health indicators with life expectancy at birth falling from 62 to 44 years between 1990 and 2008, and maternal mortality dramatically increasing from 168 in 1990 to 880 per 100,000 live births in 2005 (Government of Zimbabwe, MOHCC, 2016). The 2009-2012 period saw the economy rebounding and beginning to reverse the consequences of near collapse of the health system in 2008. However, the period 2013-2015 saw a dramatic drop in economic growth, with future growth predicted to remain sluggish. Consequently, government fiscal space is likely to shrink thereby increasing the need for external funding to support the health infrastructure, retention of health workers, medicines and commodities supply and distribution, amongst others. Improving the quality of health services and ensuring equitable access to these services is the main challenge that the strategy seeks to address (Government of Zimbabwe, MOHCC, 2016). Continued decline in current public infrastructure due to the incessant economic challenges has characterised the Zimbabwean economy (Dube & Chigumira, 2011). Institutions in the country including local authorities and parastatals with responsibility to provide utility services and critical public infrastructure are bereft of the capacity to sustain the facilities in good state to meet the increasing demand for efficient service delivery (Chiromo, 2014). In this regard, Zimbabwe faces the daunting challenge of expeditious restoration of the 3 infrastructural base. Presently the government remains burdened with ailing parastatals including a bankrupt national airline, a stressed power utility, an almost nonexistent railway system, an idle steel plant, and crippled road network in the country among others (Mutandwa, 2015). For this reason, the Government of Zimbabwe (GoZ) has taken a policy position to adopt public-private partnerships (PPP) involving collaborating with the private sector to deliver infrastructure and services. In the homegrown 5-year (20132018) economic blueprint, the Zimbabwe Agenda for Sustainable Socio-Economic Transformation (ZIMASSET), the GoZ identified PPP as one of the major infrastructural financing mechanisms for this plan. One cluster of the blueprint, the infrastructure and utilities cluster should be funded through PPPs (Government of Zimbabwe, ZIMASSET, 2013). Government has earmarked funding the following sectors through PPP arrangement: transport, road infrastructure, power and energy, education sector, water reticulation, and the health sector. An important question is why establish PPPs now given that the contracting phenomenon has always been there? While PPP could be a solution to the current public infrastructure challenges in Zimbabwe, it may not be a panacea for public infrastructural development challenges (Mukwada & Gashirai, 2017). However, at a time when the Government is financially handicapped as is the case with Zimbabwe, with a huge public debt making borrowing impossible, there are limited alternatives to PPP if the current appalling state of public infrastructure is to be corrected. It is thus critical to ensure that PPPs are promoted while measures are being taken to contain any possible challenges (Mukwada & Gashirai, 2017. 4 A systematic review of existing reports, data and evidence regarding the performance of the health sector shows that Zimbabweans still faces a double burden of communicable and non-communicable diseases (Government of Zimbabwe, MOHCC, 2016). These challenges are compounded by health systems constraints related to shortages of critical health workforce, aging infrastructure and equipment, supply of medicines and other commodities, limited health funding, and considerable challenges with the service delivery platforms or entities and the enabling environment. Addressing the challenges requires strengthened service delivery platforms or entities including primary care and hospital services, and creation of an enabling environment with attention to issues of policy and administration, multi sectorial partnerships, and research and development. Given the critical role that the envisaged PPP are expected to play in resuscitating the economy, it is important that a detailed focus on the scope for applying PPP in Zimbabwe healthcare be done. In particular, it is important to outline the substantial issues involved in PPP, particularly the key factors that need to be taken into consideration to ensure that they are successful. It was therefore necessary that the focus of this study be on the feasibility of healthcare PPP, both from a policy and institutional framework perspective as well as going deeper to focus on the technical issues involved and PPP outcomes. 1.3 Problem Statement Experiences with public private partnerships (PPPs) the world over point to generally encouraging results but the rate of PPP uptake in Zimbabwe is low. This study suggests that an array of challenges, including lack of political will, lack of enabling legislative frameworks, and lack of legal and institutional frameworks 5 among others, prevent private players from entering into PPP arrangements. As a result, the possibility of adopting PPPs in Zimbabwe in general, and in the healthcare sector in particular, remains deeply constrained. The general business problem was that there are very few comprehensive healthcare PPPs in the country. The specific business problem was the lack of information on the strategies needed for successful implementation of PPPs in the Zimbabwean healthcare sector. 1.4 Objectives of the study The main objective of this study was to explore the feasibility of healthcare PPPs in Zimbabwean healthcare in order to inform policy makers and management in decision-making. The following were the sub objectives: • To analyze whether PPPs as an intervention can help in the provision of healthcare services in Zimbabwe. • To understand the legal, institutional, structural and political frameworks necessary for the success of PPPs, and assess whether Zimbabwe has these factors in place. • To investigate the challenges being faced by Zimbabwe that hinder effective implementation of private public partnerships in the healthcare sector. • To proffer recommendations for Zimbabwe to fully engage private public partnerships in healthcare. • To contribute to existing literature on the feasibility of healthcare PPPs in countries such as Zimbabwe. 1.5 Research Questions The study sought to answer the following research questions: 6 1. Can public private partnerships be helpful in the provision of healthcare services in Zimbabwe? 2. What are the legal, institutional, structural and political frameworks that govern PPPs in the provision of healthcare services in Zimbabwe? 3. What are the barriers to PPPs in healthcare? 4. What are the PPP models available for use in the healthcare sector? 5. What are the critical issues for successful PPPs in healthcare? 1.6 Research Philosophy This study, which was in the form of systematic case reviews and face to face in-depth interviews, sought to determine the understanding and effectiveness of healthcare PPPs, and how this could be leveraged to improve accessibility and affordability of healthcare services. I chose a qualitative methodology for this study. The qualitative method is appropriate when the research purpose is to explore business processes or how people make sense and meaning of their lived experiences (Yin, 2011). Qualitative research promotes deep understanding of a phenomenon through the examination and interpretation of meanings assigned to experiences and realities by individuals (Denzin & Lincoln, 2011). To answer the research question, I needed a deep understanding of the phenomenon obtained through in-depth interviews and open-ended questioning; hence, I used a qualitative approach. Quantitative researchers concentrate on the application of mathematical logic to phenomena to test a theory or examine causal interactions (Rubin & Rubin, 2012). Mixed methods research involves the use of both quantitative and qualitative methods to study a phenomenon (Denzin & Lincoln, 2011). In this study, the qualitative 7 method more adequately addressed the research question. Accordingly, I did not select a quantitative or a mixed methods research approach for the study. Specifically, I chose the multi-case study design for this study because this design is suitable for the exploration of a particular phenomenon and enables the investigation and description of the phenomenon within a particular, contemporary context (Yin, 2014). The case study research approach facilitates the exploration of phenomena within existing context using diverse data sources (Ketokivi & Choi, 2014). Because case studies are rich in information gathered from multiple data sources, they can give insight into phenomena that a researcher cannot gain in any other way (Yin, 2014). Other qualitative designs include phenomenology, ethnography, and grounded theory (Christensen, Johnson, & Turner, 2014). In phenomenology, researchers collect data primarily through interviews (Marshall & Rossman, 2016), potentially weakening the preferred depth and scope of exploration for the study. In this study, observations and document reviews were critical to achieving the research purpose; thus, the phenomenological design was a less suitable alternative. Ethnography centers on extended cultural examination (Murthy, 2013), which was not the focus of this study. Grounded theory design centers on theory derivation from field data collection (Rubin & Rubin, 2012). Since the purpose of this study was to explore the rich case data and not to build theory, grounded theory was not suitable. 1.7 Significance of the Study Healthcare organizations need to understand and respond to healthcare consumers’ expectations. Improved understanding adds value for the healthcare industry and the society as a whole. Understanding the role of PPPs in healthcare will 8 contribute towards effective decision making and practices on PPPs in healthcare. The benefits of effective healthcare PPPs to both the patient and provider organizations are numerous, ranging from improved quality of care to business profitability. Patients are more aware of options and choices than ever before because publicly reported data for healthcare organizations provide measurements on patient satisfaction and quality of care. Healthcare organizations should employ innovative strategies if they are to remain competitive. A well-informed community is equipped with the toolkit to make appropriate healthcare decisions, and this in turn results in improved health status of the population. In this study, participants will provide insight on how PPPs can transform healthcare service and influence patient outcomes. Positive social change can occur through improving patient experiences in healthcare as superior satisfaction aligns with a higher quality of care. Further, PPPs in healthcare seek to increase the accessibility and affordability of healthcare services to consumers (Das, 2007). In addition, healthcare PPPs also provide healthcare organizations with valuable opportunities to improve infrastructure and service delivery, thereby positioning themselves more competitively in the industry, while focusing on key initiatives that can improve the quality of care. 1.8 Assumptions, Limitations, and Delimitations 1.8.1 Assumptions Assumptions in a study are issues that are somewhat out of the control of the researcher (Kirkwood & Price, 2013). One assumption was that the interview sample represented the population of key opinion leaders with PPP experience. An equally important assumption in this study was that interview respondents would answer the 9 questions honestly instead of answering how the respondent believed the researcher wanted the questions answered. 1.8.2 Limitations Limitations of a study are potential weaknesses that are out of the researcher's control (Kirkwood & Price, 2013). Conducting interviews via the telephone, as was the case for most interviews, was a limitation as this communication mode precluded observation of body language and mannerism. 1.8.3 Delimitations Delimitations are those characteristics that limit the scope and define the boundaries of a study (Yin, 2014). This study was a qualitative case study to explore the feasibility of healthcare PPPs in Zimbabwe. Only individuals with some experience in PPP participated in the study. In addition, only individuals in Harare participated in the study. 1.9 Definition of Terms Public Private Partnership (PPP). Legally binding contracts between government and business for the provision of assets and the delivery of services that allocates responsibilities and business risks among the various partners. Data saturation: The point in data collection when no new information is gained in an interview (O’Reilly & Parker, 2013). NVivo 11: Software package, used in analysing qualitative data by organizing and analysing unstructured data through identification of themes and trends (Bazeley & Jackson, 2013). 10 1.10 Summary and Transition Chapter 1 provided a background to the study, the statement of the problem, which triggered the research study, purpose and objectives of the study, research questions, and the significance of the study. Other aspects also discussed included the assumptions, limitations, and delimitations of the study, as well as ethical considerations Chapter 2 provides a comprehensive literature review to the study. Chapter 3 details the role of the researcher, participants involved in the study, research method and design, population and sampling, and data collection details. Chapter 4 provides detailed presentation and analysis of the research findings. Chapter 5 provides a summary and conclusions from the research findings, with a focus on recommendations for action and future research. 11 CHAPTER 2: LITERATURE REVIEW 2.1 Introduction In this literature review, I examined existing evidence on the challenges and benefits of adopting and implementing PPP in healthcare. Peer-reviewed journal articles, along with books and government publications, were the sources of information in this literature review. The literature review begins with an overview of PPP. A review and synthesis of literature on the impact and benefits of PPP is next, with a focus on productivity, quality, and healthcare outcomes. I then include a review of evidence on PPP implementation in developing countries with emphasis on the critical success factors, challenges, and barriers. I accessed research materials in databases including ProQuest, EBSCOhost, Science Direct, and Sage Publications. I performed additional searches using commercial search engines such as Google Scholar. Information search involved using various keywords such as: public private partnerships, healthcare PPP, PPP implementation strategies, PPP barriers, PPP models, PPP in Zimbabwe, or a combination of these keywords. 2.2 Public-Private Partnership 2.2.1 Overview In recent years, the cost of delivering health care in developed and developing countries has been rising exponentially. Governments around the world are searching for alternative mechanisms to reduce costs while increasing the capacity of social programs with significant investments in infrastructure (Rossi & Civitillo, 2014). A number of jurisdictions have begun to utilise public-private partnerships (PPPs) as a means of achieving these objectives. 