Introduction
Ensuring access to high quality healthcare for people of all ages, in the setting of rising medical costs, is a complex challenge globally. Since the 1990s, governments in high- and, more recently, lower-resource settings have looked to healthcare public-private partnerships (PPPs) as a way to respond to this challenge [, ]. PPPs are long-term, formalized contracts between the public and private sectors to provide services in a way that leverages the different strengths of each partner. Financial and operational risk is transferred to the private partner, who is accountable for defined outcomes such as quality metrics. The public partner retains ownership of the facility and equipment at the end of the contract []. Integrated PPPs add the delivery of clinical services within the private partner’s scope and are designed to create long-lasting improvements to the health sector via the combined investment in health capital and service provision []. A recently published review of hospital PPPs globally, however, suggests mixed results on hospital performance indicators and highlights important challenges to implementation including resources, trust and communication, and the policy context [].
Sub-Saharan Africa’s first and largest integrated healthcare PPP was opened in 2010–11 as a partnership between the Ministry of Health of Lesotho and T’sepong, a consortium of Basotho and South African companies headed by Netcare, a large private hospital network based in South Africa []. A primary goal of this 18-year PPP agreement was to replace the 100-year-old national referral hospital, Queen Elizabeth II (QEII), through the design, construction, and operation of Queen ‘Mamohato Memorial Hospital (QMMH). Under the agreement the private partner also constructed a new Gateway ambulatory clinic on the hospital campus and renovated three filter clinics which provide outpatient primary care services and inpatient deliveries in the capital city of Maseru. QMMH and its four affiliated clinics are referred to collectively as the QMMH Integrated Network (QMMH-IN). This strategy of bundling both hospital and primary health care services within an integrated PPP is often referred to as the Alzira Model, named after the first hospital system in Spain, to pioneer this PPP strategy [, ]. Details regarding the QMMH-IN PPP, its history, and prior evaluations are described elsewhere [, , , , ].
The PPP contract stipulated specific quality standards under which the network was to operate, ranging from waste management to personnel training metrics. If any standard was not met, the government could deduct a specific percentage from the monthly payment made to T’sepong. Two structures for monitoring these standards were employed. First, the consulting firm Turner & Townsend—referred to as “the independent monitor,” was engaged to monitor these standards quarterly []. Second, QMMH leadership was required to achieve and maintain accreditation by The Council for Health Service Accreditation of Southern Africa (COHSASA), a regulatory body for health services in southern Africa, which conducts monitoring and re-accreditation processes. QMMH facilities were first accredited in 2013 and they maintained accreditation status through February 2022 [].
An evaluation comparing QEII performance data from 2006–7 to QMMH-IN performance data from 2012 found that the network increased quality of care, delivered more services, and produced better outcomes, including reduction in overall mortality by 41% in its first year []. Interviews conducted with the executive leadership team, department heads, and staff in 2013 identified perspectives on drivers of early hospital performance, including new clinical services, better infrastructure, human resource management changes, and innovation in management systems []. A follow-up evaluation based on clinical data collected in 2018 showed that despite challenges, QMMH-IN continued to provide high-level medical services, and generally maintained better patient outcomes and quality of care compared to the QEII baseline [].
Over the course its lifespan, the PPP-managed QMMH-IN has been controversial [, ]. Against the backdrop of increasing tension between the PPP partners with numerous disagreements under legal arbitration, the Government of Lesotho announced in early 2021 its termination of the PPP contract []. The hospital network leadership transitioned to government management mid-2021, approximately five years before the termination date in the original contract [].
This paper explores the facilitators and barriers related to hospital performance under the PPP from the perspective of QMMH-IN leadership and staff (all employed by the private partner T’sepong) in early 2020. It aims (1) to generate ideas for consideration by the Government of Lesotho now responsible for direct oversight of QMMH-IN post-PPP and (2) to inform operations of health sector PPPs in other low-resource contexts.
Methods
Study design
This qualitative analysis is part of a larger evaluation of the QMMH-IN PPP in Lesotho, which included a baseline study in 2006–7 [], an initial evaluation conducted in 2012–13 [, , , ], and a follow-up evaluation in early 2020 []. Data for this analysis were collected from QMMH-IN leadership and staff between January–February 2020.
