Ideally, the government of a state is responsible for the provision of essential health services to its citizens. However, in reality, this is not often the case. Across the world, several factors impede governments’ ability to bear sole responsibility for the development and maintenance of basic services. Some of these include a shortage of funds (which in some cases, is further compounded by the poor management of available resources), a lack of expertise, limited infrastructure and so on.
World over, it has become increasingly necessary to consider Public-Private Partnerships (PPPs) as a more viable and sustainable approach to infrastructure provision.
In 2010, an Africa Business Insight article noted that the infrastructure deficit in Nigeria was so huge, it would require US$12 billion to $15 billion annually for six years to meet the requirements. It’s been 10 years and there doesn’t seem to be a significant difference in the infrastructure challenge the country is facing.
These dismal indices emphasize the need for an urgent solution. Perhaps PPPs may be considered as one avenue through which this gap can be closed.
What are PPPs?
PPPs are legalized, long-term agreements between government agencies and private organizations that facilitate the provision, management and sustained delivery of essential services. This translates to the fact that although the public sector is responsible for infrastructure development, these essential services can still be provided for without the government directly or entirely undertaking the provision. The adoption of PPPs possess the potential to accelerate project completion time, foster efficiency and innovation and simplify bureaucratic processes.
The PPP structure is a viable way of optimizing resources from both the public and private sector because it combines the competencies of both sectors and is delivered on the premise of an agreed division of risks and responsibilities, ultimately extending the coverage of risks and responsibilities. Like every other partnership, PPPs are governed by legal agreements that contain clauses and features that regulate the contribution of both parties. These agreements help to ensure transparency and accountability and ideally should feature clauses that outline the payment mechanisms, dispute resolution procedures, performance requirements, provisions for termination, management and operating agreements, monitoring/enforcement mechanisms and partial or full divestiture of public assets.
However, PPPs are not without drawbacks. Some of these challenges range from a lack of legal/regulatory framework; to conflicts of interest and communication barriers between partner organizations; to policy reforms; to a clear lack of understanding of the concept of PPPs by staff of partner organization, which in turn, affects conceptualization and successful implementation; to public acceptance/opposition caused by inadequate advocacy; to political will and interference and even to funding inadequacies caused by lack of incentives by government that attract private sector investors.
PPPs in Nigeria
In Nigeria, the concept of PPP is not entirely unfamiliar. Established under the Infrastructure Concession Regulatory Commission Act 2005, the Infrastructure Concession Regulatory Commission (ICRC) is charged with the responsibility of addressing Nigeria's physical infrastructure deficit. Since its establishment, the Commission has been known to create an enabling environment for the development of PPPs by leading conversations around PPPs and providing guidelines, policies and procurement processes to facilitate their development.
Some noteworthy examples of projects that have been executed through PPP are Murtala Muhammed Airport 2 between Bi-Courtney Limited and the Federal Government, Delivery of 3.4bcf of Gas by 2020 between NNPC and Seplat Petroleum Development Company Limited and the very popular Lekki Road Concession.
Of particular interest to us at the Healthcare Leadership Academy (HLA), is the noteworthy PPP between our alumni.
In 2019, Crestview Radiology, a private digital radiology and medical consultancy organization established an ultramodern radiology and imaging facility equipped with state-of-the-art imaging equipment at National Orthopaedic Hospital, Igbobi.
Managed by highly qualified experts, the top-of-line equipment has enabled accurate investigation of different body organs, evaluation of aneurysms, tumours, fractures etc. and improved the diagnostic capacity and in some cases, the ability to conduct biopsies and drainage procedures in seconds, ultimately mitigating patient wait time.
We caught up with the leadership of both facilities (our alumni) to gain insight into the driving factor(s) for the partnership, the results and the projections.
What was the gap?
“We conducted a walk-through and found patients, often patients with trauma, who had been referred to get an X-ray exam outside the hospital in the dire state they were in before their case could be managed. There is the known case of a patient whose X-ray results took almost two weeks before it was ready. This affected public trust in the hospital’s capacity and the quality of care they were delivering. We felt we could make a difference in enhancing the image of the hospital, the practice of the medical personnel and ultimately save more lives”
-Dr. Yemisi Toyobo and A.O Fatade, Crestview Radiology.