12 Within the literature, common characteristics that are often cited when describing a PPP model are shared risk amongst participating partners, innovation infusion from the private sector, and knowledge sharing amongst organizations (Rossi & Civitillo, 2014). The literature also contains numerous studies on PPPs as they relate to infrastructure and construction projects, but there are limited studies on PPPs in the social sector regarding services, technology, or other models that have emerged in significant numbers over the last decade. The knowledge sharing and collaboration between organizations throughout the partnership can generate enhanced solutions to public issues (Dube & Chigumira, 2011) that exceed what the individual partners could have achieved without the partnership. In addition to the enhanced solutions that are imagined there is also, an expectation that efficiencies will be derived from the partnership allowing for cost savings that would not have been recognized should the public organization have attempted the initiative without partnering (Nhema, 2015). An important component of the PPP is the understanding that it is foundationally based upon a public organization partnering in some manner with a private sector organization to deliver a shared goal or objective by sharing risks and creating efficiencies (Roehrich, Lewis, & George, 2014). Roehrich, Lewis, and George, (2014) argued that misaligned motivations amongst the partners can be driven by self-interests such as perceived increased revenue generation, access to customers, or access to new markets. This can create mistrust and conflict between the organizations that enter into the partnerships. Kong and States, (2013) suggested that PPPs often merge to finance public services when sufficient funding is not available. Similarly, Dube and Chigumira, 13 (2011) pointed out that PPPs were an essential strategic tool toward quality and sustainability of the communities and the state, and public and private organizations have different functions and goals. However, with emerging new economic changes, participatory business relationships between private-public entities are essential to long-term sustainability and the success of both entities (Nhema, 2015). The PPP has played a significant role in economic growth in social infrastructure (Kong & States, 2015). Rossi and Civitillo, (2014) noted that collaboration between two organizations implement provisions based on the assumptions that each party was entrusted to complete their tasks and draw benefits proportionate to their interest. Rossi and Civitillo added that as a public and private organization operates in different capacities and rationales, it was evident that the political environment created an asymmetrical effect on the partnership outcomes. In addition, the asymmetrical effects caused by the bureaucratic environment and lack of the notion of public-private collaboration between the two entities affected PPP uptake (Rossi & Civitillo, 2014). Durant (2014) disclosed that the enduring unpredictable political environment, the underdeveloped institutional framework, and uncertainty in enforced government commitment discouraged private companies from seeking governance partnerships. Monterrey, De La Fuente, Lozano, Fernández, and García (2013) identified autonomous PPPs as a self-governing organization structured around independent operations. Further, the private firm’s independent control of transactions under the autonomous model positioned stronger control of compensations secured by efficiencies in service delivery (Biermann et al., 2014). The public counterparts engaged primarily in monitoring and enforcement of contractual obligations and 14 provisions (Monterrey et al., 2013). Bel, Brown, and Warner (2014) added that limited oversight on requirements by public sector caused some degree of uncertainty in long-term planning for public sectors. In a self-governing structure, Hvidman and Andersen (2014) recognized that public management relied on private managerial skills and competencies to carry out the partner engagement activities. Similarly, Nissen, Evald, and Clarke (2014) concluded that in PPPs, private sector primarily undertakes the operational responsibilities because of their core competencies. In contrast, the public authority assumed limited knowledge and skills of private sector expertise that caused severe integrity concerns and uncertainty (Nissen et al., 2014). However, the complex political types of hybrid systems not residing entirely with private companies posed concerns with public sector partners (Hvidman & Andersen, 2014). According to Hoppe and Schmitz (2013), the public sector's primary choice of the preferred partnership included the dependence on public policy constraints imposed on the private sector, and these include political systems complexities and their primary responsibilities to the public. York, Sarasvathy, & Wicks (2013) identified integrative PPP as a collaborative environment where public and private organizations share operations and responsibilities toward joint public good. In an integrative PPP, both sectors unite their unique expertise and knowledge to execute their goals and objectives toward the public benefit. In the integrative environment, the private sector continues to focus on quality and efficiency in contractual fulfillment. The outcomes are, in essence, a function of public policy supported by limited funds. 15 2.2.2 History of PPPs Throughout history, PPPs included the ability to improve social wealth through collaboration and sharing innovative efforts (Reynaers & De Graaf, 2014). Geddes and Wagner (2013) argued that PPP models had no significant changes from prior centuries from the modern business environment. For example, PPPs in today’s business environment have the power to improve public services (e.g., education, health care, and public safety) through collaborative private-public sector management skills (Geddes & Wagner, 2013). A public and private partnership dates back to Athens in the 4th century BC, where prominent citizens constructed public monuments and buildings using federal funding (Stanton, 2002). During the Roman Empire, prominent citizens and government entities worked together to develop new infrastructures (Stanton, 2002). In 1890, New York’s Rapid Transit Commission awarded contracts to private companies to design and build its first subways (Kruse & Todd, 2013). In the 1930s, the United States entered into PPPs during the Great Depression to build toll roads and railroads (Wright, 2014). In the 1970s and 1980s, during the urban crisis and macroeconomic problems, the government encouraged investments in public infrastructure by private companies to strengthen the economy and improve services (Reynaers, & De Graaf, 2014). 2.2.3 Definition of Public-Private Partnership Governments the world over face the challenge of bridging the gap between the demand for investment in infrastructure and the ability to provide for these investments. As demand continues to increase, there is a realization that PPPs have the potential to bridge this gap through reinforcement of public sector engagement in 16 designing, constructing, maintaining, financing, and operating infrastructure projects under strict regulation and supervision from government (Lang, 2016). There is no existence of a single, internationally accepted definition of PPP. A literature review of the PPP approach yielded an extensive range of various definitions of PPPs peculiar to each individual country or region. The definitions range from very broad to narrow, general and specific, comprehensive and limited, depending on the perspectives, objectives and expectations of the parties and/or institutions involved. For example, the World Bank Group defines a public-private partnership as follows: "A long-term contract between a private and public party, for providing a public asset or service, in which the private party bears significant risk and management responsibility, and remuneration is linked to performance," (The World Bank Group, 2014). While, the credit rating agency Standard & Poor's defined a PPP as: "Any medium- to long-term relationship between the public and private sector, involving the sharing of risks and rewards of multi-sector skills, expertise, and finance to deliver desired policy outcomes," (Standard & Poor's, 2005). The European Investment Bank provides a more specific definition of a PPP: "Public-Private Partnership' is a generic term for the relationships formed between the private sector and public bodies often with the aim of introducing private sector resources and/or expertise in order to help provide and deliver public sector assets and services. The term PPP is, thus, used to describe a wide variety of working arrangements from loose, informal and strategic 17 partnerships, to design build finance and operate type service contracts and formal joint venture companies," (European Investment Bank, 2004). The National Treasury of South Africa defines a PPP thus: “A contract between a government institution and private party where: a) the private party performs an institutional function and/or uses state property in terms of output specifications; b) substantial project risk (financial, technical, operational) is transferred to the private party; and c) the private party benefits through unitary payments from government budgets and/or user fees,” (National Treasury of South Africa, 2012). Given the range of varying definitions, it is only logical to identify a working definition, which can be used in the negotiation and formulation of PPPs. All PPP definitions exhibit the following common elements a) contract or an arrangement between a government entity and a private entity, b) provision of public infrastructure or public services through the private sector c) substantial risk transfer to the private entity, d) compensation to private sector e) value for money, f) outcome specification, and g) medium- to long-term duration – can range from 5 to 30 years (Lang, 2016). Therefore, a PPP constitutes a long-term contract between a public-sector authority and one or more private-sector entities, in which the private sector provides for infrastructure assets or services that have historically been delivered by the government. Through this arrangement, complementary financial and technical expertise is shared, thereby allowing for increases in quality, efficiency, transparency, and accountability of a public asset and service delivery (Lang, 2016). Furthermore, as these infrastructure investments are subject to great risks due to high initial costs, long-term durability, and high irreversibility and complexity, a PPP allows for a fair 18 division of potential risks and returns between both public and private party and delivers better value for money (VfM) to the taxpayer. PPPs can be found in a wide spectrum of sectors throughout the world such as energy, waste, healthcare, education, water services, telecommunication, and transportation. Moreover, PPPs find their specific application in projects as for example hospitals, schools, roads, bridges, railways, dams, and sanitation plants (International Monetary Fund, 2016). Identification of clear, specific and realistic PPP objectives will in addition to ensuring alignment and convergence of the objectives of all the parties, stakeholders, and beneficiaries concerned, also significantly increase the prospects for success. Thus, a good working or functional definition of a PPP should make reference or show some relationship to a set of objectives, usually categorized as technical, physical, environmental, social, economic, political, and institutional. 2.2.4 The Benefits of Public-Private Partnerships Evidence from countries with a long history in carrying out PPPs suggest that that private sector involvement can help in overcoming common challenges associated with provision of infrastructure provision. Involvement of the private sector guarantees completion of projects on budget and on time. The following section will describe the advantages of PPPs for public sector authorities. Attraction of private capital investment. The public sector in many countries finds itself with the burden of inadequate public infrastructure funding due to population growth, urbanization, and ageing infrastructure. In addition, Governments often have to subsidize infrastructural projects. For this reason, PPPs can alleviate this challenge by tapping into private sector funding sources. The private 19 sector in return will benefit from periodical payments based on contractual agreements PPPs allow the public sector to avoid huge initial investments and hence to overcome short-term budget constraints (The World Bank Group, 2014). Capital investment from the private sector allows governments to generate increased revenue through the setting up of user charges, and these can then be used to pay for the project cost itself by subsidizing the infrastructure object (The World Bank Group, 2014). Private sector analysis, scrutiny and innovation. Many governments often invest resources in projects that fail to deliver return on investment due to poor selection processes, weak project analysis, and personal interests of decision makers within the public sector. PPPs provide governments with the necessary expertise and technological knowhow, as well as the innovation capabilities from the private sector. The private sector usually follows higher levels of quality assurance, when compared to the procurement process of the public sector given their perchance for correct cost estimates and revenue forecasts in order to minimize risk (The World Bank Group, 2014). Increase in efficiency and effectiveness. The public sector often only has few or no incentives for efficiency measures when carrying out infrastructure projects and is therefore often inadequately prepared to build, maintain, and operate these undertakings. The private investor enters into a PPP arrangement with the aim of maximizing profits through enhancing efficiency and effectiveness of the project. Governments can profit from this mindset by utilizing available scarce resources more efficiently and effectively. Moreover, PPPs allow governments to transfer operational 20 roles to the private sector, while placing their focus on core public sector responsibilities such as regulation and monitoring (Asian Development Bank, 2008). Private sector expertise and experience. The contribution of proficient management expertise, technological know-how, and experience of the private sector can help governments in increasing overall quality of infrastructure service provision while significantly contributing to enhancements in effectiveness and efficiency. Furthermore, the private sector is more flexible in generating innovative solutions for a better value of money (Gassner, Popov, Pushak, 2009). Quality assurance and maintenance. PPPs have the advantage that they combine the construction or renovation of infrastructure projects with the obligation to carry out periodic maintenance and repairs under one contract. This fact helps to ensure that the infrastructure asset, which is constructed by the private party, is built accurately using high quality materials. PPPs therefore can help to significantly reduce the need for follow-up maintenance and hence lower the total costs of the project over its lifetime. Moreover, PPPs incentivize the private party to carry out sufficient maintenance. In this case the private entity must ensure that the asset meets quality requirements to be able to attract users and to comply with explicit performance requirements set by the government (The World Bank Group, 2014). Reforming sectors by reallocating roles, incentives, and accountability. PPPs can function as a driving force to reform and streamline the roles, incentives, and accountabilities that a public sector consists of. A sector reformation including a PPP might be a good chance to reexamine and to overcome inefficiencies as well as potential conflicts amongst participants by rearranging the roles of regulators, policy makers, and service suppliers. These reforms can then lead to spillover gains by 21 serving as best practice examples for other sectors and other fields of application (Asian Development Bank, 2008). 2.2.5 Disadvantages of PPPs PPPs contracts are complicated by the involvement of numerous stakeholders, diverse business backgrounds, legislative provisions, and contingencies often surrounded by a complex political environment. Consequently, the goals for the public and private sector can vary significantly. The public sector is mainly concerned with the social and political impact of the PPP project (Koliba et al., 2014). Disadvantages for the private sector. PPP arrangements can create significant risks for the private sector because of the political actors and limitations since the private sector partners handle all levels of the project including capital, workforce, and on time delivery (Siemiatycki & Farooqi, 2012). The private sector faces a significant disadvantage in generating limited or capped profits from the use of public funds even though they have an obligation to their stakeholders and investors to maintain profitably (Siemiatycki & Farooqi, 2012). While investors hold the private sector partners accountable, the public sector is the decision maker, whereas the public is their primary concern. In addition, as private sector’s objective is to maximize profits, the public sector partner’s objectives may not align (Ng, Wong, & Wong, 2012). The additional challenges of PPPs are the regulatory and political structure, changes in regulations, risk management, and allocation. Similarly, the limits or caps on maximum profits, differing motivations and incentives, less flexibility to manage changing needs, and policies also pose barriers to the formation of PPPs for the private sector (Kamugumya & Olivier, 2016). 22 Disadvantages for the public sector. In PPPs, the role of the public sector is to manage policy levels of the partnership, oversight of public funds, and safety regulations (Button & Daito, 2014). Koliba et al. (2014) argued that citizens’ expectations of the project’s favorable outcome become public sector’s burden. The failure of the project or services delivery through PPP can become securitized when public’s expectations do not meet the quality services provided. Some of the challenges for PPPs in the public sector include attracting private sector partners, the sensitivity of investors because of political risks, and the diversity of stakeholders (Koliba et al., 2014). 2.2.6 The Different Forms of PPPs PPPs can be classified by infrastructure asset involved, payment scheme, or type of contact. The first differentiation between PPPs—infrastructure asset involved— is made between newly constructed (greenfield) and already existing (brownfield) assets. Another way to differentiate PPPs is to look at the underlying payment mechanisms to the private sector. The PPP types vary based on the scope of the project, interest, responsibility, and transfer of risk. Figure 1 provides an overview of commonly used notations, mapped by their respective degree of private sector involvement and private sector risk absorption (Canadian Council for Public-Private Partnerships, 2016; NCPPP, 2014; The World Bank Group, 2012). 