Skip to main content
NCBI home page
Chronic Diseases and Translational Medicine logoLink to Chronic Diseases and Translational Medicine
. 2023 Aug 11;9(4):288–298. doi: 10.1002/cdt3.88

The public–private partnerships in healthcare sector in China

Bo Liu 1, Leiyu Shi 1,✉, Hanyi Min 2, Hailun Liang 1,3, Jiahong Dong 4
Editor: Yi Cui
PMCID: PMC10617313  PMID: 37915390

Abstract

This manuscript is a narrative review on experience in the healthcare public–private partnerships (PPP) field project in China. The PPP model allows healthcare officials to share the risk of building new facilities with the private sector. The objective of this study is to evaluate and to review the PPP of healthcare sector in China, and to investigate the critical success factors and best practice of PPP. We adapted the PPP evaluation framework of the World Bank Independent Evaluation Group as our conceptual framework to summarize the literatures. The current study systematically reviewed the evolution and current status of public and private hospitals development in China, and to investigate factors related to the successful and less successful deployment and performance of PPP in the healthcare sector of China, and to develop best practice models of PPP among hospitals of China. We found that the PPP organizations providing finance and political risk coverage, thus enabling specific PPP transactions to reach financial closure—potentially setting demonstration effects. Such PPPs may then contribute to improving access to infrastructure and social services, which drives economic growth and other optimal outcomes.

Keywords: China, healthcare sector, public–private partnerships

Distribution map of hospital in difference types of institutions.

graphic file with name CDT3-9-288-g005.jpg

Highlights

  • The study summarized the evolution and current status of public and private hospitals development and factors related to the successful deployment and performance of the public–private partnerships (PPP) in the healthcare sector of China.

  • The study summarized the evolving PPP legal framework in China in recent years.

1. INTRODUCTION

A public–private partnership (PPP) is a cooperative arrangement between two or more public and private sectors, typically of a long‐term nature. It is a mode of operation where private capitals are encouraged to cooperate with the government in the constructing of infrastructure. In many cases, PPP may also mean that the private sector finances public infrastructure investments.

Healthcare PPPs are mostly long‐term projects. Typically, the government outlines the goals and the private sectors are responsible for operate on the health system. The private sectors receive their payment according to the forms and models of the PPP contract and bear technical, operational, and financial risks at the same time. The opportunity for multisector market participants includes physician groups and hospital providers, pharmaceutical, technology companies and medical device companies, private health insurers, facilities managers, and construction firms. Funding sources could be banks, private equity firms, philanthropists, and pension fund managers.

China is estimated one of the countries to have the highest health spending growth between 2010 and 2020, where health spending is expected to increase by 166%, and India, which will see a 140% increase. As health spending increases sharply it is putting pressure on governments and spurring them to turn to private capital and expertise. Due to constantly rising prices, changing disease patterns and increasing use of sophisticated technology for diagnosis and treatment have made it virtually impossible to imagine any single organization providing services without some type of institutional partnership. And with the springing of the strongly favorable policy from 2013, PPP has welcomed its own spring in China.

To date, the predominant countries for PPP research in healthcare sector have been the United States and United Kingdom. 1 , 2 , 3 As PPPs are gaining prominence globally, there is now a growing body of work in developing countries such as China, India, and Lebanon. 1 , 4 Moreover, there is also a promising body of international comparative work such as the study of Dutch and Spanish urban regeneration PPPs. 5 , 6 , 7 , 8

At a time when the recent upsurge in mergers and acquisitions has receded, we need to review the past cases of PPP in healthcare sector in China, and sum up the successful experiences and the lessons learned from the failures to better for the future large medical, health and rehabilitation of integrated medical institutions such as the establishment and development of reference.

2. METHOD

A systematic search for journal article was conducted in March 2022 on four electronic database: PubMed, Cochrane Library, EMBASE, and Google Scholar. The specific search terms were included as follows: PPP, healthcare, health sector, and China. Initial records were transferred to the reference management software Endnote 8.0 (Thomson Research Soft), and duplicates were excluded automatically. Then two independent investigators identified articles by reading the title and abstract and assessed them according to the following selection criteria: (1) focused on public–private relationships; (2) scholarly publications; and (3) of conceptual, quantitative, or qualitative empirical nature. Articles that meet these selection criteria would be kept for the next full‐text screening stage. The investigators read the full texts of the remaining articles. Data extraction was conducted by the investigators. For each article, we extracted information shown in table. Due to the high heterogeneity for quantitative analysis, descriptive statistics were presented for each included study.

3. PPP IN HEALTH SECTOR

3.1. Advantages and risks of PPP

PPP aims to achieve a better effect than operating separately as the private sectors can provide their own resource and effort. It can reduce the financial burden of government while reduce the risk of investment of the private capital. Besides, it offers governments multiple solutions for private financing of the infrastructure, utilizing the knowledge and management concept of the private factors within the contribution of the projects. It will bring a shorter implementation period and higher quality level of the provided facilities. In addition, part of the risks is transferred to the private sectors by the government.

The risks of a PPP project come from the high‐level regulation and strict selection of the private partner required. Once the standard is not met properly, the project may become a huge burden for the government as well as a means of “devouring” national resources. Besides, the long period of preparation process may also place huge implement on the public–private partnership project (Table 1). 9

Table 1.

