مشارکت های عمومی - خصوصی بهداشت و درمان اسپانیایی: مدل آلزیرا

Global infrastructure reports suggest that, in the wake of the fiscal crisis, healthcare PPPs are seen as a growing area as governments switch attention to social welfare projects. Spain is unique in having had a PPP hospital in operation for over a decade which is funded through a capitation fee. This paper takes a critical approach to evaluate this project, with our analysis showing that the original project could never have been viable and that the renegotiation of the contract has been costly to the government. Viewing the contract through a financialised lens we can see how this contract has been used to ‘make up’ a market for the private delivery of public healthcare in Spain. We also call into question the role of the Spanish savings banks in financing this type of project, which has now been replicated with further hospitals in Spain and Portugal, as well as in developing countries such as Lesotho.

Internationally, healthcare costs are increasing, due to, amongst other things, advances in medical and technological treatments, an ageing population, changing public expectations and evolving patterns of diseases, whilst at the same time government budgets are in decline. Consequently, as part of the global movement towards involving the private sector in the financing, construction and delivery of public services, the use of public private partnerships (PPPs) in the healthcare sector has contributed to the global PPP market being worth $55.5 billion by 2009 (Project Finance, February 2010). This increase in the marketisation of health has created an opportunity for medical insurance, private healthcare and construction and facilities management companies to expand their remit into the delivery of healthcare services to the public through PPP mechanisms funded by government payments, especially in the UK, Italy, Spain and Portugal, where the national health services are funded through general taxation (Barros and Martinez-Giralt, 2009). Indeed, although the market is dominated by transport projects, social infrastructure, including healthcare projects, is seen as an attractive pipeline for infrastructure investors (DLA Piper, 2009; Project Finance, March 2010). In the case of Spain, this fits with its macro-level rationale that PPP projects provide additional investment which otherwise the state could not afford or would have to delay for many years (Vázquez, 2006 and Vilardel, 2005).1 As the PPP policy matures, the models have become more complex. In relation to healthcare, most accounting literature has focused on hospital PPPs, notably the UK Private Finance Initiative (PFI) model whereby the private sector finances and constructs a hospital building and then delivers the service and maintenance functions over a period of around thirty years. This model is also in use in Spain, Italy, Mexico, South Africa, France, and Australia. However there are also many other models using private finance (IFC, 2009 and McKee et al., 2006), for example, franchising, BOO (build, own, operate) and BOOT (build, own, operate, transfer), the contracting out of clinical services, such as the UK's Independent Sector Treatment Centres (ISTCs) and similar schemes in Romania and Peru, as well as management contracts in Brazil. This paper considers the case of a PPP model which goes still further – not only does the private sector finance, construct and operate the hospital building, but it also delivers the clinical services as well. The unique feature to this contract is that the public sector role is reduced to being that of a commissioner of healthcare, as it funds healthcare services by paying the provider a capitation charge derived from the public health budget. The first hospital to use this model was the La Ribera hospital in the town of Alzira, in the autonomous region of Valencia, Spain, and this approach has become known as the ‘Alzira model’. The objective of this paper is to carry out a detailed case study of the development of the ‘Alzira model’. We analyse the financial statements and compare the empirical evidence to the available narratives about the model, to determine the information gap between the rhetoric, which declares this project to be a success story, and the financial reality. The information gap that we find is very significant because since its inception in 1999, further hospitals following the ‘Alzira model’ have opened in the autonomous Spanish regions of Valencia and Madrid as well as a related variant in Portugal, where the model is split into two separate contracts, one covering clinical activities and soft facilities, and another covering infrastructure operations (Barros and Martinez-Giralt, 2009). Some proponents, such as the Global Health Group based at the University of California, claim that such a model is well suited to the funding of healthcare in developing countries as it overcomes the problems of both financing the replacement of obsolete infrastructure and the delivery of clinical services. Lesotho in southern Africa and the Turks and Caicos Islands of the Caribbean have now pursued this model for the provision of publicly available hospitals and health centres. The paper is organised as follows. The next section reviews the literature evaluating healthcare PPPs and problematic issues arising from them. Section 3 introduces our theoretical framework. Section 4 describes the background to Spanish healthcare and Section 5 sets out our research method. Section 6 describes the project structure and provides the empirical analysis of the Alzira case. Section 7 draws out the implications of our study of the ‘Alzira model’, offers our conclusions regarding the future use of the ‘Alzira method’ and briefly considers the implications for international settings.