23 Figure 1. Classification of Public-Private Partnerships by type of contract (The Canadian Council for Public-Private Partnerships, 2016) Operate and maintain (OM). The private party operates and maintains the public asset for a contractual fixed period. The ownership of the asset remains with the government. The private sector may invest in additional capital to administer the specific services. Design-build (DB). In this model, the private sector handles the design and construction of the project. The public sector has ownership of the assets and handles operations and maintenance. As the remuneration of the private party often is a fixed amount, the risk of cost overruns can be effectively transferred to the private party. Rehabilitate-operate and transfer (ROT). Infrastructure that is already in existence is handed over to the private sector for refurbishing, maintenance, and reconditioning. The private player can operate the infrastructure for a period, following which the facility is handed back to the public sector. 24 Rehabilitate‐own and‐operate (ROO). Private sector refurbishes and owns a public facility and operates the facility in perpetuity as long as there is no franchise violation. Period to operate is dependent on franchise agreement. Build-operate-transfer (BOT). Include the design, financing, and construction of new infrastructure assets by private sector. Thereafter, the private sector operates and maintains for a period specified in the contract and is entitled to all revenues from it. Ownership remains with the public sector over the whole time of the contract. At the end of the concession the facility is transferred to the public sector. Build-Transfer-Operate (BTO). Comprises of the same specifications as a BOT contract, but ownership of the infrastructure asset is transferred to the government once construction is completed and not at the end of the concession. Build-own-operate-and-transfer (BOOT). The private sector finances, constructs, owns, and operates the infrastructure for a fixed term, while making any decisions it sees fit during the ownership tenure, with minimal or no government interference. The infrastructure is then handed over to the government after an agreed time, which would then take all responsibilities. Design-build-maintain (DBM). The private sector handles the design, construction, and provides maintenance. The public sector has ownership of the assets and is accountable for operations. The private sector also raises equity, financing, and assumes risks for completing and maintaining the project. Design-build-operate (DBO). In this partnership model, the private sector handles the design, construction and operations while the public sector has ownership 25 of the assets and handles maintenance of separate maintenance agreement. Upon completion, the project transfers to the public sector. Design-build-operate-maintain (DBOM). In this model, the private sector handles the design, construction, operations and maintenance, while the public sector has ownership of the assets and oversight of the project. Build-own-operate (BOO). Under this scheme, the private sector designs, finances, builds, owns and operates the infrastructure asset. Ownership of the facility is not transferred to the government and any residual value remains with the private party. A regulatory authority assures performance measures specified in the original contract. Buy-build-operate (BBO). In this model, the private sector assumes ownership through a sale. The private sector agrees to either rehabilitate or expand an existing public facility in a profitable manner. After the sale, the private sector assumes ownership, operating revenue risks, and any surplus for the life of the facility. 2.2.7 Classification by Degree of Risk Transfer PPPs, furthermore, can be categorized by the respective allocation of risks and hence involvement of the private sector party (Lang, 2016). This classification focusses on the different functions that the private sector is carrying out: construction, operation, financing, and ownership, as depicted in Figure 2. 26 Figure 2. Examples of different PPP contracts categorized by infrastructure asset involved (PPIAF, 2012) 2.2.8 The Key Process Phases of PPPs The success of a PPP project to a great extend is dependent on how well the parties plan and structure the project, how well it is carried-out, and how well it is managed over the lifetime of the project (Lang, 2016). Breaking down PPP projects in smaller parts can significantly simplify the process and can help to achieve efficient and effective partnerships between the public and private sector. Figure 3 shows an illustration of a typical PPP life cycle. 27 Figure 3. Overview of typical Public-Private Partnership life cycle (PPIAF, 2012) The process involves the government first conducting a needs analysis and for infrastructure projects and then selecting projects that benefit society most. The bidding and proposal processes follow project preparation. After the selection of a desired bidder, a financial contract is closed. Following closure of the contract, the government has a mandate for PPP service oversight over its lifetime. The PPP life cycle can be divided into the three main phases including a) project selection and preparation, b) procurement, and c) contact management. Project selection and preparation involves definition of priorities and objectives of possible PPP program; identification, evaluation, and selection of projects; and the preparation of PPP engagement, including definition of responsibilities as well as performance 28 and financing measures. Procurement is concerned with the issuance of tender notice with pre-qualification criteria, selection of winning bidder, and closure of contract. Finally, contract management includes facilitation of communication amongst parties, monitoring and evaluation, and termination of contract (PPIAF, 2011). 2.2.9 The Typical Financial Structure of a PPP Figure 4 shows a basic financing structure for a typical PPP project and gives an overview of the interrelations between the different parties. The actual arrangement of a PPP, however, can significantly differ from project to project and depends greatly on the number of parties involved, the financing structure chosen and the nature of the infrastructure service provided. For most PPPs, the private party forms a Special Purpose Vehicle (SPV), a legal entity that carries out the infrastructure operations and enters contractual agreements with contributing parties. The SPV raises funds through a mix of debt provided by banks or bonds, and equity from project shareholders (PPIAF, 2012). Figure 4. Typical financing structure of a Public-Private Partnership project (United Nations ESCAP, 2011) 29 An SPV cannot conduct business activities outside the scope of the project for which it was established. This helps reduce uncertainty in service output and protect the interests of all stakeholders involved. Since infrastructure projects often require gigantic investment volumes and multiple different operational skills, an SPV can help to overcome this difficulty by establishing a joint venture, in order to bring in various investors and service providers and to combine their forces under one legal umbrella. Other reasons for governmental partaking in an SVP can be (a) to address political aspects, (b) to perform social responsibilities, (c) to guarantee financial sustainability, or (d) to offer trust for national and foreign lenders. The extent of direct partaking of a government in SPVs depends on the countries' legal and regulatory agenda and can differ significantly among different regions and sectors (United Nations ESCAP, 2011). 2.3 PPP in Developing Countries PPPs increasingly find their application in low-income and low-resource regions around the world and outside their traditional field of application—in areas such as education and healthcare. The main fields of private party involvement in these regions have been in the telecommunication and energy sector. PPP endeavors in developing countries face certain obstacles that are different from similar projects in developed countries and hence need to be specifically recognized and dealt with by both the public and private party. Being aware of these challenges and factoring them in early in the preparation phase of a PPP, significantly increases the chances of a successful and sustainable project outcome and reduces the necessity of contract renegotiations down the road. 30 The main challenges for PPP infrastructure projects in low-resource and lowincome regions include the following: Administrative and regulatory bodies. Developing countries often lack the administrative and regulatory capacities and expertise to efficiently design and manage a PPP. In most countries, existing legislation regulates public sector responsibility in infrastructure projects and is not applicable for private sector participation, while independent regulators are nonexistent. Public sector budget: There is a limit on the financial resources available for infrastructure provision. Transparency. There is lack of transparency during the contract-awarding phase. Therefore, projects can be awarded by official preference for local participants, sub-contractors, or suppliers and hence result in nonoptimal contract allocation. In this light, the lack of corruption in the planning, bidding, contracting and execution phase of a project constitutes a key factor for success (Iossa Martimort, 2014). Conflicting aims. In many cases, governments expect one single project to fulfill various policy objectives, such as financial, health, social, macroeconomic, and environmental goals. Therefore, conflicts initiated by local communities or NGOs against individual PPP projects can rebound on the private parity more often than the initiating authorities. Lack of bidders. In developing countries, there are often not enough bidders to create strong competition. These circumstances can negatively affect the efficiency gains of a PPP and foreign bidders can turn this around. 31 Public governance. Misalignment of various public authorities in the process of enforcing regulations and objectives such as regulatory bodies versus ministries or national versus regional authorities. Incumbent service providers. Current service providers in developing countries—often owned and operated by the government—receive preferential treatment, which makes private sector participation less attractive. Price and tariff settings. Non-existence of independent regulators or inexperienced regulators create high uncertainty about price and tariff settings. Tariffs kept artificially low in the past through subsidies reinforce this element. Therefore, new prices and tariffs often lack public acceptance and hence are highly inflexible in crises. Political instability and commitment. In countries where governments are weak or the rule of law is not strongly implemented, new authorities have reneged on existing PPP contracts or contract terms. This behavior can lead to expropriation as well as creeping expropriation in the light of public dissatisfaction. Financial uncertainty. PPP projects in developing countries often are subject to high financial risks such as drastic changes in exchange rates or interest rates, and high levels of inflation or deflation. For example, one of the greatest risks to a foreign investor is rapid currency devaluation. The main reasons why PPPs often are performing below the expectations of the public vary from case to case but often are a result of one or a combination of the above named challenges. Efficient risk mitigation, technical assistance, and capacity building by international organizations as well as output-based aid have proven to 32 enhance the viability and sustainability of PPPs, and have resulted in significantly fewer contract renegotiations. 2.4 PPPs in the Healthcare Sector Around the globe, governments are trying to meet the increasing demand for healthcare services, while handling the respectively increasing healthcare costs. Aging populations, strong population growth in emerging and developing countries, and advancement in treatments and technology will continue to drive the health spending of governments around the world. This growth will increasingly put pressure on the budget of the public sector. PPPs can alleviate this growing burden of healthcare spending by combining the complementary capabilities of public and private sectors, while sharing risks and guaranteeing both quality and efficiency of healthcare delivery (Deloitte, 2015; Reich, 2002). 2.4.1 The Range of PPPs in the Health Sector Classification by fields of application. PPPs in the healthcare sector can range from small product alliances with the industry to large-scale infrastructure projects involving multiple governments, international development banks, and notfor profit organizations. The objectives and scope of these partnerships vary significantly from country and region. Figure 5 provides an overview of the different areas of PPP application in the healthcare sector. Health PPPs are applicable to both clinical and non-clinical areas of service provision—for specialized as well as nonspecialized services. 33 Figure 5. Fields of application for PPP in the healthcare sector (International Finance Corporation, 2016) Governments need to evaluate carefully if and in which area of healthcare systems it makes sense to adopt PPP. This task requires the public sector to analyze rigorously the private sector's strength in health service provision (Lang, 2016). Moreover, the government needs to evaluate its own capabilities in overseeing and regulating the services transferred to the private sector. Classification by purpose. PPPs in the health sector can be categorized by the purpose they serve. The U.S. Agency for International Development (USAID, 2011) classifies PPPs in three models—market-based, socially based, and balanced. These models differ in the degree of commercial or social investment. Please refer to Figure 6 for an illustration of the categorization. Figure 6. Categorization of health PPPs by core activity (USAID, 2011) 34 The market-based PPP is driven by a commercial, profit-driven nature, while the public sector commits to a secondary investment to generate social impact. In the market-based model, the social investment is carried out in such a way that it incentivizes the commercial partner to accept lower returns at the beginning of the project in exchange for higher growth and returns in the end. In the socially based PPP, the main interest of the parties is to enhance public health and not to generate profits. In the case of a socially based PPP, the parties are interested in earning a social return, which can be in the form of higher reputation and better public image. The balanced PPP model comprises both social and commercial nature, each having different process owners and revenue streams. This cooperation benefits public and private parties by improving healthcare access and educating the public, as well as generating enhanced long-term profits through efficiency gains and horizontal expansion. A clear categorization of PPPs in the healthcare sector is often difficult to establish. This is the case as PPPs are complex collaborations of multiple parties, which have different incentives and objectives. Moreover, PPPs frequently integrate several different purposes into one single endeavor. A categorization of healthcare PPPs can help the public and private party to better align their incentives and to foster better coordination and understanding. Furthermore, it simplifies the complex process of PPPs into different sub-groups thereby promoting a standardization of best-practice activities as well as required capabilities and common risks. 2.4.2 What Makes Health PPPs Different? The goals and policy context of PPPs in the health infrastructure sector are different from classic infrastructure projects in industries such as electricity, water, or 35 transportation. When establishing a health partnership between the public and private sector, it is therefore important to understand these differences and to be aware of their implications for the success of the project. The following six subjects summarize these dissimilarities (Montagu & Harding, 2012). Primary purchaser of outputs. In healthcare PPPs, the government—not the individual user of the asset—is the main purchaser of the output and almost all income of the project is generated in form of fixed scheduled lease payments or unit service payments. This element simplifies the payment process, but adds substantial political risk for the private party, as the projects require large and ongoing payment from the government. Source of risks. Given the detail that the government is the main purchaser of healthcare outputs, the main partnership risks are of political nature. This becomes more important in political unstable countries leading to a higher cost of capital, when compared to PPPs outside the field of healthcare (Lang, 2016). Measurability of output. In the field of healthcare infrastructure, outputs are measured in the number of patients treated. Therefore, it is very difficult to measure service levels, as they are dependent on the unique characteristics of the respective patient and the respective disease. Moreover, the effects of preventive care are hard to track and quantify (Montagu & Harding, 2012). Variability of outputs over time. The length of a PPP often spans over more than 30 – 40 years (Lang, 2016). During this time, the output can significantly change in composition, wealth, age, and degree of illness. This is especially true in fast changing environments, such as developing countries. 