Advantages and risks of public–private partnerships.

Advantages Risks
Flexible in investment size Increase of the prices charged to the users of the infrastructure
Savings to the budget Reduction of bargaining power of public authorities
Transfer of new technologies Hard to control the whole quality
Sharing the risk Limited accessibility to services
More competition on market Decrease of employment in the public sector
Guarantee of the services for a longer term Financial risk from public partner
Open in a new tab

Source: Adapted from Parvu and Voicu‐Olteanu. 9

3.2. Several typical types of PPP

PPP can be used for various projects. It could be a short‐term or a long‐term project, differing from the size of the capital, structure designing, constructing condition, and operation methods. There are four main types of PPPs, including financing PPP (Supporting Information: Table S1).

4. THE DEVELOPMENT OF PPP

During the macroeconomic dislocation of the 1970s and 1980s, because of the concerns about the level public debt, pressure to change the standard model of public procurement arose. Private investments were welcomed for the construction of infrastructure. Besides, it has been argued that it could yield a better allocation of risk while cutting public budget if the private sector could corporate with the government and take responsibility for the aspects of service provision for a certain project. At first, most PPP projects were negotiated individually, as one‐off deals, and much of this kind of activity began in the early 1990s in the United Kingdom. Later on, the mode of PPP is diffused and adopted by other countries.

4.1. PPP around the world, and factors related to the success and failure, not limited to China

4.1.1. PPP around the world

By the 1950s, Britain's major cities had suffered from decades of decay and neglect, from chronic disinvestment. The idea of partnership, driving developments and defining local government and private sector relations, became a central feature of the post‐1979 urban political landscape. 10 , 11 , 12 , 13 , 14 The government's attitudes towards providing public infrastructure changed dramatically in the 1990s, when the option of providing public infrastructure with private financing became a policy preference. In 1992 John Major's Conservative government introduced the Private Finance Initiative (PFI). This is a policy for which the Conservative Party is famous and proud. First, private finance provides a flexible technology that enables governments to overcome existing political paralysis and frustrating public accounting constraints to provide new infrastructure. Second, the use of “public‐private partnerships” rather than simple “private finance” agreements is a fine example of positive policy language. Privately financed infrastructure delivery has been revived as PPP and policy.

PPPs were first seen in 1970s in the United States. During those years, the US suffered from the Second Energy Crisis, which reduced the tax income of the government. The prison built in Virginia in 1998 set a perfect example for the PPP mode. It was estimated that about 15%–20% of the constructing cost was saved because of PPP. Several years later, Public‐Private Education Act, a law that permits the utilization of PPP in education industry came out. Later on, PPP was extended to other field such as water supply, hospitals, and parking lots. Roberts summarizes the role of private financing technology in providing roads, canals, and railways in the early 19th century in the United States. 15 Private financing technology clearly has a rich history as an important option for public infrastructure.

In the late 20 century, the first PPP project in China, Citong Bridge was built by government of Quanzhou with the use of build‐operate‐transfer (BOT) structure. From 2003 to 2013, theoretical frameworks of PPP had been set up gradually. With the favorable policies published by the local government, a second trend for PPP came. In 2013, PPP's participation in the construction of infrastructure was permitted at Communique of the Third Plenary Session of the 18th Central Committee of the Communist Party of China. A series of professional documents were published to help the specification of PPP in China.

4.1.2. Factors related to the success and failure of PPP

Previous studies have emphasized the contractual nature of PPPS and regarded partner characteristics and public outputs as two key characteristics that distinguish PPPS from traditional interfirm alliances. 16 By joining the public and private sectors, PPP generates different interests and incentives. Their output usually consists of pure or quasi‐public goods rather than private goods produced by traditional partnerships. Based on these factors, we believe that the distribution of control rights is a key variable affecting the efficiency of PPP cooperation. Since the PPP output of the health sector is usually composed of public goods (or services), public‐good investments by private enterprises and related nonprofit organizations increase the total return of joint projects. However, the profit‐making nature of private enterprises will encourage them to make self‐beneficial investment in the process of cooperation and try to ensure the interests of control, thus reducing social benefits. Therefore, to improve the efficiency of PPP cooperation, it is necessary to increase the public interest investment of both parties and reduce the self‐interest investment of enterprises. Specifically, the investment jointly made by private enterprises and non‐profit organizations, namely public investment, should be increased and the pure self‐profit investment should be reduced. 17

PPP program champions and leadership were believed to be critical to the development and sustainability of the initiative. Previous evidence indicated that the change in leadership and reduction in staff dedicated to the partnership may have inhibited communications in subsequent years. 18

What is more, in China, a number of policies reflect the affirmation and support of introducing social capital into hospital management and medical system construction. Legal environment for PPP development and the associated organizational structure have both changed significantly over the years. In January 2018, the National Conference on Health and Family Planning stressed the importance of vigorously developing the health industry, promoting the development of “Internet plus medical and health care”, and encouraging social funds to enter the fields of medical treatment and combination of medical care and nursing care. In August of the same year, the General Office of the State Council formulated the Opinions on Promoting the Development of “Internet plus Health Care”, which put forward the principles of inclusiveness, prudence, safety and order, fostering an inclusive development policy environment, and forming the basic principles of government‐led development, multiparty participation, fair competition, openness, and sharing.