Study setting
The Kingdom of Lesotho is a small, mountainous, lower-middle income country surrounded by South Africa, with a population of approximately 2.1 million. HIV remains the primary cause of death, followed closely by tuberculosis, and, as of 2017, life expectancy was 59 years for females and 50 years for males []. In 2020, an estimated 31% of the population lived under the international poverty line of $1.90 USD per day, with poverty highly concentrated in rural areas []. Just 29% of the population lives in urban parts of the country [].
QMMH-IN is in Lesotho’s capital city of Maseru, the country’s major urban center. The three filter clinics operated under the QMMH-IN are spread throughout Maseru district and opened in May 2010. The ambulatory Gateway clinic and QMMH, which included an intensive care unit (ICU) and a neonatal intensive care unit (NICU), opened on the same hospital campus in October 2011. After QMMH replaced the old QEII in 2011, there was no separate publicly funded district hospital for Maseru. QEII reopened as an outpatient-only facility in 2014. As of 2018, QMMH was the only higher-level hospital in the area. It had 434 operational beds, with the three filter clinics adding a combined 24 additional short-term obstetric beds. Across the network, a total of 582 clinicians, including 295 registered nurses and 85 physicians were employed. In 2018 QMMH saw 24,796 admissions, with an average length of stay of 6.5 days and a bed occupancy rate of 99% [].
Data collection
We conducted semi-structured key informant interviews with the executive team, department heads, and staff working at QMMH-IN facilities. We purposively selected respondents using a maximum variation strategy to include clinical and non-clinical roles from all levels of the organization (ranging from executive management to nursing assistants to support staff) []. We included those who worked at the main QMMH hospital, as well as the Gateway clinic and each filter clinic. We sought to include at least one from each clinic and hospital department. The study team provided a list of positions to hospital administrators who assisted in the identification of individuals and scheduling of interviews. Interviewers met with hospital leaders before commencing the study to discuss study aims, procedures, and address concerns.
Interviews were conducted in-person between January–February 2020, and each lasted approximately one hour. Questions and prompts were semi-structured and based broadly on the WHO Health System Building Blocks Framework, with primary themes encompassing: service delivery, including infrastructure, provider network, management, safety and quality; hospital workforce; information; medical products and technologies, including the core systems to manage medications, equipment, and commodities; financing; and leadership/governance within the hospital network and government []. Respondents were interviewed once and were asked to compare current hospital network performance to what they had previously known, to explain the drivers of that performance, to anticipate challenges that could emerge at the end of PPP contract, and to offer suggestions for improvement. We adapted questions as interviews evolved. We audio recorded all interviews and took hand-written field notes. We captured key demographic information using SurveyCTO® Collect Software (Dobility, Cambridge, Massachusetts, USA) on encrypted tablets.
Data management and analysis
Demographic data were summarized descriptively. Interviews were conducted in English and audio recordings were transcribed semi-verbatim into Microsoft® Word.
All transcripts were checked for accuracy by study team members against audio recording, but not returned to respondents for checking due to the evolving global emergency of COVID-19. Transcripts were imported into NVivo version 12.7.0 (QSR International, Burlington, Massachusetts, USA) for coding and analysis. We conducted a thematic analysis [] using a combined inductive and deductive approach to coding, starting with broad codes from the interview guide and allowing room for new codes to emerge. Two researchers (CMM, JLK) coded all transcripts with the initial codebook. Given the heterogeneity of respondent demographics, we coded all interviews instead of stopping when saturation was reached within particular thematic areas. CMM then constructed a coding tree which contained emergent categories of barriers and facilitators and re-coded the data. Three authors (NAS, JLK, CMM) discussed and arrived at the major and minor themes. Memoing was used throughout this process to aid in reflexivity []. Further inputs (ENN, BWJ, TV) on identified themes informed the discussion.
Qualitative findings were organized by themes and sub-themes that emerged as facilitators and barriers of QMMH-IN performance, those related to respondents’ perceptions of QMMH’s future transition post-PPP, and their recommendations. Illustrative quotations were lightly edited for clarity and are displayed in tables, referenced by corresponding letters.