36 Capital expenditure vs. operating expenditure. The ongoing operating expenses of a health infrastructure constitute the major project cost driver. The potential of private sector efficiency gains in the design and construction phase of the project is therefore limited, while significantly shifting the importance to service provision (Lang, 2016). Variability of technology and organizational configuration over time. In healthcare, there is rapid change in technologies, hence changing healthcare service delivery processes over time. These shifts add an additional layer of uncertainty and therefore risk to the PPP. These imperfect contract conditions create opportunities for the private party to push for additional business while not being exposed to competitive market pressure. For this reason, the government has to build strong contract management capabilities that allow for robust competences in anticipating and assessing all possible future strategies by the private party in order to prevent potentially negative strategic moves (International Finance Corporation, 2011). 2.5 PPP in Africa PPPs in Africa can ameliorate the infrastructure financing gap, estimated by the African Development Bank (AfDB) in 2014 at $50 billion annually in energy, transport, telecommunications, water, and sanitation (Kong & States, 2013). There has been a slowdown in the financial markets, especially investments from China, as PPPs gain prominence. The IMF and World Bank are simultaneously championing PPPs by spearheading PPP projects and providing capacity building for governments, however, it remains elusive if this approach is best for Africa. According to the World Bank’s Independent Evaluation Group, PPPs are now used in more than 134 37 developing countries, contributing about 15–20 per cent of total infrastructure investment between 2002 and 2012 (Patrinos & Barrera-osorio, 2009). Critics of PPPs among development practitioners quickly point out that the profit motive, the main driver of the private sector, is in conflict with the social contract governments have with its citizenry to provide affordable and universal services (Kong & States, 2013). Kong and States (2013), observed that PPPs are expensive and risky, have mixed development outcomes, are difficult to negotiate, have poor planning and project selection, and generally lack transparency and accountability. In this regard, PPPs should be cautiously implemented as results of their use are mixed. In deciding on PPPs’ development outcomes, the needs of the marginalized and poor should be put ahead of the private sector’s profit motives (Dube & Chigumira, 2011). Skepticism also exists around the perceived successes of PPPs within the literature. This skepticism has largely arisen from partnerships that have experienced excessive budgetary overruns and poor delivery of the expected services. The partnerships that experience challenges regarding budget and service delivery are then plagued by a perceived lack of ownership within the partnership structure as to which organization is at fault for the failures (Lang, 2016). Another study of PPPs in growth corridor initiatives in the agriculture sector in Ghana, Tanzania, Mozambique, and Malawi noted, “the poorest people are all too often likely to lose out or be bypassed”. The study also noted that mega-PPPs are inherently risky in sub-Saharan African countries, where governments have low levels of government effectiveness, challenges in regulating markets, and difficulties with including the voices of the poor in policy-making (Lang, 2016). 38 There are inadequate legal and regulatory frameworks for PPPs in Africa and most countries lack the technical skills to manage PPPs (Dube & Chigumira, 2011). Since PPPs rely on the private sector, Africa needs to improve its business environment first, as African countries bear the cost of unfavorable investor perceptions (Nhema, 2015). Limited local financial markets and infrastructure makes PPPs expensive. For PPPs to work in Africa, the risks need to be minimized. Risks often include the degree of skills transfer when the final product is handed over to the government, and exchange rate fluctuations. International experience indicates that successful PPP programs require good public-sector management systems, transparent tender processes, enforceable contracts, minimum political interference, and a relationship of trust between the public and private sectors (The World Bank Group, 2014). African countries should adopt integrated policies that ensure that the debt accrued from PPPs is sustainable and transparent. They should consider the full fiscal implications of public borrowing and ascertain the true costs and benefits of PPPs over the lifetime of the project. Governments need to disclose information on performance and completion of public contracts and risk assessments, including environmental and social impact assessments. Governments should allow informed consultations, broad civil society participation, and monitoring by other stakeholders. Finally, in deciding on PPPs’ development outcomes, the needs of the marginalized and poor should be put ahead of the private sector’s profit motives (The World Bank Group, 2014). 39 2.6 PPP in Zimbabwe 2.6.1 Historical Perspective The idea of PPPs was first mooted in1998. In 2004, the Ministry of Finance attempted to come up with the PPP framework investment. This was outlined in the Public Private Partnership in Zimbabwe Policy and Guidelines of 2004.The guidelines tried to provide the parameters for the development of an appropriate legal and regulatory framework to protect investors and consumers (Dube & Chigumira 2011). However, the guidelines did not take off notably. There were three projects involving PPP, namely Beitbridge Bulawayo Railway (BBR), the New Limpopo Bridge (NLB) and the Newlands By-Pass (NBP) (Sai, Muzondo, & Marunda, 2015). Newlands Bypass project. The Newlands Bypass was completed in 2007 and was done on a BOT basis with the constructor handing over to the government upon completion. The NLB involved the financing and building of a toll bridge over the Limpopo River and was awarded to a private player in 1993 by the Governments of Zimbabwe and South Africa on a BOT basis (Dube & Chigumira 2011). The project was the first BOT project of that nature in the African continent. The construction of the bridge was completed in a record time of thirteen months. The New Limpopo Bridge (Pvt) Ltd, a private company is still operating the bridge and has managed to computerise its systems to ease procedures for crossing the border and aid the promotion of trade and development (Sai et al., 2015). Beitbridge Bulawayo Railway (BBR). The BBR is a project also implemented in Zimbabwe on a BOT basis by Beitbridge Bulawayo Railway (Pvt) Limited, established to implement the project. The BBR line links an essential corridor of development in Zimbabwe and also shortened the time of the journey by 40 railway between the South African border and Bulawayo, thus providing seamless rail service from the South African ports to Bulawayo and other destinations along this line (Dube & Chigumira, 2011). Low uptake. However, there has been a low uptake of PPP from the private sector for which several possible explanations have been given, including the general uncertain political environment and the absence of a sound legal framework to guide implementation of PPP projects (Dube & Chigumira 2011). Other possible reasons include currency risks, lack of political commitment, lack of financial resources, lack of expertise and capacity, and policy inconsistency (Sai et al., 2015). From the perspective of potential investors, the combination of the unsuitable legal framework, uncertainty about the regulatory environment, and the weak financial position of the public partners translate into a high degree of risk and uncertainty about the attractiveness of these PPP opportunities (Dube & Chigumira 2011). Noticeable progress. As a way towards implementation, there has been some noticeable progress toward the operationalizing of PPP over the past few years. One critical recommendation was the need to speed up the setting of the policy and institutional framework for PPP, to allay fears from the private sector as well as introduce transparency into the process (Sai et al., 2015). Critical documents prepared, which would anchor the future road towards PPP in Zimbabwe include the Public-Private Partnership Policy, 2013; Public-Private Partnership Guidelines, 2013; Public Private Partnership: Legislative Review for Zimbabwe, 2013; and the Institutional Framework, Public-Private Partnership, 2013 (Dube & Chigumira, 2011; Nhema, 2015). These documents form the basis upon which PPP would be structured. 41 Critical questions. Various reviews have, directly and indirectly, also raised several basic issues on the approach required for successful implementation of PPPs in Zimbabwe. These include, what are the most appropriate formats for private participation in the infrastructure sectors under consideration in Zimbabwe?, and what can be said about international experiences and best practice on these choices? What are the most appropriate mechanisms for mobilizing the private financing required for various types of PPPs? What are the lessons from international experience in managing the fiscal risks that governments may take upon themselves under various types of PPPs? Experience indicates clearly that there is no universal norm for the most appropriate design of PPP arrangements (Sai et al., 2015). 2.6.2 Healthcare in Zimbabwe In Zimbabwe, the public health system has been traditionally the largest provider of health-care services, with Mission hospitals and health care delivered by non-governmental organisations (NGOs) playing a complementary role. The infrastructure in the public health institution was also well managed and maintained. However, years of economic decline, have resulted in almost a reversal of this pattern, with the public sector failing to perform its leading role. The health system infrastructure in Zimbabwe is in a deplorable state as a result of lack of maintenance. Equally affected is the hospital equipment which is also in various states of disrepair. The period 2008-2009 saw public hospitals closing doors to patients as the lack of supplies took its toll, with those who could not afford private medical facilities being left vulnerable. While this was happening, the privately run health institutions managed to soldier on, and they more or less managed to carry the burden placed upon them by 42 the public sector failure, but only for those who could afford their service charges. This drives home the important role that a combination of the public and private sector can play in bringing back normalcy in the sector, which is where PPP can come in. What is of paramount importance in the health sector is to make the existing public institutions operate at full capacity before any plans are made to build new institutions, especially the major referral hospitals, Parirenyatwa in Harare and Mpilo in Bulawayo. Thus PPP can play a more significant role whose impact can be immediately felt in the upgrading and rehabilitation of existing infrastructure in the existing public institutions than building new ones. This would also involve building or buying new equipment where the extant is dilapidated. ROT schemes are recommended for the sector to achieve this purpose. The private player can be given an opportunity to operate public hospitals in partnership with the government, with roles and territories being however different (Dube & Chigumira, 2011). Co-location PPP can be used to ensure that the major public hospitals in Zimbabwe become fully operational. Such schemes are already being implemented on a small scale at Parirenyatwa Hospital for example, where some wards are already being operated by private doctors, although a concern has been raised on the possibility for the doctors to try to lure patients from the public system (Dube & Chigumira, 2011). While there is need to gather more evidence on the potential role of private sector financing and partnerships with the public sector, there is potential scope to adopt models that promote public–private funding partnerships in the health sector. There may also be potential to tap the private sector via voluntary contributions. Some 43 private companies may also be willing to finance health care in partnership with the government, development partners, or other private sector entities. More widely, the government may wish to explore examples from other resource-rich countries like Chile where vast mineral wealth has been leveraged to achieve better health outcomes (Lang, 2016). Public–private partnerships (PPP) in service delivery represent another option that could help in mobilizing resources in the private sector (Nhema, 2015). The Lesotho Hospital PPP offers some experience (Lang, 2016; Vian, et.al, 2015). Supported by the International Finance Corporation (IFC) and started in 2007, the Partnership is an initiative by the Lesotho government to involve the private sector— Tsepong consortium—to design, build, and operate a 425-bed hospital and associated clinics with the aim of providing high-quality health care services affordably (Vian, et.al, 2015). The project is currently being touted as an example of a successful healthcare PPP in a low resource setting (Lang, 2016; Vian, et.al, 2015). 2.7 Requisites for Successful PPP While the list of potential benefits from PPP engagements is long, there are a number of conditions that must be met for a PPP project to be successful. Critical success factors mentioned in a review of the literature on PPP implementation across multiple national contexts include the public-sector competence, private partner selection, proper risk allocation, and availability of funding (Lang, 2016; Sithole, Gore, & Gondo, 2017). These critical success factors are generally categorized as procurement, implementation, financial environment, economic conditions, political climate, and risk transfer (Dube & Chigumira, 2011; Nhema, 2015, Lang., 2016). 44 In procurement, a competent and strong private consortium is essential to ensure that the project achieves its goals. Project implementation depends primarily on the private consortium’s ability to provide its contracted services in a timely and efficient manner while adhering to well-defined quality standards (Sithole et. al., 2017). Economic conditions are crucial to ensure that private partners can recoup their investments. Prior to any contractual agreement, the parties involved must necessarily conduct a realistic cost-benefit analysis of the project (Lang, 2016). Political will is an essential component of PPPs to ensure continued support throughout the project’s life cycle (Roehrich, et al., 2014). Since PPPs are typically long-term investments, changes in political leadership have the potential to reverse the support behind a project. Therefore, having the highest levels of government behind PPPs as well as gaining the support of the public is important to ensure the stability and commitment behind a project. Involvement of the public, especially when revenue streams are dependent on user fees, is the only means of ensuring that the needs of all stakeholders are met (Lang, 2016). In addition, broad public support for PPPs helps bolster the continued interest of governments. Allocating risks to the party best able to manage them through a reliable contractual arrangement is what gives PPPs an advantage over purely private and public sector approaches. The appropriate allocation of risks depends heavily on the legal and regulatory frameworks set up by the government and the transparent negotiation of the contract (Sithole et al., 2017). The role of government is to ensure that the legal and regulatory environment is well defined for PPP investments to take place. 45 2.8 Transition and Summary Chapter 2 provided a preliminary review of the literature, which indicated that there is an apparent dearth of information in the scholarship to create a common understanding on the importance of PPPs and the role of PPPs in improving the delivery of healthcare systems. The study of PPPs in healthcare requires a greater degree of extensive research as it is a critical area in the development of healthcare. Chapter 3 contains a discussion of the research methodology. The supporting sections include research method, research design, population, sampling, ethical research, data collection, data collection technique, data organization techniques, data analysis, and reliability and validity. 