In addition, the PPP performance was affected not only by authorizing and supportive legislation in the policy domain—but also by interaction among contractual arrangements—private partner selection, financial arrangements, role division, risk allocation, and project characteristics. Yin Wang, etc. pointed that contracts are critical to partnership success by proposing a conceptual framework that evaluates PPP performance by comparing actual project outcomes to initial government goals, and then explores how contractual arrangements affect the partnership performance on each identified goal. 19

4.2. The evolution of public and private hospitals in China

Since Reform and Opening Up, it has been lawful in China for private ownerships to coexist with public ownerships in healthcare industry. Medical institutions established by social capital have arosed since then. Over the past few decades, the government has issued a number of policy documents on reforms in the medical industry.

In the past, although private ownership is common for outpatient services such as village clinics, private presence in inpatient delivery is limited and recent. 20 Policies begun in the late 1990s and reinforced by the 2009 health policy reforms—which for the first time prominently called for expansion of private not‐for‐profit investments in health service delivery in China—set the stage for nationwide reform from almost universal government ownership of hospitals to more ownership types, albeit with government ownership still in the lead. Only a few studies have examined how public and private providers compete in China. Most patients may self‐refer to a provider of their choice, and many aspects of operations appear similar across ownership types. For example, all Chinese clinics and hospitals employ physicians on their staff. Evidence suggests that providers respond to the incentives of the system in similar ways, such as avoiding unprofitable (public health) services and overproviding profitable high‐tech diagnostic services and drugs. 21 , 22 , 23 Some studies find that private hospitals, seeking to attract patients in a public‐dominated system of insurance and delivery, often charge prices that are lower than those of public hospitals, attract lower‐ and middle‐income patients, and achieve higher patient satisfaction. 21 Similarly, Huang and colleagues 24 find that nongovernment hospitals charge prices that are generally lower than or equal to those of government hospitals. However, evidence specific to the quality of care provided in public versus private hospitals remains limited.

A significant trend in the current and future trajectory of Chinese healthcare is the increasing privatization of medical hospitals and clinics. This development is driven by both consumer desires for a more patient‐centered experience and government initiatives that aim to distribute the burden of care from public hospitals. However, due to many specific policy restrictions and constraints, social medical services have not formed a scale. That means despite the rapid expansion of private options, several barriers prevent private models from gaining widespread use and societal acceptance. 25 Within the last decade, there has been a nearly exponential growth of the number of private hospital beds, while public hospital growth has been comparatively stagnant. 26 , 27 , 28 , 29 The number of private hospitals in China doubled to a total of 16,900 hospitals in just 6 years, from 2011 to 2017, and now account for 57.2% of Chinese hospitals. However, despite the growth in the number of facilities, private hospitals create significantly lower revenue compared to public hospitals. In 2016, private hospitals accounted for the majority of hospitals but generated less than 10% of the total revenue. 30 The reasons for this discrepancy mostly lie in the lower patient volume. Private hospitals are more likely to be smaller and specialized hospitals, while public hospitals typically have more beds, staff, and tertiary care capacity.

Considering that social medical services have many unique advantages compared with public hospitals, coupled with the strengthening of government reforms in recent years and the impact of the new crown epidemic, social medical services will usher in new development opportunities. In 2009, the government allowed physicians to practice at multiple sites to help them simultaneously work in private and public hospitals. 31 Additionally, the government lowered barriers to private investment in healthcare. In the 13th Five‐Year Plan, the government allowed up to 100% foreign ownership in private hospitals, which previously required a minimum 30% Chinese ownership, and encouraged private elderly and home care services. Additionally, in 2014, private investors were allowed to acquire and manage existing public hospitals.

Government financial investment is an important channel of hospital compensation and plays a vital role in the survival and development of public hospitals. Nationwide, the proportion of financial subsidies in the total revenue of hospitals in China also increased year by year, from 7.06% in 2014 to 8.27% in 2017. 32 It can be seen that the state pays attention to the development of public hospitals. The amount of financial allocation will directly affect the normal operation of our hospital. However, most hospitals believe that the national financial allocation is still insufficient, and many hospitals even take out loans to relieve the pressure of capital turnover. In general, in the context of encouraging the establishment of public hospitals, the policies of controlling the expansion of public hospitals, abolishing general clinics in large hospitals, and zero markup on drugs and consumables have brought great challenges to the operation of public hospitals.

