ABSTRACT
Health sector projects within Kiambu County are faced with financial, Technical and human resource challenges resulting from increased cost of goods, staffing, and budget. However, in spite of the government financial and human resources support through the Public Private Partnership strategy, it is not certain if the community has gained substantial improvement in their livelihood with regard to service delivery. The purpose of the study was to investigate the influence of Public Private Partnership on Health Care Service Delivery: A Case of Githurai 45 Community Life Center Project in Kiambu County. The study’s objectives were to determine the influence of PPP’s financial, technical, human and managerial support on service delivery in the health sector. The study was grounded on two theories namely: Stakeholders Theory and the Transaction Cost Theory. The study adopted descriptive survey research design and relied mostly on primary data sources. The study’s target population was the staff working at Githurai 45 CLC project, which included residence doctors, technical staff, community health care nurses, community health workers, Ministry of Health officials and project beneficiaries, totaling to 300 respondents. The sample size for the research study that was a representative of the target population was 169 respondents, derived using Krejcie and Morgan table. This study adopted purposive sampling and stratified random sampling due to the heterogeneous nature of the target population. A questionnaire and an interview guide were used as the study’s research instruments. The quantitative data was coded by the SPSS tool and the descriptive statistics was analyzed by the use of arithmetic means, standard deviation, frequencies and percentages. Inferential statistics using Pearson Moment Correlation was computed to measure the influence of the independent variables on the dependent variable. Data was presented in tables. Qualitative data obtained from the interviews was analyzed according to themes, and constructs aligned to the research objectives. Content analysis identifying similarities and differences that emerged during the interviews were identified. Secondary data obtained from published books, scientific dissertations, peer-reviewed journals and other related scholarly publications were augmented with the primary data. From the study findings, the healthcare service delivery attained a composite mean of 3.141 and standard deviation of 2.850. On the theme of PPP managerial support, the composite mean and standard deviation was found to be 3.516 and 3.195 respectively. On the theme of PPP human support, the composite mean and standard deviation was found to be 2.847 and 2.547 respectively. On the theme of PPP procurement support, the composite mean and standard deviation was found to be
3.280 and 2.939 respectively. On the theme of project PPP financial support, the composite mean and standard deviation was found to be 3.426 and 3.113 respectively. The values of Pearson Correlation Coefficient were found to be ranging from 0.730 to 0.876, indicating that there was a positive correlation between the independent variables and the dependent variable. The study concluded that PPP managerial support, human support, procurement support and financial support influence healthcare service delivery. The study recommended that the financiers should ensure that funds are available and adequate for operations. It also recommended that health project technical staff should have a corresponding technical qualification. The study findings recommended that the government and private partners should work on a modality to ensure that the procurement process is not long and complex. Finally, the study findings recommended that the management should ensure the smooth operations of the projects. Areas for further research were identified
CHAPTER ONE INTRODUCTION
- Background of the Study
The Public Private Partnership (PPP) is a cooperation between the government and the non-government sector to provide service delivery or construction of infrastructure projects, whereby the private companies provide public services and then transfer ownership to the government (Colla, Hellowell, Vecchi & Gatti, 2015). In order to renovate, build or operate a building or a system, the government contacts the private sector. The government maintains control of the project, and additional decision rights on how the project will be completed are granted to the private sector (PPP Act, 2013). The limited resources, however, cannot be stretched by governments, hence the need for PPP to bridge the gap. Microeconomic dislocation in the 1970s and 1980s, much of the government was dealing with high debt and thus needed to adjust the public procurement mode (Atkinson, 2014). Financing a project through a public-private partnership will make it possible to complete a project faster or to make it an incentive in the first place. Private investment in public facility procurement has been promoted by the majority of the government (Jim, 2019). The first proposal to promote a public-private relationship was the Private Finance Proposal (PFI) in the United Kingdom (UK). Actually, 24% of public spending is paid for by the UK’s PPPs (World Bank, 2019). This is achieved in the expectation that the disparity between need and availability of medical services facilities will decrease in the growing mismatch.