46 CHAPTER 3: RESEARCH METHODOLOGY 3.1 Introduction Chapter 2 provided a comprehensive literature review on Public Private Partnerships, with a focus on PPPs in healthcare. Chapter 3 provides information about research method, research design, population and sampling, data collection, organization, and analysis techniques. The chapter will conclude with a discussion of issues of reliability and viability as well as research constraints. 3.2 Research Method The options for research methods are quantitative, qualitative, and mixed method. In this study, I employed qualitative research method to explore the feasibility of healthcare PPPs in Zimbabwe. Qualitative researchers are concerned with developing explanations of social phenomena and aim to understand the world in which we live and why things are what they are (Denzin & Lincoln, 2011). Quantitative research centers on the application of mathematical logic to phenomena with the goal of testing a theory or examining causal relationships (Rubin & Rubin, 2012). The research objective did not require the quantification and analysis of factors. Mixed methods research involves the use of both quantitative and qualitative methods to study a phenomenon (Denzin & Lincoln, 2011). The mixed method is most useful when one method does not provide a complete understanding of the study topic. In this study, the qualitative method adequately addressed the research question. Accordingly, I did not select a quantitative or a mixed methods research approach for the study. 47 3.3 Research Design I choose a case study design for this research. Case study design supports the exploration of a particular phenomenon and enables the investigation and description of that phenomenon within a particular, contemporary context (Tsang, 2013; Yin, 2014). Other qualitative research designs did not support the rich case exploration and description that the study called for. Application of a phenomenological design would permit data collection primarily from the conduct of interviews (Marshall & Rossman, 2016), but would not allow for the gathering of information from other available sources. Ethnographic study designs are appropriate for the examination of the beliefs and behaviors of culture-sharing groups (Marshall & Rossman, 2016), which was not the focus of this study. Grounded theory centers on developing or unearthing a fundamental theory (Rubin & Rubin, 2012) and would not support the study objective of in-depth case exploration and analysis. 3.4 Population and Sampling The population for the study consisted of key opinion leaders in Zimbabwe with experience in healthcare PPPs. The objective of this study was to explore the feasibility of healthcare PPPs using data from documents and interviews with participants with specific knowledge of PPPs. Eligible participants were individuals with some experience in PPPs from Zimbabwe. Persons who did not meet these parameters were not eligible to participate in the study. Accordingly, I employed purposive sampling to recruit participants with relevant knowledge and experience. I determined an appropriate sample size for the study in line with the requirements for qualitative case study research. A large sample is not necessary to achieve balance and thoroughness during the conduct of a qualitative case study 48 (Rubin & Rubin, 2012). O’Reilly and Parker (2013) observed that sample population adequacy for a qualitative study is a function of the study topic, participant availability, and sufficiency of sample size for permitting the examination of study research questions. Two to three participants per subsample area are sufficient to ensure the achievement of a suitable depth and diversity of perspectives in qualitative research (Rubin & Rubin, 2012; Yin, 2014). In this study, I interviewed seven participants who met the required criteria. Except for three participants who opted for face-to-face interviews all interviews were conducted telephonically. Each interview lasted between 30 and 60 minutes. 3.5 Ethical Research The research study was explained to all participants prior to any questions being asked to ensure voluntary participation. The participant was only then asked to sign an informed consent form, which emphasized the voluntary nature of the interview, and the freedom of the participant to withdraw at any time. Identities of participants in this study will remain confidential forever. In this regard, any data in relation to this research will be secured for a period of 5 years after which it will be permanently destroyed. For purposes of privacy and confidentiality, all participant names and identities in the narrative are classified as Participant 1, Participant 2, and so forth. There were no incentives offered for participation in this research. 3.6 Data Collection 3.6.1 Instruments Yin, 2014 noted that the researcher in qualitative studies is the primary data collection instrument. As the primary data collection instrument, I collected data using a semistructured interview guide consisting of open-ended questions covering 49 participants’ experiences and perceptions on the feasibility of healthcare PPPs in Zimbabwe. In line with Yin’s recommendation of triangulating data from multiple sources to ensure research reliability, I use data from organizational documents to complement the interviews. Desktop research of examples of healthcare PPP in developing nations provided additional information to buttress the study. 3.6.2 Data Collection Technique Data collection consisted of desktop research from literature and organizational documents as well as interviews with seven participants purposefully selected from key opinion leaders with experience in PPPs. The first step was to contact potential study participants in person, via email, or over the phone in order to introduce myself and explain the purpose of the study. This was followed by the presentation of the informed consent form to willing participants. I then retrieved the signed informed consent forms from willing participants before scheduling interviews at the participant’s convinience. Data collection was through face-to-face and telephone interviews using semi-structured questions. Each interview lasted 30-60 minutes at a time, date, and location mutually agreed upon with the participant. The use of semistructured questions allowed participants to provide depth in their responses. With the consent of the participant, I audio-recorded all interviews in addition to taking notes on key comments during each interview. Transcription of the interviews verbatim at the end of each interview followed. Audio recording the interviews allows for thorough analysis of the responses of participants and the ability to quote statements verbatim when required (Rubin & Rubin, 2012). To ensure data accuracy I sent copies of interview transcripts and interpretations to the participants for transcript review, member checking, and 50 verification before commencing data analysis. Member checking is a technique used by researchers to enhance the credibility and trustworthiness of research data and the accuracy of interpreted meanings through participant review and feedback (Boesch, Schwaninger, Weber, & Scholz, 2013). 3.6.3 Data Organization Techniques In order to ensure confidentiality of research data, I assigned generic codes to mask the identities of the study participants. Audio recording all interviews assisted in ease of storage and retrieval of the data. I transcribed the recorded interviews verbatim into written documents, which I kept in individual folders for each participant on a password protected hard drive. I used a qualitative data analysis software, NVivo to input and store data for coding and exploring themes while maintaining the confidentiality of research participants. I stored all data on a password-protected external hard drive that I will keep locked in a cabinet for five years. 3.7 Data Analysis Technique In qualitative research, the object of data analysis is to uncover themes that answer a central research question (Yin, 2014). In this case study, data analysis provided a framework to understand the feasibility of PPPs in Zimbabwean healthcare. I used the method described by Yin (2011), for data analysis. This method includes the following steps in sequence (a) compilation, (b) disaaggregation, (c) reassembling, (d) interpretation, and (e) making conclusions. I used Nvivo software to aid in the data analysis process. The software automates complex tasks such as codebook formation and easily links interview documents together, so a theme is 51 traced through different interview responses (Bazeley & Jackson, 2013). Data interpretation and conclusion followed the data organisation. 3.8 Reliability and Validity The discussion in this subsection includes information about the reliability of the instruments and processes referenced in this study. The second topic in this subsection is the identification of internal and external threats to the validity of the study. I will review the controls and strategies used to mitigate the threats and to ensure the integrity of the study results. Researchers use the following criteria proposed by Lincoln and Guba (1985) to assess the rigor of qualitative research: dependability, credibility, confirmability, and transferability. Dependability refers to how reliable the data are and can be compared to the concept of reliability in quantitative research (Elo et al., 2014). Credibility is concerned with the accuracy and trustworthiness of the findings from the viewpoints of the researcher, the participants, and the reader (Lincoln & Guba, 1985). According to Cope (2014), credibility is the truth inherent in the data and enhanced by the accuracy of the researcher’s confirmed interpretation. Transferability refers to speculations on the possible applicability of findings to other situations under similar, but not identical, conditions (Bloomberg & Volpe, 2012). Confirmability is a criterion for assessing the accuracy and reasonableness of the findings obtained from the data and observation of the participants (Houghton, Casey, Shaw, & Murphy, 2013). 3.8.1 Reliability The Reliability refers to the extent that research findings are replicable in other similar studies (Bloomberg & Volpe, 2012).Qualitative researchers demonstrate the trustworthiness of research through dependability (Denzin, 2012). I used NVivo 52 software to create and maintain a case study database for the study. Use of the case study database enhances study dependability by providing other investigators with insight into the data products and analytical methods used to derive study findings and conclusions (Chenail, 2011). Member checking to verify correct interpretations of participants’ experience also enhanced dependability. 3.8.2 Validity Qualitative researchers implement measures that ensure credibility and transferability to safeguard the integrity of their research (Marshall & Rossman, 2016). I used (a) data triangulation, (b) the assessment of rival explanations, (c) researcher bias identification, and (d) member checking to safeguard the study’s credibility. Researchers also use document reviews, interviews, and direct observations to achieve study credibility and enhance the quality of case studies (Roy, Zvonkovic, Goldberg, Sharp, & LaRossa, 2015). Likewise, the use of methodological triangulation of findings from data collected from documents review and interview questions augmented the quality of the study. The gathering of study data from example PPP sites also ensured spatial variability in the study and supported the broad exploration of the feasibility of PPPs in the healthcare sector in Zimbabwe. In qualitative research, credibility is the corollary to internal validity (Denzin, 2012). In this study, I enhanced credibility by the assessment of rival explanations as recommended by Yin. Rival explanations for phenomena do not undermine case study designs or procedures. I employed researcher bias identification as a second strategy for ensuring the credibility of the case study. The self-awareness of personal and professional beliefs and responsibilities as a researcher will decrease the likelihood of interspersing bias in data collection and data analysis (Tufford & Newman, 2012). 53 I used member checking as a third technique for establishing the credibility of this qualitative case study. Member checking is a process by which researchers share draft interpretations with participants in person or over the phone so that the participants may comment on the accuracy of the materials (Marshall & Rossman, 2016). Feedback from participants helped enhance the accuracy and credibility of the study process. Rather than focusing on the external validity of study findings, researchers in qualitative research are concerned with the transferability of the findings (Denzin, 2012). I addressed transferability through the thick and rich description of the study population and the context. The inclusion of this information will enable readers to evaluate the transferability of study findings and conclusions appropriately. Confirmability in qualitative research resembles the concept of objectivity in quantitative research (Lincoln & Guba, 1985). Researchers use this criterion to assess the accuracy and reasonableness of the findings obtained from the data (Houghton et al., 2013). The implication is that the study findings must be the result of the research and not merely reflections of the biases and subjectivity of the researcher (Bloomberg & Volpe, 2012). To achieve confirmability, I recorded all interview data, maintained an audit trail, and collected data from multiple data sources. I also used member checking so that findings reflected the understandings of the participants. Data saturation occurs when no new themes, concepts, or findings are evident in the data (Silverman, 2015). I achieved data saturation by employing criterionoriented purposive sampling (Robinson, 2013) and by interviewing the participants in incremental numbers until there was redundancy in data collected. Methodological triangulation of data obtained from interviews, and information gathered from 54 organizational documents desktop research was the main strategy for achieving data saturation. 3.9 Transition and Summary In Chapter 3, I discussed the role of the researcher, the participants’ demographics and the sample size, the research method and design, the data collection and analysis, and the reliability and validity of the data. Chapter 4 includes data presentation and analysis. Finally, I will end Chapter 4 with a summary and conclusions. 55 CHAPTER 4: DATA PRESENTATION AND ANALYSIS 4.1 Introduction The data collected were analyzed using NVivo software, which organizes and analyses unstructured data and helps identify themes and trends. In the following narrative, I will provide a detailed discussion of the study findings with reference to the overarching research question and existing literature on PPP. After that, I will articulate the application of the findings to professional practice, the implications of the study to social change. From the study results, the researcher established that healthcare PPP are feasible if certain prerequisites are met. These include the legal and institutional framework, political will, adequate funding, common goals between the partners, as well as buy in from the community. An analysis of the data suggests solid support of the literature review indicating that PPP arrangements are indeed an alternative model of procurement developing nations can use for both infrastructural development and service delivery. The most common theme was a lack of policy and institutional framework to guide PPP implementation in Zimbabwe. 4.2 Presentation of the Findings The interview responses gave details of the knowledge obtained from the literature review. In that regard, there are key issues that need attention to facilitate the interaction of the stakeholders for successful designing and construction of PPP. The research findings were grouped under the targeted research themes as follows: 56 Table 1 Initial Coding Schema based on Research Questions Theme Name (Node) Understanding of PPP as model for development Barriers to PPP adoption Critical success factors Healthcare PPP models Benefits of PPP Stakeholder roles in PPP Funding and infrastructural challenges PPP legal and policy framework Healthcare PPP models Community resistance Recommendations Sources 7 7 7 7 7 7 6 6 4 4 7 References 112 68 68 63 60 60 54 51 48 39 18 Table 2 Major Themes & Subthemes Major themes Understanding of PPP as model for healthcare development Barriers to PPPs Critical Issues to be addressed Subthemes PPP versus privatization Stakeholder roles Benefits of PPPs Models of PPPs Social barriers Legal barriers Economic Barriers Environmental barriers Technological Barriers Financing challenges Policy & institutional framework Risk analysis Expertise for PPPs Culture of maintaining infrastructure Although participants came from diverse backgrounds, common themes emerged early on in the research process. While several themes emerged, major 57 themes included PPPs as a model of healthcare development, PPP barriers, and the critical issues that need to be addressed to ensure successful PPP implementation in healthcare. 