Ethical issues
The Ministry of Health Research and Ethics Committee in Lesotho (Protocol 230-2019) and the Boston University Medical Campus Institutional Review Board (Protocol H-39448) approved the study. The interviewers (JLK, TN) were trained in research ethics, the overarching study, and the specific interview guides. After introducing themselves, interviewers shared an information sheet with each respondent about the study and described study objectives, potential risks, benefits, and guarantees of confidentiality, addressing respondent questions and concerns. Verbal informed consent was obtained for each interview and audio recording. Respondents skipped questions they were not comfortable answering. No individual refused to participate or withdrew. Interviews were conducted in a private office, with only the interviewer and respondent present. Data are presented in aggregate form and anonymized to ensure responses remain confidential.
Results
Demographic characteristics
The mean age among respondents was 43.3 years (standard deviation [SD] 8.4 years) and just over half were female. Twenty-one respondents (80.8%) worked at QMMH, while five worked at the network clinics. Sixteen (62.5%) held clinical roles. Fifteen (57.7%) were in higher management positions, and respondents had been employed in the PPP for an average of 7.7 years (SD 2.5 years) (Table 1).
CHARACTERISTIC VARIABLES | INTERVIEW RESPONDENTS (n = 26) |
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Female, n (%) | 15 (57.7%) |
Age (years), mean (SD) | 43.3 (8.4) |
Organization, n (%) | |
QMMH | 21 (80.8%) |
Network clinicsa | 5 (19.2%) |
In clinical role b, n (%) | 16 (62.5%) |
In higher management position c, n (%) | 15 (57.7%) |
Years in current position, mean (SD) | 4.1 (2.6) |
Years employed in PPP, mean (SD) | 7.7 (2.5) |
Facilitators of QMMH-IN performance
Three major themes emerged as facilitators of QMMH-IN performance: (1) a commitment to quality improvement supported by protocols, monitoring, and actions; (2) high levels of accountability and discipline; and (3) well-functioning infrastructure, core systems, workflows, and internal referral network (Table 2).
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Protocols, monitoring, and quality improvement
The first driver of QMMH-IN performance was a dedication to quality improvement (QI) facilitated by use of clinical protocols, internal and external monitoring, and steps taken to address quality gaps.
Clinical protocols: There was broad agreement that the availability and routine use of specific clinical care guidelines and protocols, sometimes referred to as standard operating procedures for care, were key drivers of quality clinical care. Following evidence-based practices was perceived to lead to improved patient outcomes and thus network performance (Table 2, quotes a–b).
Internal and external monitoring: Respondents emphasized that they perceived monitoring at QMMH-IN to be regular and consistent. A variety of internal monitoring structures were described as facilitating performance. For example, respondents’ spoke about routine clinical audits to identify opportunities for targeted training, updates to the clinical protocols, or quality improvement projects (Table 2, quotes c–d). Monitoring also included risk assessments and ratings of departments based on the frequency of adverse events, near misses, and sentinel events (Table 2, quote d). Respondents discussed regular evaluation visits by the external Independent Monitor who assessed everything from hand-hygiene to waste management, as well as the pressure to maintain COHSASA accreditation standards (Table 2, quotes e–f).
Taking action to improve quality: Respondents reported that the gaps identified through monitoring activities resulted in actions that, in turn, improved performance. They emphasized how quality improvement and risk mitigation are taken seriously (Table 2, quote g). Clinical and non-clinical respondents alike discussed how they regularly applied tools such as root cause analysis to act on identified gaps and make corrective changes to avoid future mistakes. A dedicated office of quality and risk led these actions and demonstrated the network’s commitment to QI implementation (Table 2, quote h).
Accountability and discipline
Respondents explained that the focus on QI at QMMH-IN translated to policies, tools, and other factors that promoted a high level of individual accountability and discipline.
Clear roles and policies: Respondents reported to have clarity regarding their roles, performance expectations, and the policies to follow. This, in turn, promoted individual accountability and behaviors such as arriving to work on time and completing all expected tasks (Table 2, quotes i-j).
Balanced scorecards: Employees’ performance was regularly monitored by using a tool called the balanced scorecard, which provided very specific metrics based on the job description of the employee (Table 2, quote k). Supervisors used balanced scorecards to develop individualized action plans to address deficiencies. Respondents noted that the metrics tracked on their own balanced scorecard related to broader QI goals, such as reducing mortality rates (Table 2, quote i).