The Private Finance Initiative (PFI) model has been adopted by several Organization for Economic Cooperation and Development (OECD), developed and average-earning countries, in which the non- governental sector bears the responsibility for catering for the infrastructure, which is inclusive of fully- equipped hospitals, whereas the public sector can provide the other core health services (Jim, 2019). In Australia, the PPP model has been preferred by the powers-that-be, with the non-governmental sector shouldering responsibility for full-service delivery. An example is New Midland Health campus undertaking with 310 municipal beds (plus 60 private beds), (Perrow, 2016). This form of collaboration is important because not only the scarcity of up-to-date implements, but also the shortage of specialists is the subject of the issue (Williamson, 2011). All of these variables balance each other to ensure that the health system operates smoothly. The growing number of foreign private health organizations with close links to the private sector in the United States makes it very clear that the counts of such collaborations will increase dramatically in the days to come (Thadani & Khushbu, 2014). Since 1997, the City of Valencia has fundamentally changed the way public health care system is given in Spain. The Public-
Private Integrated Partnership (PPIP) paradigm has made it possible for almost 20 percent of the populace to attain a substantial return on it’s own health ventures, while raising accessibility to high-standard medical services, extending and improving health facilities, and fostering innovative practices to enhance healthcare management (Sosa, Brashers, Foong, Montagu and Feachem, 2016). By experimentation with various models to satisfy its increasing healthcare needs, Peru has shown creativity in its approach to health PPPs. Three healthcare PPP ventures have been awarded to Peru to date, all at the state level (Lileu, 2016). The design and clinical operations of new hospitals, each one with corresponding primary and immediate care facilities, were involved in two programs. Both projects implement the DBOD PPIP scheme and have been based in the metropolitan region of greater Lima. In the Sabogal and Rebagliati networks, each hospital extended insurance to 250,000 benefactors, respectively. A similar DBOD scheme was followed by the third initiative, but it included the renovation of an old abandoned high-rise building into an outpatient care facility. The fresh centre was set up with the aim of providing coverage for around 4 million benefactors, according to Torchia and Calabr’o (2018).
Chile tendered its first healthcare PPP projects in 2009, and tendered three additional replacement hospitals in 2014 (Bataringaya & Lochoro, 2012). In an attempt to accomplish global health care coverage, Colombia was among the pioneer nations in Latin America to adopt health care bill. The government enacted a law 100 in 1993, that changed the way the health care system was financed, required individual participation in a medical insurance plan and consolidated diverse social welfare, public and private healthcare programs all under social security system for general health (Sinisammal, 2016). In 2005, Mexico implemented its first ever healthcare PPP pilot program and tendered a total of 10 projects over a 10-year period. At the federal level, four of the projects were financed, and then at the national level, six. All programs in Mexico come under the conventional DBOT system and include medical equipment and distribution of services (Estache & Philippe, 2012). According to healthcare PPP project study by Becton and Dickinson (2017), the US spent US$ 18 million between 2007 and 2012 to improve national laboratory technologies in eight African countries seriously affected by HIV / AIDS and TB. As a direct consequence, advances in multidrug-resistant TB detection, patient care, and clinical outcomes have indeed been made by improving professional skills, creating protocols, and preparing referral networks (De & Mangano, 2013). For instance, in Uganda, Nsawe, (2018) noted that the healthcare PPP projects initiated by the US government took to training 120 laboratory laborer’s on antiretroviral remedy and upscaled valuable services of management in laboratories that attend to close to 100,000 people. According to Williamson (2011), it has been noted that in the African states such as Mozambique, Rwanda and Burundi, and in Asian states such as Indonesia and Mongolia, the Dutch Government is active in PPPs, investing over EUR 483 billion on thousands of PPP ventures. PPP healthcare projects have shown
a quantifiable, growth oriented, evidence-based model to proliferate the individual abilities of the public and private sectors (Leigland, 2018). The Queen Elizabeth II hospital was upgraded in Lesotho in collaboration with Tšepong, a bring up by Netcare, a South Africa-based group, to design, build, piece- finance and run a 425-bed tertiary hospital and a gateway center adjoining the hospital (Legtong, 2015). Three filter clinics, which would handle patient referrals to that same hospital, were also revamped and re-equipped by the initiative.