4.2.1 Understanding of PPP as Healthcare Development Model This theme emerged mostly from analysis of responses from the first research question: Can public private partnerships be helpful in the provision of healthcare services in Zimbabwe? It was clear from the outset that participants had some knowledge of what PPP was, but lacked depth in terms of details of the concept. Of the respondents only 40% (n = 7) clearly articulated an understanding of PPPs, and went further to describe how they can be applied to healthcare effectively. Seventy percent of the participants (n=7) confused PPP with privatisation while, all participants mentioned some benefits of PPP arrangements. Only three participants mentioned PPP models correctly, while 70% of the respondents related to the role of the various stakeholders. Table 3 Understanding PPP as a Model for Healthcare Development Response PPP and privatisation Stakeholder roles Knowledge of PPP benefits Knowledge of PPP models Respondents Number % 3 43 5 71 7 100 3 43% PPP versus privatization. The issue of PPP versus privatization emerged as a dominant theme indicating that there is misconception regarding the two concepts. Participants noted that there was a thin line between privatisation and PPP. One key 58 informant who noted, “There is no difference between a PPP and privatisation except that in a PPP, the public sector remains the major shareholder”, aptly demonstrated this confusion. Similarly, participant 3 stated, “A PPP is like privatisation, except the government has a role to play.” Only three participants clearly articulated the difference between a PPP and privatisation whilst the remainder could not commit themselves. Stakeholder roles. The role of the stakeholder involved in PPP arrangements was also a major talking point. All participants agreed that a in a PPP there is a role for the private party and a role for the public partner. What could not come out clear was the explicit roles of either party, which were frequently confused. However, 70% of the respondents noted that in most of these arrangements, the public sector remains the custodian of the services and provides rules and regulations for operation. Participant 5 stated “it is critical that the public sector retains the oversight roles, and sets the do’s and don’ts in such a relationship for the sake of the public,” while Participant 2 observed, “the role of the private sector is to fund the project and not to run it. This should be the responsibility of the government.” All participants mentioned that such arrangements are usually at the behest of the government due to financial challenges. Another participant also noted that the government usually seeks the services of the private sector in order to improve service delivery. Benefits of PPP. While acknowledging that PPP arrangements brought some benefits to the public services, most of the participants (83%), expressed concern over the lack of oversight by the government, especially when it comes to pricing of goods and services. There was a perception among participants that current PPP arrangements, which particular reference to the Chitungwiza Hospital, have resulted 59 in the denial of services to the poor and indigent. This was in spite of the fact that Chitungwiza Hospital is a public institution. Participant 6 had this to say, “The quality of services at Chitungwiza hospital have improved, but my poor sekuru can no longer afford an X-ray at the hospital and has to go to Harare hospital.” Participants 2 and 3 concurred, but noted that the cost differential was not that huge, but the government needed to put in place control measures. Other stated benefits include improved customer service and efficiency. PPP models. Understanding of PPP models was clearly lacking, with only three of the seven participants having an idea of PPP models. The most common models mentioned included the BOT and ROT models. Examples that participants mentioned included the recently finished Plumtree – Mutare highway as well as the arrangements at Chitungwiza hospital. The three participants indicated that there was a need for the government to assume ownership at the end, as long as the private partners have recouped their expenses. 4.2.2 Barriers to PPP Adoption Respondents identified a large number of barriers to PPP project implementation in Zimbabwean healthcare. These barriers were classified as social, legal, economic, environmental, political, and technological as shown in Table 3. Recognition of the barriers and elimination by the stakeholders in PPPs will allow the partnerships to function effectively and ensure successful implementation of present and future PPPs. 60 Table 4 Barriers to PPP Response Social barriers Frequency % 17 Legal barriers 16 Poor regulatory framework; weak institutional capacity; Lack of policy framework Economic barriers 19 Country risk; liquidity constraints; forex issues Environmental barriers Political barriers 12 Lack of transparency & accountability, security of tenure; rampant corruption Instability; policy inconsistency; politicisation Technological barriers 20 16 Examples Public mistrust, cultural impediments Lack of expertise and experience; poor risk profiling and management; a lack of qualified professionals; poor due diligence Social barriers. These include public opposition, cultural impediments, societal discontent against the private sector, public resentment due to tariff increases, lack of confidence, and mistrust in PPP among others. All participants stated that public misconception of PPP and lack of information constituted the main reason for pubic mistrust. Participant 5 noted “the public does not trust the private sector mainly due to issues to do with corruption scandals.” Therefore, it becomes necessary that all the stakeholders’ in PPP implementation in developing countries identify the public interest goals before embarking on any PPP project. 61 Legal barriers. The respondents identified weak /poor enabling policies (80%), poor regulatory frameworks and enforcement (50%), weak institutional capacity (83%), and PPPs strategy (65%) among others as legal barriers to PPP implementation. Participants 3, 5, and 6 noted that it was futile to try to implement PPP without the right policy and legal framework. They noted that these are necessary to avert issues of disagreements between the parties to the PPP. Economic barriers. This emerged as a major theme among all the respondents. Economic issues perceived to militate against adoption of PPP included country risk profile, lack of capacity by local institutions to provide long-term financing, liquidity constraints, and forex challenges among others. Participants observed that for the government to attract private partners, it is necessary to create a stable economic environment. Participant 1 observed that the country risk profile is very high, and the easy of doing business very low with the country ranked a lowly 112th in the world. “This scenario does not induce confidence in both local and foreign PPP investors,” noted Participant 1. Environmental barriers. Environmental barriers identified include; security of tenure, lack of transparency and accountability, accusations of corruption, and corrupt tendencies among others. Three key informants noted that security of tenure, as well as the indigenization law in its current form scare away foreign direct investment. Participant 4 observed “There are a lot of potential investors out there…but they are not ready to risk their hard-earned cash in an uncertain environment, characterized by policy inconsistencies, and rampant corruption.” Similarly, participant 7 noted, “The issue of indigenization is a challenge. I think it needs to be reviewed so that we can have more PPP takers.” These sentiments are in 62 harmony with the call for the government to improve the ease of doing business to make PPPs attractive. Political barriers. This subtheme was common across all participants who concurred that the current political environment was not conducive for investment. In particular, participants 1, 2, 4, and 6 stated that the current political environment has so much uncertainty and investors are being very cautious with investments. In addition, the challenge of policy inconsistencies stands as a major deterrent to PPP investments. Participant 6 stated, “Today you hear one minster saying this, and the following day another minister saying completely the opposite. It is difficult to understand what exactly is happening. We can’t run a country like that.” In addition, participants cited political grandstanding, populism, politicization of the franchises, bureaucracy, lack of political will and commitment for PPPs among others as barriers. Technological barriers. All participants cited a number of technological barriers, and these included lack of expertise and experience, poor risk profiling and management, a lack of qualified professionals, poor due diligence and project information by public sector among others. Participants 1, 2, and 4 especially singled lack of suitable skills and experience and lack of project preparation capacity on the part of the public sector as barriers to PPPs project implementation. For this reason, participants believed that most PPP projects in the country were relying on foreign expertise and skills. Participant 5 and 6 believed that the country needed to do more in terms of technological readiness and capacity building in both the public and private sectors. 63 4.2.3 Critical Issues to Address Table 4 lists the issues identified by participants as requiring urgent intervention before implementation of PPP in Zimbabwe, and particularly in the healthcare sector. All participants mentioned the need to address financial challenges and develop a PPP policy and institutional framework to allow for the effective implementation of healthcare PPPs. Table 5 Critical Issues to Address Response Financing challenges Policy & institutional framework Risk analysis PPP expertise Culture of maintaining infrastructure Respondents Number % 7 100 7 100 3 43 4 60 5 71 Financing challenges. It was not surprising that this theme featured prominently amongst all participants given the characterization of the economy as one of the major barriers. Participants indicated that financing mechanisms for the PPP schemes needed regularization. One participant noted, “While it is largely the private sector that brings in the finance, the manner in which the funds are channeled towards the infrastructure needs regularization. We do not even understand how some of the tenders are awarded.” The process according to the majority of the participants was shrouded in secrecy and prone to corruption, hence the call for transparency and accountability. Participant 1 noted, “The process is shrouded in secrecy and that 64 hinders participation of equally competitive players and, therefore, reduces competition and an opportunity to choose the most favorable partner.” Participant 5 suggested the setting up of a Special Purpose Vehicle (SPV) before any PPP is initiated to facilitate finance mobilization. Participants once again observed bureaucracy as an impediment to the resource mobilization, and respondents called for removal of bottlenecks that can affect the smooth coordination and interaction among all the stakeholders. The laying of the basic policy and institutional framework to support PPP was identified as a key precondition for successful healthcare PPPs. Policy and institutional framework. Another observation was political commitment as one of the key elements for the success of PPP by all participants. One measure of political commitment is the policy and institutional framework for PPP. Eighty percent of the participants observed that Zimbabwe lacked the policy and institutional framework for PPP. This scenario according to the participants was militating against PPP adoption not only in healthcare, but also in all sectors of the economy. Participant 3 noted that countries like South Africa, Namibia, and even Zambia had in place PPP policy and institutional framework, and called for Zimbabwe to go the same route. Such institutions are responsible for governing PPP project conduct, as well developing the legislative framework governing PPP operations. Participant 6 noted, “Legislation acts as both insurance and assurance to investors that the government will honor the contract.” Participant 7 added “Another reason lies in our lack of a national PPP framework and regulation. We also have little knowledge of PPP structures and mechanisms. The corruption factor is present in high magnitude. To avoid being ripped off, we must have a 65 national framework on PPPs, a national policy on infrastructure, an empowered regulator, as well as up our PPP skills and knowledge. We should also deal with the corruption element whose stakes becomes high especially in mega infrastructure deals.” It is important for the government to develop a policy framework on PPP, which would guide the PPP process. In addition, a public institution to oversee the whole process also needs to be developed. The institution would also play an active role in developing the legislative framework for PPP. The existence of these three issues (policy framework, legislation and PPP institution) plays the most critical role in making PPP successful. Chigumira and Dube (2011) noted that Zimbabwe has made some strides towards laying the basic policy and institutional framework in that a draft PPP policy and draft guidelines have already been completed, and are currently being reviewed by stakeholders for finalization. In addition, the PPP Legislative Review for Zimbabwe, which is a general review of legislations in Zimbabwe, which have a bearing on investment and business environment, is now in place (Chigumira & Dube, 2011). It is thus important to assess the extent to which these ventures are in line with international best practice. Risk analysis. Three of the seven respondents mentioned the issue of risk. While they did not have a clear understanding of the whole picture, at least they managed to identify risk analysis as a key factor in PPP adoption. The participants noted that PPP arrangements create several elements of uncertainties about future outcomes hence the need for proper risk profiling. Risk analysis involves the assessment of the possible uncertain environment concerns, measuring them and 66 strategizing on managing them. Participant 3 observed “Strategies must be developed to minimalize risk, as inadequate risk management can easily result in the project being derailed.” Participants identified the following as potential PPP risks: construction risk, financial risks, performance risk, and demand risk. Expertise for PPP. About 60% of the participants believed that availability of expertise was a critical success factor for healthcare PPPs. Participant 2 stated, “It is important that the necessary expertise and capacity to deliver healthcare PPP is available in the country”. Participants noted that this expertise is mostly in the private sector and includes such expertise as medical engineers, operators, and contractors. There is no way that healthcare PPP can succeed without such expertise, echoed Participant 4. It should however be noted that such expertise is readily available in the country, and thus the issue of expertise cannot be used as a basis for delaying the initiation of healthcare PPP in Zimbabwe. Inculcating a culture of maintaining infrastructure. The majority of the participants interviewed bemoaned the lack of a culture of maintaining infrastructure especially in the public sector. While PPP can bring with it state of the art infrastructure a lack of a maintenance culture can result in rapid decay of the same. Participants agreed that a deliberate policy on the part of the Government to ensure that there is a culture of maintaining the infrastructure should precede the rehabilitation of public infrastructure. Preventive maintenance should be mandatory for all public infrastructure if PPPs are to bring the required results, observed participant 5. Failure to address this will lead to infrastructural decay and injection of more resources in rehabilitation. 67 4.2.4 Chitungwiza Central Hospital Case Study The study involved an in-depth study of the PPP arrangements at Chitungwiza Central Hospital and these are presented in the following narrative. The findings were derived from interviews with key stakeholders from the hospital as well as documentary evidence and a tour of the hospital for direct observations of the PPP arrangements. The hospital. Chitungwiza Hospital is the major government health care service provider in the town of Chitungwiza with a population of around 2 million, and acts as a referral centre for other outlying areas. The hospital has a bed capacity of 500 beds which is far too short from ideal. Due to the large catchment area and high numbers of referrals who require admission and cannot be turned away, volumes continue to increase daily. Patient categories. There are three categories of patients admitted namely cash paying, public assistance fund patients, and medical aid members. Emergency cases are attended to without the need for cash up front or prior arrangement for payment. It is only after the patient has been attended to that arrangements are made for the payment of hospital bills. It should however be emphasized that all patients have equal access to the hospital irrespective of the category they fall into. PPP arrangements. While the Hospital previously benefited from the Target Approach and appropriately utilized the funds, these funds were exhausted and the hospital resorted to operating with some PPPs on a small scale in the following areas: theatres, ophthalmology, renal, laboratory, radiology, training, pharmacy, dental, mortuary, and public coffee shop and confectionary. 