Since 2015, the development of China's nonpublic hospitals under the new health policy has provided a more level policy and competitive environment, and nonpublic hospitals are also developing healthily on their own advantages. Compared with the present, there is a big gap between public and private hospitals in terms of medical resources, scientific research strength, and policies and systems. 33 With the release of the new medical reform plan, the government appropriately revised relevant policies to promote the reform process, providing a more relaxed policy environment for nonpublic hospitals. Nonpublic hospitals should comply with the new policy of medical reform, give full play to their own advantages, pay attention to the introduction and training of talents, honest management, so as to achieve stable, long‐term, and sustainable development. 34

4.3. The PPP in healthcare sector in China

Since the 2009 New Healthcare Reform, the government has introduced a number of policies to prompt public hospitals reform and encourage social capital to invest in healthcare market. In 2010, the General Office of the State Council published The Notice of Opinions about Further Encouraging and Guiding Private Hospitals, in which it required lower barriers to entry and eliminations of polices barriers, to ensure that private and public hospitals share the same treatment in entry, operation, and so forth. In May 2015, it was first introduced in The Guidelines of the General Office of the State Council for the Pilot Comprehensive Reform of Urban Public Hospitals to strictly control the bed size, construction standards, and large‐scale medical equipment of public hospitals and take comprehensive measures to gradually reduce the number of beds for public hospitals that exceed the scale standards. In December 2017, Law of the Basic Medical Hygiene and Health Promotion (Draft), deliberated at the 31st meeting of the Standing Committee of the 12th National People's Congress, emphasized that public hospitals include all income and expenditure in departmental budget management, control scale, and adhere to the nonprofit nature. The state has issued relevant policies to strictly control the expansion of public hospitals and provide favorable treatment and support to the private hospitals in terms of entry, financing, taxation, medical insurance, and so forth, so as to gradually solve the problems encountered by social capital in the process of establishing medical institutions, and solve problems such as insufficient medical resources and monopoly of the market by public hospitals. Table 2 shows the main relevant policies of private ownership hospitals since the reform and opening up.

Table 2.

The main relevant policies of private ownership hospitals since the reform and opening up.

File number File name
Guofa〔1985〕 No.62 Report on Policy Issues in Health Sector Reform
Zhongfa〔1997〕No. 3 Decision of the State Council on Health Industry Reform
Zhongfa〔2009〕No. 6 Opinions on Deepening the Reform of the Medical and Health System
Weiyiguanfa〔2010〕 No.20 Notice on Issuing Guidelines on the Pilot Reform of Public Hospitals
Guofa〔2012〕No. 57 The Twelfth Five‐Year Plan for the Development of Health Industry
Guobanfa〔2012〕No. 33 Notice of the Opinions on the Comprehensive Pilot Reform of County Public Hospitals
Guofa〔2013〕No.40 Opinions on Promoting the Development of Health Service Industry
Guoweitigaifa〔2013〕No. 54 Opinions on Accelerating the Development of Private Hospitals
Guobanfa〔2015〕No.14 National Medical and Health Service System Planning Outlines (2015‐2020)
Guobanfa〔2015〕No. 45 Political Measures to Promote the Development of Private Hospitals
Guofa〔2016〕No. 78 The Thirteenth Five‐Year Plan for Deepening the Reform of the Medical and Health System
Guobanfa〔2017〕 No. 44 Opinions on Supporting Social Forces to Provide Multi‐level and Diversified Medical Services
Fagaijiage〔2017〕No. 1941 Opinions on Comprehensively Deepening the Price Mechanism Reform
Guoweiyifa〔2019〕No. 42 Opinions on Promoting the Sustainable and Standardized Development of Private Hospitals
Open in a new tab

We also developed a table (Table 3) to summarize the evolving PPP legal framework in China in recent years. The main elements in the table include: Regulation Name, Adopted Year, and Main Provisions. 35 From the table it is clear that in 2018, the policy emphasizes to encourage social funds to enter the medical field. By 2019, the government will continue to introduce supporting policies, and it is clear that the government should increase its support for social medical institutions. Due to the COVID‐19 outbreak in 2020, the government encourages social medical institutions to assume corresponding responsibilities and tasks in the prevention and control work.

Table 3.

The evolving public‐private partnerships legal framework in China.

Adopted year Regulation name Main provisions
2018.1.4 National Health and Family Planning Conference Developing health industry and promoting the development of the ‘Internet plus healthcare' system, as well as encouraging nongovernmental investment in healthcare sector and the combination of medical care and nursing care
2018.1.6 Medical and health industry Investment and financing Summit Forum Let nonpublic medical institutions join in the construction of medical consortium to promote the construction of hierarchical medical system
2018.4.28 Views on promoting the development of ‘Internet plus Medical Health’ It is proposed to uphold the principles of inclusiveness, prudence, security and order, foster an inclusive development policy environment, and form the basic principles of government‐led development, multi‐party participation, fair competition, openness, and sharing
2019.6.4 Deepen reform of the medical and healthcare systems and set priorities for 2019 We should actively promote the sustainable and standardized development of medical institutions run by the public, and formulate measures to promote the sustainable and standardized development of medical institutions run by the public
2019.6.12 Suggestions on promoting the sustainable and standardized development of medical services run by the community Increasing government support for nongovernmental hospitals; promoting division of labor and cooperation between public and private medical institutions
2019.10.9 Notice on improving management capacity and medical quality and safety level of social medical institutions Strengthening organization and leadership, gradually form a long‐term mechanism for promoting the healthy development of medical institutions run by the public, and integrating them into a unified medical quality management system
2020.2.16 Notice on further strengthening the management of public hospitals and hospitals for coVID‐19 Prevention and control Social medical institutions, as an important part of China's medical and health service system, undertake quite important tasks in the prevention and control work
Open in a new tab

Since the release of graded diagnosis and treatment policies in 2015, China has increasingly emphasized the development of family doctors. China has defined the direction of socialized medical management, and also continuously refined relevant policies for socialized medical management, providing a large policy environment for PPP to participate in public hospitals. While relaxing the admission standards, the state also further promotes the implementation of multipoint professional system of doctors, which provides the convenience for the socialized medical management.