Disciplinary action: Many respondents stressed that disciplinary action was taken when needed, and employees were let go if their performance was consistently poor. Clinicians were assessed on their skills and knowledge before being offered a contract renewal. Respondents said this was in contrast with the public facilities where it was difficult to terminate employees (Table 2, quotes m-n).
Accountability systems to foster professionalism: QMMH-IN used a variety of systems that promoted accountability, such as biometric clocking (Table 2, quote o). Another example was the use of employee numbers to record who had logged into a system that tracks movement of money from a cashier to the safe (Table 2, quote p). Respondents generally described these systems as powerful tools that increased discipline and professionalism. They perceived this as translating to increased punctuality, decreased theft, and overall improved performance (Table 2, quote q). A few respondents reported some employees were dissatisfied with the intense oversight and accountability systems (Table 2, quotes r, l).
Infrastructure, core systems, workflows, and internal referral network
The high quality and functionality of physical infrastructure, core hospital systems and workflows, and internal network collaboration were also perceived to facilitate QMMN-IN performance.
Facilities, equipment, and their maintenance: Nearly all respondents spoke highly of the QMMH-IN physical infrastructure, describing it as well-maintained, clean, and well-designed to ensure patient privacy (Table 2, quotes s–t). This was perceived to improve the well-being of not only patients, but also employees, who work better in a comfortable and safe environment.
Respondents generally felt necessary equipment was available and well-maintained. With a few exceptions, mostly related to delays in receiving parts from South Africa, respondents were pleased with the company contracted to provide, maintain, and repair the medical equipment, and felt it improved clinical performance and patient satisfaction (Table 2, quote u–v).
Core systems and workflows: When comparing to public facilities, respondents generally felt the core systems such as pharmacy and laboratory services facilitated performance, particularly emphasizing the availability of medications. Respondents felt that procuring supplies weekly and outsourcing when needed decreased pharmacy stock-outs (Table 2, quote w). Respondents felt this improved patient outcomes and shortened hospital stays.
Respondents had mixed opinions of the laboratory system, citing a recent change from sub-contracted lab services to the lab being managed in-house. Despite challenges with the new, in-house lab, most respondents still considered this core system a facilitator, highlighting the quick turnaround times and ability to track specimens digitally from collection through receipt of results (Table 2, quote x).
Other examples of specific workflows perceived to improve QMMN-IN performance included individualized delivery of medications to patients on the wards, stock monitoring, and computerized maintenance schedules for equipment.
Internal referrals and network collaboration: The system for referring patients from the filter clinics to the QMMH hospital also emerged as a perceived facilitator. Respondents felt that referral audits and regular communication through academic meetings between clinicians at the various network facilities improved the timeliness and quality of referrals. Collaboration across the network also allowed for other efficiencies that were perceived to improve patient care, such as the ability to share medications between sites (Table 2, quotes y–z).
Barriers to QMMH-IN performance
Two major themes emerged as barriers to QMMH-IN performance: (1) challenges within human resource management; and (2) broader health system and referral network limitations (Table 3).
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Human resource management
Recruitment and retention of adequate levels of staff and specialty clinicians were described as barriers to performance.
Recruitment and retention: Respondents felt that QMMH-IN performance was limited by its inability to recruit and retain experienced employees, primarily due to inadequate compensation. Respondents from across departments expressed dissatisfaction with their salaries, in relation to the work they are doing, and in comparison to salaries thought to be offered at governmental health facilities (Table 3, quote a), non-governmental organizations, and private mining companies. One respondent specifically described that while most did not mind working longer hours than their government counterparts, they wanted appropriate compensation (Table 3, quote b).
Respondents felt inadequate compensation led to poor morale and high employee turnover in all departments, explaining QMMH-IN struggled to recruit experienced nurses and physicians, and then to keep them after they were trained (Table 2, quote c). They perceived this to affect patient outcomes since newer clinicians often do not have the necessary experience to provide the level of care expected at a referral hospital.