68 PPP benefits. Chitungwiza management believes the partnerships have created a strategic win-win situation between Chitungwiza Central Hospital and the private partners. The involved private partners agree that there has been a lot of positives from the partnership both for the hospital and the public at large. The private partners have rehabilitated the physical infrastructure and provided state of the art equipment in some areas of the hospital. As a result of the PPP arrangements the hospital now offers improved service delivery. The partnerships have also created a strategic win- win situation between the hospital and the private partners and managed to transform the hospital into a centre of excellence. Through the partnerships, physical infrastructure has been rehabilitated and the private partners have helped equip the hospital with modern state of the art equipment in targeted areas. Other benefits attributed to the PPP arrangements include high degree of funding certainty, managerial expertise, professional staff retention, attraction of medical specialists, a commercial flair on all operations, and world class hospital exterior and interior design. The respondents also believe that the hospital now has a capability to tap into new information and medical technology and improve the training environment for students. Public concerns. The respondents noted that concern can be raised that the partnership is merely driven by the profit motive and charge astronomical prices to patients in pursuant to profit agenda. However, the pricing model is governed by rates agreed upon by healthcare funders and providers, and approved by the Ministry of Health and Child Care. It is therefore believed there is no scope for arbitrage behaviour or rent seeking at the expense of the patients. The financial viability of the partnership is a function of volume and quality rather than price margins. 69 However, there have been public concerns on the cost of services now being offered at the hospital, with some informants blatantly stating that the hospital has been privatised. Challenges faced by Chitungwiza residents in trying to realize the right to health include alleged segregation against the poor, high health care fees, and corruption by hospital staff and management. Informants believe that most of these problems are a result of a poorly structured PPP arrangements, which did not consider the interests of the major stakeholder, the patient. One parliamentarian alleges that the Chitungwiza PPP model has resulted in the commoditization of basic public services, as it is not any different from privatization. In this regard, the general feeling is that before any PPP arrangement, there is need for health care needs assessment, feasibility assessment, stakeholder engagement, transparency, and accountability. 4.3 Transition and Summary This chapter provided a detailed data presentation and analysis of the findings from data collected from the participants including evaluation of the relationship between the data and research question and the purpose of the study. Chapter 5 provides the summary and conclusions from the research as well as recommendations for action and further study. 70 CHAPTER 5: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 5.1 Introduction The challenge in Zimbabwean healthcare is to develop and sustain an affordable and easily accessible quality healthcare system. The purpose of this qualitative case multi-study was to determine the feasibility of healthcare public private partnerships in Zimbabwe. The study, which was in the form of in-depth interviews, sought to determine the underlying challenges of PPPs, and how PPPs in healthcare can be leveraged to improve service delivery and drive quality affordable healthcare. This chapter provides a summary and conclusions from the research findings, with a focus on recommendations for action and future research. 5.2 Summary The data gathered from the study provided solid support of the literature review, which indicated that healthcare PPPs, although feasible, are complex and require a lot of groundwork and prior experience. The results demonstrated varying levels of the knowledge and understanding of PPP among the participants. Furthermore, the results indicated an array of barriers and critical issues that need urgent attention for successful PPPs, not only in healthcare, but also in any sector of the economy. All participants were purposefully selected from individuals with some knowledge and experience of healthcare PPP in Zimbabwe. The research question for this qualitative case study was: What is the feasibility of healthcare PPP in Zimbabwe. The findings demonstrated the feasibility of healthcare PPP if the government attends to various critical issues. NVivo software aided in analysing the data and provided subthemes for this study. Based on the 71 research objective of determining the feasibility of healthcare PPP in Zimbabwe, three major themes were identified namely understanding off PPP as a model for healthcare development, barriers to healthcare PPP, and critical issues to be addressed for successful PPP project adoption. Each of these themes had several subthemes, which related to the feasibility of healthcare PPP in Zimbabwe. Each of these themes can be the basis for further research on PPP in general, and on the feasibility of healthcare PPP in particular. This research has added to the body of knowledge by ascertaining that the healthcare system is complex and for PPPs to be successful, the government must address certain critical issues. Critical to the success of healthcare PPP in Zimbabwe is the establishment of an enabling environment, institutional framework, as well as appropriate risk analysis. All stakeholders with some role in public private partnerships in any sector should have access to this knowledge. 5.3 Conclusion The analysis of the study findings has shown that health PPPs are highly complex undertakings, which require large amounts of resources as well as robust experience and know-how from both the private and public sector. The numerous hurdles for health infrastructure PPPs in developing countries—which even exacerbate because of mutual reinforcement—show, how difficult it is for the government to successfully engage and manage this kind of projects. There is evidence of lack of a clear understanding of PPPs in general and this is probably due to the wide range of PPP definitions as was demonstrated in the literature review. While appreciating the role of PPPs and the many benefits that can accrue from the arrangement, an appreciation of the major differences between a PPP 72 and privatisation is lacking. This may be a result of absence of policy framework to guide PPP projects in the country. What was worrying was that even the key opinion leaders, with experience in PPP implementation still referred to PPP as an example of privatisation. Evidence from the data suggests there are many potential benefits from PPP arrangements in healthcare ranging from improvement in infrastructure to enhanced quality of service delivery. Both the public sector and the private sector stand to benefit in PPP arrangements, but there was a general agreement that the public sector stands to benefit more if the PPP is properly structured. The structuring of the PPP arrangements largely depend on the objectives of the partnership. The study also revealed a gap in the knowledge of PPP types as evidenced by the few respondents who could identify a few models of PPP arrangements—those they had experienced and these included the BOT and ROT arrangements. The study has demonstrated that to implement PPP in Zimbabwean healthcare is a noble idea as PPP can indeed help in bringing investment into the sector, an area traditionally reserved for the public sector, especially at a time like now where the Government is financially handicapped. However, there are multitudes of barriers to overcome on the way to effective implementation of PPP projects in healthcare. These barriers are classified into social, legal, economic, environmental, political and technological. Technological barriers constitute the largest barrier category, and some of the barriers include lack of expertise, poor risk profiling, and shortage of professionals. There is a need address holistically all the barriers identified in order to create the necessary ground for the takeoff of PPP projects. 73 The study findings revealed some critical issues to attend to if the full potential of PPPs is to be realized and assessed fairly. These issues generally centre on financing challenges, policy and institutional framework, risk analysis and management, expertise on PPP, and inculcating a culture of infrastructure maintenance. Presence of a policy and institutional framework is reflective of the political commitment within the public sector and is a key driver of PPP success. PPP projects are designed based on time, budget, operating revenues and expenses, forecasted targets, and expected quality. Risk sharing is the basis of most PPP projects. However due to unexpected events, such as failure to perform as expected, the project can be prevented from meeting the expectations. Thus, success of a PPP project hinges largely on transferring risk to a party that is best suited to manage or minimize it. While PPP can bring with it state of the art infrastructure, a lack of a maintenance culture can result in rapid decay of the same. Therefore, a deliberate policy, on the part of the Government to ensure that there is a culture of maintaining the infrastructure, should precede rehabilitation of public infrastructure. The Chitungwiza Hospital PPP example is ample evidence of the feasibility of healthcare PPP in Zimbabwe. However, there are obvious challenges with the PPP arrangements ranging from negative public perception as well as lack of clarity on whether the arrangements are straightforward PPPs or joint ventures. The case study demonstrates how involvement of the private sector in terms of both infrastructural development and service delivery in healthcare services can transform healthcare in the country. 74 This paper has noted that the most serious challenge in the emerging PPP arrangements in Zimbabwean healthcare is the absence of appropriate policy and institutional framework. Accordingly, there is need to put in place sound policy and regulatory frameworks pertinent to the country circumstances and aims for healthcare PPP arrangements. These legal frameworks require meaningful public participation in both the formulation and implementation for them to be acceptable and sustainable. 5.4 Recommendations 5.4.1 Recommendations for Action Taking into cognizance that there is a policy position from Government of Zimbabwe on PPP as a driver of infrastructural development under ZimAsset, there is need to adopt a model for healthcare PPP based on evidence from case studies in and around the region. The study has demonstrated that although PPP are indeed feasible in the healthcare sector, they are possible if parties apply different PPP models and strategies across sectors and PPP objectives. Most health infrastructure in Zimbabwe is in a state of disrepair and requires various levels of rehabilitation. This study therefore recommends the adoption of the ROT model to resuscitate the Zimbabwe healthcare sector. This stands a bigger chance for success if co-sharing of infrastructure in existing public health facilities for an agreed time is adopted, which would also form part of the public-sector contribution. However, PPPs for health infrastructure should not be off the table entirely. The government should organically build the healthcare PPP capacities step-by-step by (a) carrying out small-scale, easy to manage health PPP projects and (b) undertaking less complex PPP projects outside the field of health to develop general 75 PPP capabilities. It is important to collect extensive data regularly for future references and best practices. While doing so, the government can acquire the required expertise and capabilities for ambitious PPP projects in the future. In light of this, the following are recommendations that can help Zimbabwe adopt successful PPP projects. Improvement of the legal environment. There must be a legal framework, which protects all stakeholders in the partnerships to ensure trust and accountability. This legal framework has to provide sufficient security for the state and its citizenry. An investor needs to be confident that the judiciary will enforce laws and enforce contracts in the case of disputes. A legal framework will help empower citizens, improve skills base, reduce bottlenecks in the system, thereby reducing corruption. Establishment of a PPP unit. The country needs to establish or improve the institutional quality, with special emphasis on developing appropriately skilled human capital needed for negotiating and monitoring the implementation of PPP contracts. The PPP unit, set up either as stand-alone entity or within a government ministry will facilitate an enhanced capacity building on PPP related issues. Although a PPP unit only plays a supporting role, it helps in project preparation; helps in the selection and management of specific advisors; ensures that the project fits into the overall PPP policy, and plays a role in project approval and quality assurance. The PPU unit has potential to improve the regulatory environment. Improvement in the regulatory environment increases accountability of all stakeholders involved in PPP. Furthermore, regulation increases monitoring and evaluation of projects to ensure that the objectives and benefits of the partnership accrue as per the contract agreement. 76 Improve initiatives on capacity building. Improvement of PPP skills should be a medium to long-term goal for the government. The government should also consider inclusion of PPP issues in the educational curriculum especially at tertiary institutions. PPP are the future for building infrastructure globally so as a nation, we must invest in acquiring knowledge on all aspects of it. It is no secret that capital responds better to political stability. Thus, the Government must continue on the path of improving the political environment and demonstrate political commitment and policy consistency. These moves will go a long way in improving long-term financial markets—the bedrock of successful PPPs. Finally, development partners should help with learning forums to exchange ideas and experiences, and help conduct research for deeper understanding of healthcare PPPs and how these can be used as delivery modalities for the much-needed healthcare services in the country and the sub-region. 5.4.2 Recommendations for Further Study Conclusions from this research will benefit public and private healthcare actors in particular and the management field in general. Public-private partnerships can combine the strengths of private actors, such as innovation, technical knowledge and skills, managerial efficiency, and entrepreneurial spirit, and the role of public actors, including social responsibility, social justice, public accountability, and local knowledge, to create an enabling environment for delivering high quality health infrastructure and services. Through these partnerships, public and private actors may realize benefits such as the creation of jobs, educational development, incentives for innovation and competition, and health infrastructure development. Future research should develop a 77 richer understanding of the circumstances for creating alliances between private and public actors from a strategy perspective, explore the impact of incentive mechanisms and risk management procedures on health service performance throughout the extended project life cycle, and create conducive environments to foster inter-project learning. Researchers should in future investigate the PPP failures across different sectors and countries to draw out guidance on when and to what extent PPP arrangements should be favored. Thus, research can investigate the limitations of PPP arrangements in delivering public sector infrastructure and services. These proposed research avenues will help integrate the private political and social perspectives at the public-private nexus in health public-private partnerships. 