With the policy incentives, influx of social capital, and growing demands, private hospitals in China have developed greatly in aspects of total numbers, institution scales, and market shares. In terms of institution numbers, private medical institutions account for close to 70% and have played a vital role in China's medical market. Besides, after their early explorations, private medical institutions have focused on medical technology and appropriate scales, and steadily improved their service quality. Domestic and international medical service institutions, and other new entrants such as pharmaceuticals, medical equipment, insurance, and real estate companies have successively tapped into the market, and a diversified pattern of social medical services has taken shape. However, private sector is still facing trouble. Public hospitals are still the main body of medical services. From the perspective of the hospital numbers, the numbers of public hospitals and private hospitals are basically the same, but public hospitals have an absolute advantage in terms of resource ownership (Figures 1, 2, 3, 4). 36 A series of internal and external factors have led to the failure of the society to run medical services as expected, such as the intensified public trust crisis, the imbalance of talent structure, and the difficulty of policy preferences to play a substantive role. It is difficult for the government to eliminate the discriminatory attitudes towards nonpublic medical institutions, and it is also related to the deep‐rooted distrust of nonpublic medical institutions in society. 37 Public hospitals do not lack financial support, with the supply of medical services far from meeting demand, and therefore have sufficient internal expansion incentives, making it unrealizable for the government to control the expansion of public hospitals by administrative means. 38 , 39 , 40 , 41 , 42 , 43 Private medical institutions lack competitiveness and can only provide primary medical services, so their charging standards are generally the same as those of public medical institutions, or even lower. However, public medical institutions receive the privilege of government financial subsidies, which account for about 8%–10% of total revenue, and bear no tax burden. Although the policy stipulates that for‐profit hospitals are exempt from taxation in the first 3 years of their establishment, it takes 5–8 years for a newly established hospital to turn profitable. The 3‐year tax holiday can scarcely play a major role in supporting for‐profit private hospitals. As a self‐financing unit, private hospitals need to bear certain medical risks, and are small in scale and poor in risk resistance.

Figure 1.

Figure 1

Open in a new tab

The number of public and private hospitals in China (Data source: National Health Commission of the People's Republic of China. China Health Statistics Yearbook 2020).

Figure 2.

Figure 2

Open in a new tab

Public and private hospital percentage of bed distribution (Data source: National Health Commission of the People's Republic of China. China Health Statistics Yearbook 2020).

Figure 3.

Figure 3

Open in a new tab

Distribution map of various levels of hospital (Data source: National Health Commission of the People's Republic of China. China Health Statistics Yearbook 2020).

Figure 4.

Figure 4

Open in a new tab

Distribution map of hospital in difference types of institutions (Data source: National Health Commission of the People's Republic of China. China Health Statistics Yearbook 2020).

According to previous studies, leadership, funding, and other resources allow for the development of inputs, which ideally contribute to outcomes at the institutional and population level over time. 44 , 45 , 46 , 47 However, not all partnerships have an adequate amount of resources, nor are programs and other strategies always maintained long enough to realize projected outcomes. 48 , 49 , 50 , 51 Additionally, positive health outcomes on the population level may not be evident until long after decisions have been made in regard to whether the partnership should continue. 52 , 53 , 54

PPP program champions and leadership were believed to be critical to the development and sustainability of the initiative. Program champions within each organization leveraged their own resources to continue initiative activities in light of funding challenges. Although there was evidence of strategic planning and strong communication at the inception of the partnership, previous evidence indicated that the change in leadership and reduction in staff dedicated to the partnership may have inhibited communications in subsequent years. 18 , 55 , 56 , 57 , 58 , 59

In deepening the medical and healthcare system reform, China encourages innovation in healthcare system and optimizes medical resources allocation. In this context, hospital trusteeship, as an important means of the distribution and development of high‐quality medical resources, has attracted more and more attention. Hospital trusteeship is a continuation of state‐owned enterprises in the field of medical services hosted mode, hospital trusteeship at present our country has a lot of practice and gradually formed a pattern, with corporate model for hospital management, investment to introduce the advanced medical equipment and personnel on one hand, on the other hand also introduce advanced hospital management mode, promote the modernization development of hospital entrusted.

5. CONCLUSION

PPP is an important mode of investment and financing in the field of infrastructure and public services. At the same time, the PPP reform is a major institutional innovation in China's governance system and governance modernization, and an institutional reform. China's new round of PPP process has a significant feature: high industrial concentration. The research literature on PPPs is in its nascent stages and lacks systematic and thorough analyses. 60 , 61 , 62 , 63 , 64 , 65 , 66 In addition, such research mainly focuses on the motivation for cooperation between stakeholders. From this point of view, we reviewed the past cases of PPP in healthcare sector in China, and sum up the successful experiences and the lessons learned from the failures to better for the future large medical, health and rehabilitation of integrated medical institutions such as the establishment and development of reference.