Staffing and specialists: Some respondents noted that staffing ratios and number of specialists had improved within QMMH-IN compared to before the PPP and to other hospitals. However, others expressed that these figures were still insufficient and limited network performance, noting specifically a lack of ICU and Emergency Medicine specialists (Table 3, quotes d–e).
Training: While some described the training offered by QMMH-IN positively, most respondents described a lack of training opportunities that limited employee potential. Some respondents felt the lack of emphasis on training and professional development for clinicians made QMMH-IN fall short of its contractual mandate (Table 3, quote f). Another respondent discussed the limited focus on capacity building in the broader health system (Table 3, quote g).
Lesotho health system and referral network
Limitations in structure and function of the district health system and referral network posed important barriers to QMMH’s performance and ability to serve as the national referral hospital.
District health system capacity: A common perspective among respondents was that Lesotho’s district health system lacked capacity in terms of needed equipment, medications, and staff to appropriately mange patients. This resulted in a “flooding” of patients who should have been managed at the district level coming to QMMH instead (Table 3, quote i). Respondents described patients as preferring to seek care at QMMH-IN due to a lack of capacity at the district level (Table 3, quote j).
Inappropriate referrals: Respondents also described receiving referrals who are not medically complex and should not be at QMMH (Table 3, quotes i, k). Respondents suggest this pattern has contributed to a decline in skills and further reduction of capacity at the districts (Table 3, quote l). Other respondents perceived that some patients are referred too late and arrive with advanced disease, resulting in poor clinical outcomes (Table 3, quote m). The use of resources to manage inappropriately referred cases at QMMH was perceived to have diverted resources away from cases that required specialty care, and overall leading to QMMH not performing at the level of a national referral hospital (Table 3, quote n).
Perspectives and recommendations on transition of QMMH-IN Post-PPP
At the time of the interviews, the early end of the PPP contract had not yet been announced and a transition in QMMH-IN management was anticipated to happen in approximately six years. Respondents were asked what they anticipated to happen at the time of this transition and to provide recommendations for improvement now and at the time of transition. Table 4 outline the themes and illustrative quotes from their responses.
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Respondents expressed concern over the anticipated transition of QMMH-IN to government management and many predicted a decline in hospital performance (Table 4, quote a). Some felt frustrated that, at the time of the interviews, they did not feel the government was actively planning for the transition, nor learning from what worked well at QMMH-IN in order to prepare for it (Table 4, quote b). One respondent detailed an earlier unsuccessful attempt to pilot the implementation of COHSASA quality standards at government hospitals to illustrate their concern over the management transition of QMMH-IN (Table 4, quote c).
Recommendations for transition
Respondent-generated suggestions specific to the transition of QMMH-IN to the governmental management are summarized below.
The first recommendation was to keep, reinforce, and expand upon what works well now, including culture of quality improvement, a focus on evidence-based practice, and well-functioning medication supply, equipment maintenance, and communication systems within the network. To help achieve this, respondents suggested continuing to work with specific private contractors, especially in the early years of transition, to retain institutional knowledge and continue benefiting from well-established workflows (Table 4, quotes d–f). Respondents recommended the government invest in training managerial staff who will assume operations of the QMMN-IN to ensure they are adequately prepared for the transition (Table 4, quote g). Additionally, it was recommended to improve staffing levels and number of specialists by focusing on job satisfaction, recruitment, and retention. Specifically, respondents emphasized the need to offer employees training and career advancement opportunities and ensure salaries are competitive (Table 4, quotes h–k).
Furthermore, respondents suggested the government consider designating QMMH as a training facility, similar to how QEII previously functioned, to help maintain a standard of care for health providers working across the health system (Table 4, quote l). This could be part of an overall effort to invest in much needed strengthening the greater Lesotho health system. Lastly, respondents recommended improving the referral system between outside facilities and QMMH so that QMMH can function as a referral hospital as intended. The QMMH-IN internal referral network could then serve as a model for needed changes to the external referral network (Table 4, quotes m–n; Table 3 quote i).