Projects involving coalitions between organizations such as the Global Alliance for Vaccination and Immunization, collaborations with independent companies such as the Dutch energy company Nuon in the Mali Rural Energy Services Foundation and Product Creation Collaborations (Williamson, 2011) have been undertaken. Usually, project collaborations are involving a multinational corporation and a contributor, usually research organizations (Gates Foundation, 2019). A common illustration of the above is a scheme of drug donation in which medications are offered no-cost or at a discounted rate to certain foreign organizations for the highly effective use of subsidized rates for HIV / AIDS medications for a particular reason (Metcalfe, 2013). Organizations like to build effective methods of providing preventive measures such as vaccines or wellness therapies in addition to this. According to Mohammed (2017), the healthcare partnership initiated in 2001 between the Abbott Fund and the Government of Tanzania aided retool amenities, train personnel, upgrade hospitals, manage patients, and extend HIV / AIDS screening and medication capability in more than 90 hospitals and remote medical centers across the region. It was further noted that, in addition to providing the professional expertise of Abbott volunteers to resolve a number of critical health areas, the Abbott Fund has heavily invested over US$ 50 million in the program. The PPP has enhanced healthcare services and facilitated health outcomes that have improved.
The 2030 Plan for Sustainable Development, which comprises 17 Sustainable Development Goals (SDGs), was adopted, in September 2015, by the United Nations General Assembly. They are likely to risk moving focus and money away from the goals of national growth. SDG 3 is focused on maintaining safe lives and encouraging well-being for all of all ages. The government needs to upgrade the existing facilities and equip them with the latest technologies and equipment in order to effectively enforce the SDG, and get trained workers to improve the procurement process. Kenya ranks among the top 10 in Sub- Saharan Africa (SSA) in the implementation of PPP programs, with around 64 PPPs currently in the pipeline, health and energy sectors (World Bank, 2019). However, since 1996, private investment has taken place in the public sector, with the health sector benefitting from the schemes. In its feasible development roadmap, Vision 2030, that strives to turn Kenya into a average-earning region, the Government of Kenya (GoK) strongly supports PPPs (GoK, 2018). The government recently passed the 2013 Public Private Partnerships Act. The Act developed regulatory and project creation agencies under
the PPP Act (2013), and outlined the project cycle and procurement methods. The tender process, contract award, and execution phases were also controlled in the law. The United Nations (UN) is convinced that Kenya is a leading representative for timeless development, according to the World Bank (2018), and emphasizes the significance of PPPs in its growth route, and multifaceted organizations are increasingly partnering with GoK and the non-governmental sector to introduce PPPs in the region.
The Githurai 45 Community Life Centre (CLC) project is based in Kiambu’s County Githurai 45 area. As an integrated project approach for primary health care and service facilities, launched in June 2014, and offering community development in terms of health care, lighting and safe living perspective. Developed in alliance with the County Government of Kiambu, Kenya and Philips Africa Innovation Center, the project covers an area of about 1,000 m2, has the latest solar powered LED lightning technology, relying on 100% of its solar energy and does not rely on the national electricity grid, Ministry of Health, Kiambu County Report (2019). The report further indicated that the Githurai 45 CLC project is evidence of the notion that grants accessibility to health care, makes after dusk communal, academic and business activities and improves the asylum and security of the community. A crucial point of interest of the CLC project is to deal with infant mortality and improve maternal health care, adjourned to the current UN Millennium Development Goals 4 and 5. With the latest diagnostic medical equipment that enhances diagnosis, the facility has been built and the medical staff have been qualified. In that culture, the facility caters for a population of over 46,000 people. Since the opening of the center, there has been a remarkable rise in the use of services in the facility. The average number of clients seen in the prenatal clinic each month increased by 14 times after the launch of the CLC compared to the period between January 2013 and May 2014, according to the Ministry of Health, Kiambu County Report (2019). The Philips Africa Innovation Hub Report (2020) reported that the general outpatient department for curative services has the highest number of patients registered. In 2018, an average of 3,886 patients were seen monthly, with a minimum of 3,138 in April and a maximum of 4,517 in July. The report added that within the first 18 months of the launch, the monthly number of women attending prenatal care visits increased from six to
94. The overall number of patients accessing the CLC rose from 900 to 4,080 per month during the same period. An average of 158 ultrasound examinations have been performed every month since the launch, with a minimum of 149 in December 2016 and a maximum of 283 in April 2018 (Ministry of Health, Kiambu County Report, 2019). This has further demonstrated that with less than $10 per person per year, at the primary level, quality healthcare service delivery can be achieved.