In the new round of PPP investment boom, the development of China's healthcare field is obviously lagging behind. Based on the previous review of China's recent relevant policies, we first conclude that more and more policy documents show support for social capital to run hospitals. The changes in the macro environment in recent years have brought new hopes for the development of private hospitals. The government is also making more efforts to introduce new policies that are more detailed and cover implementation to promote the development of private hospitals.

PPP can achieve a better effect than operating separately. It also can reduce the financial burden of government. And it offers governments multiple solutions for private financing of the infrastructure, utilizing the knowledge and management concept of the private factors within the contribution of the projects. Therefore, we can see that healthcare field focusing on improving the quality of public service and operational efficiency will be an important direction of China's PPP development in the next stage. So it is of sufficient practical significance for this study to evaluate the PPP model in China's healthcare sector and to explore the success factors and best practices of the PPP model. 67 , 68 , 69 , 70

AUTHOR CONTRIBUTIONS

Bo Liu, Leiyu Shi, and Jiahong Dong conceptualized the study. Bo Liu and Hailun Liang provided the analyses; all authors drafted and approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

None.

Supporting information

Supporting information.

Click here for additional data file. (16.5KB, docx)

ACKNOWLEDGMENTS

The authors have nothing to report.

Liu B, Shi L, Min H, Liang H, Dong J. The public–private partnerships in healthcare sector in China. Chronic Dis Transl Med. 2023;9:288‐298. 10.1002/cdt3.88

Edited by Yi Cui.