Discussion
QMMH-IN, as sub-Saharan Africa’s first and largest integrated PPP, is an important global experiment of how to fund and deliver high-quality medical care in lower-resource settings. Through this research, we explored insights and lessons learned from the insider perspective of QMMH-IN employees just prior to the early termination of the PPP contract. Facilitators of QMMH-IN performance included a focus on quality improvement; accountability and discipline; and well-functioning infrastructure, core systems, and workflows. Many of these elements were also observed in the 2012–2013 evaluation of the network. Major barriers were related to human resource management and QMMH’s relationship to the greater health system, both of which had newly emerged since the 2012–2013 evaluation []. At the time of data collection, although PPP partners were actively attempting to renegotiate the QMMN-IN contract, there was no known plan for an early termination of the PPP and transition in management. When asked about the anticipated contract end in six years, respondents expressed concern about the government’s capacity to manage QMMH-IN and maintain the level of hospital performance observed under the PPP and provided key recommendations for consideration around the time of transition. Perspectives on the early PPP contact termination are explored elsewhere []. As of mid-2021, the Government of Lesotho had assumed management responsibility of QMMH-IN. These findings may be relevant when making strategic planning decisions going forward.
We identified a strongly embedded culture of QI and accountability at QMMH-IN as a primary facilitator of the network’s performance. Sustaining this culture will therefore be important for the continued success of QMMH-IN. Doing so requires an intentional and systematic strategy [] that includes each of the foundational elements of QI culture, namely: leadership commitment, empowered employees, customer focus, a collaborative environment, and the maintenance of an explicit QI infrastructure, including continuous data collection and monitoring by dedicated employees []. Employee empowerment, which was identified as a facilitator in the earlier evaluation of the network [, ], appears to have declined in our 2020 evaluation in the setting of poor morale, and will need to be a focus of future efforts if this overall culture of QI and accountability is to be sustained. The continued use of the balanced scorecard or similar tool may be helpful to retain, as respondents in this study perceived it as motivating for employees. Other research supports the usefulness of balanced scorecards in linking individual roles and organizational performance goals [] and stimulating QI culture []. Additionally, taking holistic view that includes sustaining workflows that ensure reliable procurement, quality assurance of needed medical products and technologies, and maintenance of the physical infrastructure and equipment cannot be overemphasized []. Each of these pieces of the system is interdependent and overall builds to a what has been previously described at QMMN-IN as a “reliable work environment [].”
The primary barriers internal to QMMH-IN perceived to limit performance were related to human resource management, with low salaries in comparison to outside facilities and lack of investment in training opportunities driving poor recruitment and retention of experienced employees. Unanticipated wage increases of approximately 80% for government hospital workers announced in 2013 meant that QMMH-IN employees went from being paid 3–54% more than their governmental counterparts (depending on job category) to being paid less [], partly due to a failure to renegotiate the PPP contract to take into account increased wage expenses. Financial strains on the network and the poor payment history by the Government of Lesotho [] may have contributed to a decreased emphasis on training opportunities over time. It is widely recognized that the management, training, and retention of highly skilled medical staff is a key factor in health system performance and demands significant effort to sustain [].
The main identified performance barrier external to QMMN-IN was the perception that lack of resources elsewhere in the health system was resulting in inappropriate referrals of low-complexity patients. This was also new in our analysis relative to the 2012–2013 QMMH evaluation [], and is illustrative of how a PPP may influence supply and demand for healthcare over time. This barrier must be considered within the context of having no Maseru district hospital at the time, which undoubtedly exacerbated the number of patients presenting to QMMH-IN facilities []. Additionally, similar to what was seen in the comparative evaluation of PPP-run versus publicly run district hospitals in India [], respondents in our study reported that patients themselves were also driving the “flooding” of QMMN-IN due to perceived higher quality care. PPP design and implementation must consider not only the hospital network itself, but also the broader healthcare system, as neither operates in isolation and effective national healthcare delivery strategies must consider care across the continuum[, ].
Considerations for Implementers and Management of PPPs
Below we summarize three considerations from these findings that may be of use to others interested in implementing healthcare PPPs, especially those in lower-resource contexts.
- Build, embed and sustain a culture of QI and accountability that is supported by core systems, clinical and administrative workflows, and consistently maintained facility infrastructure. Our results suggest that this culture was a key driver of QMMH-IN performance and that maintaining it would be important for the continued performance of the hospital network. Some specific considerations include intensive succession planning for any new network managers, maintaining structures such as the Office of Quality and Risk, and continuing the use of accountability tools such as balanced scorecards. A follow-up study post-PPP could help to understand what happened with the transition and explore the degree to which this culture and the overall reliable work environment were sustained. This is responsive to identified gaps in the PPP literature including a lack of “whole life cycle” evaluations [] and the need for evidence regarding transitions of healthcare PPPs [].