78 References Asian Development Bank. (2008). Public-private partnership handbook. Bazeley, P., & Jackson, K. (2013). Qualitative data analysis with NVivo. Thousand Oaks: Sage. Bel, G., Brown, T., & Warner, M. (2014). Editorial overview: Symposium on mixed and hybrid models of public service delivery. International Public Management Journal, 17, 297–307. doi:10.1080/10967494.2014.935231 Biermann, F. M., Naroditskiy, V., Polukarov, M., Nguyen, T., Rogers, A., & Jennings, N. R. (2014). Task assignment with controlled and autonomous agents. Mathematical Social Sciences, 17, 116–122. doi:10.1016/j.mathsocsci.2014.04.007 Bloomberg, L. D., & Volpe, M. (2012). Completing your qualitative dissertation: A roadmap from beginning to end. Thousand Oaks, CA: Sage. Boesch, I., Schwaninger, M., Weber, M., & Scholz, R. W. (2013). Enhancing validity and reliability through feedback-driven exploration: A study in conjoint analysis. Systemic Practice and Action Research, 26, 217238. doi:10.1007/s11213-012-9248-6 Button, K., & Daito, N. (2014). Sharing out the costs of a public-private partnership. Applied Economics Letters, 21, 383–386. doi:10.1080/13504851.2013.856995 Chenail, R. J. (2011). Interviewing the investigator: Strategies for addressing instrumentation and researcher bias concerns in qualitative research. The Qualitative Report, 16(1), 255-262. Retrieved from http://www.nova.edu/ Chiromo, A. T. (2014). Public-private partnerships in water infrastructure projects in Zimbabwe : The case of the Kunzvi water development project. Stellenbosch 79 University. Retrieved from http://scholar.sun.ac.za Christensen, L. B., Johnson, B., & Turner, L. A. (2014). Research methods, design, and analysis (12th ed). Boston, MA: Pearson. Cope, D. G. (2014). Methods and meanings: Credibility and trustworthiness of qualitative research. Oncology Nursing Forum, 41, 89–91. doi:10.1188/14.ONF.89-91 Das, A. (2007). Public-private partnerships for providing healthcare services. Indian Journal of Medical Ethics, IV(4), 174–175. Denzin, N. K. (2012). Triangulation 2.0. Journal of Mixed Methods Research, 6(2), 80–88. doi:10.1177/1558689812437186 Denzin, N. K., & Lincoln, Y. S. (2011). The Sage handbook of qualitative research (4th ed.). Thousand Oaks, CA: Sage. Dube, C., & Chigumira, G. (2011). The Scope for Public-Private Partnerships for Infrastructure Development in Zimbabwe. Zimbabwe Economic Policy Analysis and Research Unit (ZEPARU). Elo, S., Kääriäinen, M., Kanste, O., Polkki, T., Utriainen, K., & Kyngas, H. (2014). Qualitative content analysis: A Focus on trustworthiness. SAGE Open, 4, 1– 10. doi:10.1177/2158244014522633 Geddes, R. R., & Wagner, B. L. (2013). Why do U.S. states adopt public–private partnership enabling legislation? Journal of Urban Economics, 78, 30–41. doi:10.1016/j.jue.2013.05.003 European Investment Bank. (2004). The EIB’s role in Public-Private Partnerships (PPPs). European Investment Bank, (July), 1–21. Retrieved from http://www.eib.org/attachments/thematic/eib_ppp_en.pdf 80 Government of Zimbabwe (2013). Zimbabwe Agenda for Sustainable SocioEconomic Transformation (ZimAsset)—Towards an Empowered Society and a Growing Economy—October 2013- December 2018 Government of Zimbabwe, MOHCC (2016). National Health Strategy for Zimbabwe, 2016-2020— Equity and Quality in Health: Leaving No One Behind Hoppe, E. I., & Schmitz, P. W. (2013). Public‐private partnerships versus traditional procurement: Innovation incentives and information gathering. The RAND Journal of Economics, 44, 56–74. doi:10.1111/1756-2171.12010 Houghton, C., Casey, D., Shaw D., & Murphy, K. (2013). Rigor in qualitative casestudy research. Nurse Researcher, 20(4), 12-17. doi:10.7748/nr2013.03.20.4.12.e326 Hvidman, U., & Andersen, S. C. (2014). Impact of performance management in public and private organizations. Journal of Public Administration Research and Theory, 24, 35–58. doi:10.1093/jopart/mut019 International Finance Corporation. (2016). PPPs in healthcare. Retrieved from http://wwxv.ifc.org/wps/wcm/connect/ASEXTContent/What+We+Do/IFC+an d+PPPs /PPPs+by+Sector/Health/ Iossa, E., & Martimort, D. (2014). Corruption in public-private partnerships, incentives and contract incompleteness, 14-16. Kamugumya, D., & Olivier, J. (2016). Health system’s barriers hindering implementation of PPP at the district level : A case study of partnership for improved reproductive and child health services provision in Tanzania. BMC Health Services Research, 1–13. doi.10.1186/s12913-016-1831-6 Ketokivi, M., & Choi, T. (2014). Renaissance of case research as a scientific method. 81 Journal of Operations Management, 32, 232–240. doi:10.1016/j.jom.2014.03.004 Kirkwood, A., & Price, L. (2013). Examining some assumptions and limitations of research on the effects of emerging technologies for teaching and learning in higher education. British Journal of Education Technology, 44, 536-543. doi:10.1111/bjet.12049 Koliba, C., DeMenno, M., Brune, N., & Zia, A. (2014). The salience and complexity of building, regulating, and governing the smart grid: Lessons from a statewide public–private partnership. Energy Policy, 74, 243–252. doi:10.1016/j.enpol.2014.09.013 Kong, H., & States, U. (2013). On the development of public–private partnerships in transitional economies: An explanatory framework, 73, 301–310. doi.10.111/j.1540-6210.2012.02672.x.On Kruse, T. A., & Todd, S. K. (2013). Price manipulation at the NYSE and the 1899 battle for Brooklyn Rapid Transit shares. Financial History Review, 20, 279– 303. doi.10.1017/S0968565013000218 Lang, A. M. (2016). Healthcare Infrastructure Public-Private Partnerships in Developing Countries: The Queen ’Mamohato Hospital in Lesotho. MIT Sloan School of Management. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. Newbury Park, CA: Sage. Marshall, C., & Rossman, G. (2016). Designing qualitative research (6th ed.). Thousand Oaks: Sage. Montagu, D., & Harding, A. (2012). A zebra or a painted horse? Are hospital PPPs infrastructure partnerships with stripes or a separate species? World Hospitals 82 and Health Services : The Official Journal of/the International Hospital Federation, 48(2), 15-9. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22913125 Monterrey, M., De La Fuente, D., Lozano, J., Fernández, I., & García, N. (2013). Modeling a system of public–private management of business areas. International Journal of Trade, Economics & Finance, 4, 314–318. doi:10.7763/IJTEF.2013.V4.308 Mukwada, P., & Gashirai, S. (2017). Challenges in financing imaging services in Zimbabwe: Is public private partnership the panacea ? Presented by Ellen F . Maguranyanga. Financing medical imaging services, (February). Murthy, D. (2013). Ethnographic research 2.0. Journal of Organizational Ethnography, 2(1), 23-36. doi:10.1108/JOE-01-2012-0008 Mutandwa, H. (2015). An analysis of the potential use of public-private partnerships in water infrastructural development in Zimbabwe : The case of Harare City Council, 5(1), 110–136. PPIAF. (2011). How to Engage with the Private Sector in Public-Private Partnerships in Emerging Markets. PPIAF. (2012). PPP Basics and Principles of a PPP Framework, (May), 1-8. National Treasury of South Africa. (2007). Introducing Public Private Partnerships in South Africa. Retrieved from http://www.ppp.gov.za/Documents/ Ng, S. T., Wong, Y. M., & Wong, J. M. (2012). Factors influencing the success of PPP at feasibility stage: A tripartite comparison study in Hong Kong. Habitat International, 36, 423–432. doi:10.1016/j.habitatint.2012.02.002 Nhema, A. G. (2015). Public-private partnerships : Critical review and lessons for 83 Zimbabwe. Public Policy and Administration Research, 5(6), 39–44. Retrieved from www.iiste.org Nissen, H. A., Evald, M. R., & Clarke, A. H. (2014). Knowledge sharing in heterogeneous teams through collaboration and cooperation: Exemplified through public-private-innovation partnerships. Industrial Marketing Management, 43, 473–482. doi:10.1016/j.indmarman.2013.12.015 O’Reilly, M., & Parker, N. (2013). “Unsatisfactory saturation”: A critical exploration of the notion of saturated sample sizes in qualitative research. Qualitative Research, 13, 190–197. doi:10.1177/1468794112446106 Patrinos, H. A., & Barrera-osorio, F. (2009). The role and impact of public-private partnerships in education. Washington, DC: The World Bank. Peredaryenko, M. S., & Krauss, S. E. (2013). Calibrating the human instrument: Understanding the interviewing experience of novice qualitative researchers. The Qualitative Report, 18(43), 1-17. Retrieved from http://www.nova.edu/ssss/QR/QR18/peredaryenko85 Reynaers, A. M., & De Graaf, G. (2014). Public values in public-private partnerships. International Journal of Public Administration, 37, 120–128. doi:10.1080/01900692.2013.836665 Roehrich, J. K., Lewis, M. A., & George, G. (2014). Are public private partnerships a healthy option? A systematic literature review. Social Science & Medicine, 113, 110–119. doi.10.1016/j.socscimed.2014.03.037 Rossi, M., & Civitillo, R. (2014). Public Private Partnerships : A general overview in Italy. Procedia - Social and Behavioral Sciences, 109, 140–149. doi.10.1016/j.sbspro.2013.12.434 84 Roy, K., Zvonkovic, A., Goldberg, A., Sharp, E., & LaRossa, R. (2015). Sampling richness and qualitative integrity: Challenges for research with families. Journal of Marriage and Family, 77, 243–260. doi:10.1111/jomf.12147 Rubin, H. J., & Rubin, I. S. (2012). Qualitative interviewing: The art of hearing data (3rd ed.). Thousand Oaks, CA: Sage. Sai, J. P., Muzondo, N., & Marunda, E. (2015). Challenges affecting establishment and sustainability of tourism public private partnerships in Zimbabwe. Asian Social Science, 11(23). doi.10.5539/ass.v11n23p35 Siemiatycki, M., & Farooqi, N. (2012). Value for money and risk in public–private partnerships: Evaluating the evidence. Journal of the American Planning Association, 78, 286–299. doi:10.1080/01944363.2012.715525 Silverman, D. (2015). Interpreting qualitative data. Thousand Oaks, CA: Sage. Sithole, K., Gore, S. N., & Gondo, K. (2017). Critical success factors for publicprivate partnerships in higher education : A review of literature. International Journal of Social Science and Humanities Research, 5(1), 71–75. Retrieved from www.researchpublish.com Standard & Poor's. (2005). Public-Private Partnership Credit Survey 2005. Stanton, G. R. (2002). Athenian politics C800-500 BC: A sourcebook. New York, NY: Routledge. The Canadian Council for Public-Private Partnerships. (2016). Models of PublicPrivate Partnerships. Retrieved from http://www.pppcouncil.ca/resources/about-ppp/models.html The National Council for Public-Private Partnerships. (2014). Types of public-private partnerships. Retrieved from http://www.ncppp.org 85 The World Bank Group. (2012). World Bank Group support to public-private partnerships: Lessons from Experience in Client Countries, FY02-12. Retrieved from https://openknowledge.worldbank.org/handle/10986/21309 The World Bank Group. (2014). Public-private partnerships reference guide Version 2.0. Tsang, E. W. K. (2013). Case study methodology: Causal explanation, contextualization, and theorizing. Journal of International Management, 19, 195–202. doi:10.1016/j.intman.2012.08.004 Tufford, L., & Newman, P. (2012). Bracketing in qualitative research. Qualitative Social Work, 11, 80–96. doi:10.1177/1473325010368316 United Nations ESCAP. (2011). A Guidebook on Public-Private partnership in infrastructure, 83. doi.10.1017/CBO9780511974403 USAID. (2011). Designing Public-Private Partnerships in Health. Vian, T., Mcintosh, N., Grabowski, A., Limakatso, E., Jack, B. W., Vian, T., … Jack, B. W. (2015). Hospital public–private partnerships in low resource settings: Perceptions of how the Lesotho PPP transformed management systems and performance. Health Systems & Reform, 1(2), 155–166. doi.10.1080/23288604.2015.1029060 Wright, R. E. (2014). Specially incorporated transportation companies in the United States to 1860: A comprehensive tabulation and its implications. Journal of Business and Economics, 5, 972–989. doi:10.15341/jbe(21557950)/07.05.2014/005 Yin, R. K. (2011). Qualitative research from start to finish. New York, NY: Guilford Press. 86 Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Thousand Oaks, CA: Sage. York, J. G., Sarasvathy, S. D., & Wicks, A. C. (2013). An entrepreneurial perspective on value creation in public-private ventures. Academy of Management Review, 38, 307–309. doi:10.5465/amr.2012.0097 87 Appendix A: Consent and Confidentiality Form You are invited to take part in a research study to determine the feasibility of healthcare PPP in Zimbabwe.You are being invited because you meet the criterion of being a leader or end-user in a health institution in Zimbabwe, which has attempted to implement or successfully implemented PPP. This form is part of a process, called “informed consent,” to allow you to understand this study before deciding to take part. Nixjoen Mandaza Mapesa, a master’s student at Mount Carmel Institute of Business Intelligence, is conducting the study. Background Information: The topic of the study is The Feasibility of Healthcare PPP in Zimbabwe. The purpose of the study is to collect data that will aid the researcher in obtaining information on the research question, "What is the feasibility of healthcare PPP in Zimbabwe?" Procedures: If you agree to be in this study, you will be asked to: • Answer questions in regards to the feasibility of healthcare PPP in Zimbabwe. • This is a one-time audio recorded interview that will take approximately 30-60 minutes. Voluntary Nature of the Study: This study is voluntary. Everyone will respect your decision as to whether or not you choose to be in the study. No one will treat you differently if you decide not to be in the study. If you decide to join the study now, you may still change your mind later and end your participation at any time. Risks and Benefits of Being in the Study: The time commitment related to this study is that you complete the 30 to 60-minute interview during or after normal work hours with Nixjoen Mandaza Mapesa. You will be given a copy of the results of this study for your personal information. There are no other risks related to this study. More importantly, your participation will contribute to the knowledge base relevant to the feasibility of healthcare PPP in Zimbabwe. Payment: There will be no compensation provided for your participation in this study. Privacy: Some individuals in the company may know that you participated in the study. However, any information that you provide (e.g., responses to interview questions) will be kept confidential. The researcher will not use your personal information for any purposes outside this research project. Also, the researcher will not include your name or anything else that could identify you in the study’s reports. The electronic information will be stored on a password-protected external hard drive, and documents related to this study will be kept in a locked file storage cabinet that only the researcher will have access. Data will be kept for a period of at least five years. 88 Contacts and Questions: You may ask any questions you have now. Or if you have questions later, you may contact the researcher via phone number +263785000994 and/or email at [email protected] If you want to talk privately about your rights as a participant, you can call Prof Gunduza, the University rector who can discuss this issue with you.. The researcher will give you a copy of this form to keep. Statement of Consent: I have read the above information, and I feel I understand the study well enough to make a decision about my involvement. By signing below, I understand that I agree to the terms described above. _____________________________________________________________________ Printed Name of Participant______________________________________________ Date of consent________________________________________________________ Participant’s Signature__________________________________________________ Researcher’s Signature__________________________________________________ 89 Appendix B: Interview Questions Interview participants will answer the following questions: 1. Can public private partnerships be helpful in the provision of healthcare services in Zimbabwe? 2. What are the legal, institutional, structural and political frameworks that govern PPPs in the provision of healthcare services in Zimbabwe? 3. What are the barriers to PPPs in healthcare? 4. What are the PPP models available for use in the healthcare sector? 5. What are the critical issues to consider for successful PPPs in healthcare? 90 Appendix C: Email Invitation Dear __________________________: My name is Nixjoen Mandaza Mapesa and I am a Masters in Business Intelligence (MBI) student at Mount Carmel Institute of Business Intelligence. I am conducting research to complete my MBI dissertation. You are invited to take part in a research study to determine the feasibility of healthcare PPP in Zimbabwe. You were chosen for the study because you have some experience in PPP adoption and are a resident of Harare. If you meet the above criteria and agree to be in this study, please contact me via email ([email protected]) or by phone at +263785000994. You can decide if you would rather be interviewed in person or by phone. I will schedule an appointment convenient with you, respecting your busy schedule. I will review and ask you to sign a consent form (attached to this email). The interview should last no more than 30 to 60 minutes. I have included the interview questions below for your review. Thank you so much for this opportunity for me to interview you for my study.