Internationally, healthcare costs are increasing, due to, amongst other things, advances in medical and technological treatments, an ageing population, changing public expectations and evolving patterns of diseases, whilst at the same time government budgets are in decline. Consequently, as part of the global movement towards involving the private sector in the financing, construction and delivery of public services, the use of public private partnerships (PPPs) in the healthcare sector has contributed to the global PPP market being worth $55.5 billion by 2009 (Project Finance, February 2010). This increase in the marketisation of health has created an opportunity for medical insurance, private healthcare and construction and facilities management companies to expand their remit into the delivery of healthcare services to the public through PPP mechanisms funded by government payments, especially in the UK, Italy, Spain and Portugal, where the national health services are funded through general taxation (Barros and Martinez-Giralt, 2009). Indeed, although the market is dominated by transport projects, social infrastructure, including healthcare projects, is seen as an attractive pipeline for infrastructure investors (DLA Piper, 2009; Project Finance, March 2010). In the case of Spain, this fits with its macro-level rationale that PPP projects provide additional investment which otherwise the state could not afford or would have to delay for many years (Vázquez, 2006 and Vilardel, 2005).1 As the PPP policy matures, the models have become more complex. In relation to healthcare, most accounting literature has focused on hospital PPPs, notably the UK Private Finance Initiative (PFI) model whereby the private sector finances and constructs a hospital building and then delivers the service and maintenance functions over a period of around thirty years. This model is also in use in Spain, Italy, Mexico, South Africa, France, and Australia. However there are also many other models using private finance (IFC, 2009 and McKee et al., 2006), for example, franchising, BOO (build, own, operate) and BOOT (build, own, operate, transfer), the contracting out of clinical services, such as the UK's Independent Sector Treatment Centres (ISTCs) and similar schemes in Romania and Peru, as well as management contracts in Brazil. This paper considers the case of a PPP model which goes still further – not only does the private sector finance, construct and operate the hospital building, but it also delivers the clinical services as well. The unique feature to this contract is that the public sector role is reduced to being that of a commissioner of healthcare, as it funds healthcare services by paying the provider a capitation charge derived from the public health budget. The first hospital to use this model was the La Ribera hospital in the town of Alzira, in the autonomous region of Valencia, Spain, and this approach has become known as the ‘Alzira model’. The objective of this paper is to carry out a detailed case study of the development of the ‘Alzira model’. We analyse the financial statements and compare the empirical evidence to the available narratives about the model, to determine the information gap between the rhetoric, which declares this project to be a success story, and the financial reality. The information gap that we find is very significant because since its inception in 1999, further hospitals following the ‘Alzira model’ have opened in the autonomous Spanish regions of Valencia and Madrid as well as a related variant in Portugal, where the model is split into two separate contracts, one covering clinical activities and soft facilities, and another covering infrastructure operations (Barros and Martinez-Giralt, 2009). Some proponents, such as the Global Health Group based at the University of California, claim that such a model is well suited to the funding of healthcare in developing countries as it overcomes the problems of both financing the replacement of obsolete infrastructure and the delivery of clinical services. Lesotho in southern Africa and the Turks and Caicos Islands of the Caribbean have now pursued this model for the provision of publicly available hospitals and health centres. The paper is organised as follows. The next section reviews the literature evaluating healthcare PPPs and problematic issues arising from them. Section 3 introduces our theoretical framework. Section 4 describes the background to Spanish healthcare and Section 5 sets out our research method. Section 6 describes the project structure and provides the empirical analysis of the Alzira case. Section 7 draws out the implications of our study of the ‘Alzira model’, offers our conclusions regarding the future use of the ‘Alzira method’ and briefly considers the implications for international settings.