DATA AVAILABILITY STATEMENT

The data sets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

REFERENCES

  • 1. Roehrich JK, Lewis MA, George G. Are public–private partnerships a healthy option? A systematic literature review. Soc Sci Med. 2014;113(7):110‐119. [DOI] [PubMed] [Google Scholar]
  • 2. Winch GM. Thirty years of private finance in the United Kingdom. In: Winch GM, Onishi M, Schmidt S, eds. Taking Stock of PPP and PFI Around the World, Summary of Research Report 126. Association of Chartered Certified Accountants; 2012:117‐125. [Google Scholar]
  • 3. Latham M. Constructing the Team, Final Report of the Government/Industry Review of Procurement and Contractual Arrangements in the UK Construction Industry. HMSO; 1994. [Google Scholar]
  • 4. Chen C, Li D, Government SO, University YS. Policy Change and Policy Learning in China's Public‐Private Partnership: Content Analysis of PPP Policies between 1980 and 2015. Chinese Public Administration. 2017.
  • 5. Shaoul J. A critical financial analysis of the private finance initiative: selecting a financing method or allocating economic wealth? Crit Perspect Account. 2005;16(4):441‐471. [Google Scholar]
  • 6. Appleby J. Five‐year health check a review of government health policy 1997‐2002. King's Fund; 2002. [Google Scholar]
  • 7. Edwards P, Shaoul J. The control of the PFI process: regulatory context or policy promotion? In: Proceedings of the EIASM International Conference on the New Public Management, vol. I;2000:197‐206.
  • 8. Mcfadyean M, Rowland D. The PFI versus democracy? School governors and the Haringey schools PFI scheme. Menard Press London; 2002:1‐10. [Google Scholar]
  • 9. Parvu D, Voicu‐Olteanu C. Advantage and limitations of the public‐private partnerships and the possibility of using them in Romania. Transylv Rev Adm Sci. 2009;5(27):189‐198. [Google Scholar]
  • 10. Shapely P, Harding A, Keil R, Seekings J. Governance in the post‐war city: historical reflections on public‐private partnerships in the UK. Int J Urban Reg Res. 2013;37(4). [Google Scholar]
  • 11. Saunders P. Urban politics. Hutchinson; 1979. [Google Scholar]
  • 12. Blunt ME, Goldsmith MJF. Goldsmith Housing Policy and Administration: A Case Study. Occasional Papers in Politics no. 1. Department of Sociology, Government and Administration, University of Salford; 1969. [Google Scholar]
  • 13. Mollenkopf JH. A Phoenix in the ashes: the rise and fall of the Koch Coalition in New York city politics. Acta Cirurgica Brasilra. 1993;19(2):120‐125. [Google Scholar]
  • 14. Stone C. Regime Politics: Governing Atlanta 1946‐1988. University Press of Kansas; 1989. [Google Scholar]
  • 15. Abrams RM, Alasdair R. The logic of discipline: global capitalism and the architecture of government. Public Organ Rev. 2011;11(4):429‐431. [Google Scholar]
  • 16. Zhang Z, Jia M, Wan D. A research on proper allocation of control rights in PPP from a perspective of incomplete contract and relational contract. Foreign Econ Manag. 2007;29(8):5. [Google Scholar]
  • 17. Zhang Z, Jia M, Wan D. Allocation of control rights and cooperation efficiency in public‐private partnerships: theory and evidence from the Chinese pharmaceutical industry. Int J Health Care Finance Econ. 2009;9(2):169‐182. [DOI] [PubMed] [Google Scholar]
  • 18. Yancey AK. The meta‐volition model: organizational leadership is the key ingredient in getting society moving, literally! Prev Med. 2009;49(4):342‐351. [DOI] [PubMed] [Google Scholar]
  • 19. Wang Y, Zhao ZJ. Performance of public‐private partnerships and the influence of contractual arrangements. Public Perform Manag Rev. 2018;41(1):177‐200. [Google Scholar]
  • 20. Ma J, Lu M, Quan H. From a national, centrally planned health system to a system based on the market: lessons from China. Health Aff. 2008;27(4):937‐948. [DOI] [PubMed] [Google Scholar]
  • 21. Liu Y, Berman P, Yip W, et al. Health care in China: the role of non‐government providers. Health Policy. 2006;77(2):212‐220. [DOI] [PubMed] [Google Scholar]
  • 22. Preker AS, Harding A. The Economics of Public and Private Roles in Health Care: Insights from Institutional Economics and Organizational Theory. World Bank. 2000. [PMC free article] [PubMed]
  • 23. Bennett S, Dakpallah G, Garner P, et al. Carrot and stick: state mechanisms to influence private provider behaviour. Health Policy Plan. 1994;9(1):1‐13. [PubMed] [Google Scholar]
  • 24. Peng H, Huang Y. Welfare pluralism: welfare provision transformation from state to multi‐sectors. Nankai J. 2006;6. [Google Scholar]
  • 25. Jin JJ, Dong LJ, Qian WJ, Xia ZM, Huang JY. Development of China's private healthcare providers under the governments' encouragement and guiding policies. Chin J Health Policy. 2017;10(9):68‐74. [Google Scholar]
  • 26. Wang X, Pan J. Assessing the disparity in spatial access to hospital care in ethnic minority region in Sichuan Province, China. BMC Health Serv Res. 2016;16:399. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27. Zang X. Market reforms and Han–Muslim variation in employment in the Chinese state sector in a Chinese city. World Dev. 2008;36(11):2341‐2352. [Google Scholar]
  • 28. Gao W, Smyth R. Economic returns to speaking ‘standard Mandarin' among migrants in China's urban labour market. Econ Educ Rev. 2011;30(2):342‐352. [Google Scholar]
  • 29. Cao H. Urban–rural income disparity and urbanization: what is the role of spatial distribution of ethnic groups? A case study of Xinjiang Uyghur autonomous region in Western China. Reg Stud. 2010;44(8):965‐982. [Google Scholar]
  • 30. Sun J, Wang QQ, Wen QL, Chen F, Zhu PH. A study on the current situation and prediction of development of private hospitals in China. Smart Healthcare. 2017;3(13):123‐128. [Google Scholar]
  • 31. Keqiang L. Deepening the reform of health care. Qiushi, English. 2012;004(001):25‐45. [Google Scholar]
  • 32. Hao Z. Research on the Reform of Operating Fund Compensation Mechanism in Public Hospitals (Master of Management), Chinese Medical Sciences University. 2018:R197.3.
  • 33. Jiang W, Qing LI, Zhu ZF. Research on the development status of private hospitals in China. Chin Health Econ. 2016;35(5):29‐31. [Google Scholar]
  • 34. Mei SZ, Huang HX. The development of non‐profit private hospitals in China: institutional obstacles and policy suggestions. Chin J Health Pol. 2014:33‐36. [Google Scholar]
  • 35. Antonio N, Feng C. Public–private partnerships in Chinese hospitals and knowledge transfer 1. Organizational Learning in Asia. 2017;24:153‐169. [Google Scholar]