Dr. Mustapha Alimi of National Orthopaedic Hospital, Igbobi, couldn’t agree more. According to him,
“The major gap that necessitated this collaboration was the delay in getting investigation results and the need for machines that could carry out Computerized tomography (CT) scans and Magnetic Resonance Imaging (MRI).”
How did the process begin?
As a radiology practice, Crestview felt that their impact would be felt more in an orthopaedic practice, especially one at Igbobi’s level. And so, when Igbobi advertised for a PPP collaboration in the national dailies, they applied. Although it was a competitive bidding comprising interviews, presentations and facility inspection, they scaled through excellently and were selected.
How has this changed things for the facilities?
For Igbobi, the partnership with Crestview is mutually beneficial and has reduced the turnaround time for x-ray services. This has been of great benefit to patients and improved service delivery as a whole.
Since the beginning of the partnership, Crestview feels they have been able to contribute to giving Igbobi a facelift.
“As both a WHO accredited centre and a teaching hospital, Igbobi needed a good imaging centre to change the narrative of the quality of care delivered by the public sector. People are surprised at the quality of the care they can receive at a government hospital and for us as a private practice, this partnership has given us the opportunity to see more patients, with varying peculiarities, thus improving our capacity.”
Other than having to deal with the added operational costs that come with running a facility in the same premises, Igbobi hasn’t faced any pressing challenges. Crestview, on the other hand, faced suspicion from the personnel at Igbobi. According to them,
“This distrust was fueled by the notion that we were coming to take their jobs and expose their inadequacy. They initially barricaded our entry so we had to communicate clearly that we were only there to augment their service delivery and not displace them.”
It is interesting to note that the leadership of both facilities had some takeaways from their enrolment at the HLA Healthcare Executives Leadership Program (HELPS) which impacted their collaboration.
Dr. Alimi notes that,
“The HELP fellowship helped to remove the civil service lens about protocols and broadened my mindset regarding service delivery. Health service delayed means health service denied so if the goal is to provide healthcare service, then it is necessary to improve the capacity for service delivery. Partnerships and collaborations play a key role in achieving this.”
Dr. Toyobo and Fatade also affirmed the same thought,
“Our HLA training impacted the collaboration tremendously. The action-learning element of the HELP course prepares you to work with different scenarios, equipping you for problem-solving, strategy, data collection and leadership and management of the facility or centre.”
In the end, both leaders agree that PPPs are a welcome idea for the healthcare sector because it improves your delivery of care and increases your scale. In their view, PPPs have come to stay and have the potential to completely change the way services in public sector hospitals are delivered by augmenting their capacity with the efficiency and discipline of the private sector.
Drs Toyobo and Fatade noted that with the unavailability of funds to procure high-end equipment and the budget of the radiology department equalling about half of the hospital’s total budget, the PPP between Crestview and Igbobi has to some extent, relieved the financial burden on the public hospital and enabled it to plan better and to do more. Another advantage of the role of PPPs is the room for research that it creates by allowing the public hospital prioritise resources to undertake research studies.
Recommendations for organizations that intend to undertake a PPP
“Private sector organizations considering a PPP should be tenacious and focused. Don’t be easily discouraged by the suspicion and distrust you encounter. Consistently and clearly communicate your role as augmentary. And most importantly, do your homework and be sure that you can sustain your management of the facility.”
-Dr. Yemisi Toyobo and A.O Fatade, Crestview Radiology.
“If you want improved service delivery especially for essential services that you have been unable to consistently provide, then get a partnership. It reduces the burden of service failure and recurrent costs so it is not a regrettable choice. And in the end, you will achieve improved service delivery.”
-Dr. Mustapha Alimi of National Orthopaedic Hospital, Igbobi
No doubt, this collaboration has set the template for many more collaborations that can contribute to improving the delivery of care and ultimately, the health outcomes in Nigeria.