- Invest in people as substantively as in infrastructure, equipment, and core systems. Employee morale is crucial to hospital network performance; we observed a perceived lack of investment in employees over time, including lower pay than government counterparts and insufficient training opportunities. QMMN-IN did not respond to external changes to governmental healthcare worker wages, potentially to the detriment of network performance. Integrative PPP agreements should be flexible enough to allow for adjustments to external conditions in order to continue to prioritize adequate human resource investment over time. The importance of contract flexibility and responsiveness to changing external factors has been echoed throughout the PPP literature [, , ].
- Invest in broader health system strengthening. Without adequate, concurrent investment in the health systems at the district and clinic level, QMMH-IN was unable to function as intended. An adequately resourced and capacitated health system must be the foundation for a PPP like QMMH for it to operate at the level of a national referral hospital. This would require more balanced investments at all levels of the health system from the beginning of the PPP agreement. Going forward post-PPP, QMMH-IN could support the greater health system by transitioning more fully into a medical training institution focused on building internal and external capacity. This is consistent with recommendations by the WHO [] as well as those which were generated from the QMMH-IN baseline evaluation [] and represents a missed opportunity within the QMMH-IN PPP.
Limitations
This study has several limitations. First the qualitative data explore, but do not attempt to measure the frequency of perspectives and attitudes. Second, interviews were conducted by Boston University researchers, which may have introduced a social desirability bias; however, as evidenced by the quotes, respondents seemed to feel free to express concerns and provide constructive comments on the PPP and QMMH-IN. Third, our sample of 26 included only five respondents from network clinics and thus our findings are likely more hospital-centric in nature. In addition, the scope of this paper did not include perspectives from governmental officials in charge of the regulation and financing of QMMH, nor respondents from district hospitals. As such, the findings as a whole and specifically the recommendations regarding the Ministry of Health’s role/management and greater district health system must be interpreted cautiously.
Conclusions
Healthcare PPPs are important and promising strategies to finance healthcare systems. It is critical to consider employees as key stakeholders who can help to elicit the nuances of the barriers and facilitators of PPP performance in varying contexts. Implementors of integrative PPPs in lower-resource settings should pay special attention to healthcare system allocation of resources, human resource investment over time, PPP contract flexibility, and succession planning as means of facilitating and sustaining hospital network performance.
Reflexivity statement
Grounding our methods in reflexivity, here we provide details on authors’ gender, seniority, field of expertise, role in the evaluation, and their relationship to the QMMH-IN PPP. ELNN is a Mosotho while all other study authors are American. BWJ is male while the rest of authors are female. ELNN is a nurse, registered nurse-midwife, holds a Master of Public Health degree and is currently a PhD candidate at Sefako Makgatho University of Health Sciences. CMM and BWJ are family physicians. CMM holds a Master of Science degree in health systems and services research. ELNN, CMM, and BWJ have clinical experience in district hospitals in Lesotho but not within QMMH-IN. All three are also affiliated with Lesotho-Boston Health Alliance, a Lesotho-based organization who served as the implementing partner for the overall evaluation. At the time of data collection, JLK was a Boston University research fellow, with five years of experience in conducting mixed-methods health systems research in sub-Saharan Africa. TN was a Doctor of Public Health candidate at Boston University. JLK and TN, the study interviewers, were not involved in the previous work in Lesotho conducted by Boston University, and held no prior beliefs regarding the performance of QMMH-IN. TV and NAS are both senior public health researchers with a combined 49 years of experience in mixed-methods evaluations.
Data Accessibility Statement
The qualitative transcripts analyzed for the current study are not publicly available due to the sensitive nature of the end of the PPP and our inability to ensure confidentiality of individual responses. Hospital leadership in particular had unique and public-facing roles and it would not be possible to make their transcripts completely unidentifiable while retaining the content of the information they provided. Please contact the corresponding author with any questions.