  • 36. National Health Commission of the People's Republic of China . China Health Statistics Yearbook. 2020. Accessed June 6, 2023. http://www.nhc.gov.cn/mohwsbwstjxxzx/tjtjnj/202112/dcd39654d66c4e6abf4d7b1389becd01/files/7325fee02bf84676a15ebcfa827c9cd5.pdf
  • 37. Wei Y. Current problems of and governance strategy for the development of private medical institutions. Chin General Pract. 2016;19(13):1560‐1564. [Google Scholar]
  • 38. Zhang S, Gao Y, Feng Z, Sun W. PPP application in infrastructure development in China: institutional analysis and implications. Int J Project Manag. 2015;33(3):497‐509. [Google Scholar]
  • 39. Ge PJ, Zhang L. Operations and Practices of BT in Infrastructure Development. Fudan University Press; 2009. [Google Scholar]
  • 40. Xia Q, Ke Y, Wang SQ. Analysis of critical risk factors causing the failures of China's PPP projects. China Soft Science. 2009;5:107‐113. [Google Scholar]
  • 41. Tan SG, Bian JL. A Study of China's Judiciary System Reform. People's Public Security University of China Press; 2013. [Google Scholar]
  • 42. Wang SQ, Tiong R, Ting SK, Ashley D. Political risks: analysis of key contract clauses in China's BOT project. J Constr Eng Manag. 1999;125(3):190‐197. [Google Scholar]
  • 43. Bo Z. Look at the Chinese legal modernization from legal culture. Public Admin Law. 2013;2013(03):28‐31. [Google Scholar]
  • 44. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health. 2000;21(1):369‐402. [DOI] [PubMed] [Google Scholar]
  • 45. Butterfoss FD, Goodman RM, Wandersman A. Community coalitions for prevention and health promotion: factors predicting satisfaction, participation, and planning. Health Educ Q. 1996;23(1):65‐79. [DOI] [PubMed] [Google Scholar]
  • 46. Cheadle A, Beery W, Wagner E, et al. Conference report: community‐based health promotion—state of the art and recommendations for the future. Am J Prev Med. 1997;13(4):240‐243. [PubMed] [Google Scholar]
  • 47. Fawcett SB, Lewis RK, Paine‐Andrews A, et al. Evaluating community coalitions for prevention of substance abuse: the case of project freedom. Health Educ Behav. 1997;24(6):812‐828. [DOI] [PubMed] [Google Scholar]
  • 48. Scheirer MA. Is sustainability possible? A review and commentary on empirical studies of program sustainability. Am J Eval. 2016;26(3):320‐347. [Google Scholar]
  • 49. Labonte R, Laverack G. Capacity building in health promotion, part 1: for whom? And for what purpose? Crit Public Health. 2001;11(2):111‐127. [Google Scholar]
  • 50. Johnson K, Hays C, Center H, Daley C. Building capacity and sustainable prevention innovations: a sustainability planning model. Eval Program Plann. 2004;27(2):135‐149. [Google Scholar]
  • 51. Pluye P, Potvin L, Denis JL. Making public health programs last: conceptualizing sustainability. Eval Program Plan. 2004;27(2):121‐133. [Google Scholar]
  • 52. Simon PA, Fielding JE. Public health and business: a partnership that makes cents. Health Aff. 2006;25(4):1029‐1039. [DOI] [PubMed] [Google Scholar]
  • 53. Friedman C, Mckenna MT, Ahmed F, et al. Assessing the burden of disease among an employed population: implications for employer‐sponsored prevention programs. J Occup Environ Med. 2004;46:3‐9. [DOI] [PubMed] [Google Scholar]
  • 54. Finkelstein E, Fiebelkorn IC, Wang G. The costs of obesity among full‐time employees. Am J Health Promot. 2005;20(1):45‐51. [DOI] [PubMed] [Google Scholar]
  • 55. Dearing JW, Maibach EW, Buller DB. A convergent diffusion and social marketing approach for disseminating proven approaches to physical activity promotion. Am J Prev Med. 2006;31(4‐suppl):11‐23. [DOI] [PubMed] [Google Scholar]
  • 56. Fenton M. Battling America's epidemic of physical inactivity: building more walkable, livable communities. J Nutr Educ Behav. 2005;37:S115‐S118. [DOI] [PubMed] [Google Scholar]
  • 57. Green L, Daniel M, Novick L. Partnerships and coalitions for community‐based research. Public Health Rep. 2001;116(1_suppl):20‐31. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58. Kushner KE. Embodied context: social institutional influences on employed mothers' health decision making. Health Care Women Int. 2005;26(1):69‐86. [DOI] [PubMed] [Google Scholar]
  • 59. Tavares LS, Plotnikoff RC. Not enough time? Individual and environmental implications for workplace physical activity programming among women with and without young children. Health Care Women Int. 2008;29(3):244‐281. [DOI] [PubMed] [Google Scholar]
  • 60. Francesconi M, Muthoo A. Control rights in public‐private partnerships. Soc Sci Electr Publ. 2006;2(1):26‐27. [Google Scholar]
  • 61. Martimort D, Pouyet J. To build or not to build: normative and positive theories of public‐private partnerships. Int J Ind Organ. 2008;26:393‐411. [Google Scholar]
  • 62. Daniels R, Trebilcock M. An Organisational Analysis of the Public‐Private Partnership in the Provision of Public Infrastructure. MIT Press; 2000. [Google Scholar]
  • 63. Oliver H. Incomplete contracts and public ownership: remarks, and an application to public‐private partnerships. Econ J (London). 2003;486:C69‐C76. [Google Scholar]
  • 64. Laffont JJ, Martimort D. Collusion and Delegation. Institut d'Économie Industrielle (IDEI); 1995. [Google Scholar]
  • 65. Mookherjee D, Tsumagari M. The organization of supplier networks: effects of delegation and intermediation. Econometrica. 2004;72(4):1179‐1219. [Google Scholar]
  • 66. Schmitz PW. Allocating control in agency problems with limited liability and sequential hidden actions. Bonn Econ Discussion Papers. 2005.
  • 67. Zhang X. Critical success factors for public–private partnerships in infrastructure development. J Constr Eng Manag. 2005;131(1):3‐14. [Google Scholar]
  • 68. Delmon J. BOO/BOT Projects: A Commercial and Contractual Guide. Sweet & Maxwell Limited; 2000. [Google Scholar]
  • 69. Morledge R, Owen K. Developing a methodological approach to the identification of factors critical to success in privatized infrastructure projects in the UK. Proceeding CIB W92 and CIB TG 23 Joint Symposium: Profitable Partnering in Construction Procurement, 487–498.
  • 70. Zhang X. Concessionaire selection: methods and criteria. J Constr Eng Manag. 2004;130(2):235‐244. [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supporting information.

Click here for additional data file. (16.5KB, docx)

Data Availability Statement

The data sets generated and analyzed during the current study are available from the corresponding author upon reasonable request.

Articles from Chronic Diseases and Translational Medicine are provided here courtesy of Chinese Medical Association

RESOURCES