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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Very often&#44; the literature on public-private partnerships in healthcare assimilates public outsourcing&#44; public-private management competition&#44; market emulation&#46;&#46;&#46; with privatization&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> And from any of these managerial formulas some authors jump to political views on consequences such as an eventual reduction of finance &#40;austerity&#44; budget cuts&#41;&#44; elimination of services or inequity&#46; This is supposed to be driven by lower utilization&#44; which is always assumed to be related to a poorer quality&#44; leading to worse outcomes for the population in terms of mortality often under very short latency times anchored to some convenient political horizon&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The process is empirically measured by private spending&#44; more than by funding&#46; The private sector expenditure however aggregates data from a wide range of situations&#58; different contracts with a wide extent of policies<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#44; including in some cases cleaning&#44; security or catering services&#59; legal and accounting management tasks&#59; consulting services&#59; IT support&#59; ambulances and transfers&#59; social workers and certain home care services&#46; To the miscellany of content must be added the diversity of recipients&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> including transfers to charities and private not-for-profit organizations&#46; And when data are compared&#44; it is common to make <span class="elsevierStyleItalic">tabula rasa</span> of the legitimate healthcare policy actions&#44; according to the limits of the public responsibilities&#59; for example&#44; mixing up the case of the English regions &#8212;with no political autonomy&#8212; with the Spanish autonomous communities&#44; or the Italian local authorities &#8212;with quite large political decentralisation&#8212;&#44; or even inside countries &#8212;say between England and the rest of nations in the United Kingdom&#33;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In assessing impacts&#44; commonly language does not help either&#58; in Spanish&#44; &#8220;could affect&#8221; sounds similar to &#8220;might affect&#8221;&#46; That semantic dissociation emerges when one reads the abstract of some papers&#44; or the implications derived from the results&#44; with the complete more enriched content of the analysis&#46; By forgetting the associations that are not statistically significant in alternative measures to those chosen&#44; or the endogeneity of the relations that impede causality&#44; the policy-making purposes of the exercise seems to neglect the study&#59; particularly on the disclaims that the authors make when discuss the results&#44; or on the required future research agenda to &#8220;know better&#8221;&#46; These caveats usually come too late to be considered for political recommendations&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Having acknowledged this&#44; it is true that if we want to emulate in Spain such a nonsense approach in judging the effects of public-private partnerships&#44; even a daring analyst cannot do so properly due to lack of data &#40;risk premium for private finance&#44; proper case-mix adjustments in comparing activity&#44; actual direct and indirect transaction costs&#44; public deficits overruns or time delays in care provision&#44; existing public finance restrictions&#44; short and long term effects of those policies&#44; etc&#46;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What are we talking about when we speak about privatization&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">First of all&#44; in order to put the debate on the right track&#44; it is necessary to clarify the meaning of privatization<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#46; There is often an abuse of concepts&#44; including indirect public management services &#40;medium-long term &#8220;administrative concessions&#8221; or year by year contracting-out or <span class="elsevierStyleItalic">conciertos</span>&#41;&#44; private collaboration in building infrastructures&#44; running some facilities&#44; the logistical management of some equipments or publicly delegated management know-how of some public healthcare services&#46; All of them are forms of public management&#44; under budgetary finance and public regulation&#58; not a pure privatization of a social service&#46; This should be identified by limited access just to those individuals who can pay for it with no risk mutualisation&#46; Without this clear-cut clarification&#44; any public vs&#46; private analysis in my view loses academic interest from the beginning&#46; The cards are marked when any form of public provision with public responsibility but no public production is labelled as &#8220;privatisation&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Second&#44; translating all the forms and modalities of public-private partnerships in a unique variable does not make sense&#46; If all the contractual diversity is quantified in an item of expenditure&#44; the account unit cannot be interpreted thereafter for efficiency analysis&#58; the one who spends is not necessarily the same one who has financed the service&#44; or who is ultimately responsible for it&#46; From this it does not seem plausible to derive a pure coefficient that measures &#8220;the marginal impact of the resources utilisation&#8221;&#44; say on &#8220;mortality&#8221;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Third&#44; to translate resources from the &#8220;healthcare industry&#8221; into population health outcomes is a triple somersault&#59; even more if they are measured as mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a> It is well known that mortality is affected by so many and such diverse factors&#44; like education&#44; lifestyles&#44; income or social capital&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;7</span></a> that the <span class="elsevierStyleItalic">caeteris paribus</span> assumption either in cross sectional studies or over time is systematically violated&#44; leaving causality and the implications for health policy in speculative grounds&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Fourth&#44; comparisons across countries are impossible without fully accounting the institutional settings&#46; Even beyond the label of National Health Services&#44; the health systems of Greece&#44; Italy&#44; Spain or England &#40;not to say countries within UK&#41; are very different realities&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> Think of the English GP &#40;basically&#44; self-employed professionals&#41; and the Spanish statutory staff &#40;salaried public servants&#41;&#59; or with respect to some East European countries&#44; still with serious <span class="elsevierStyleItalic">under-the-table</span> pay problems&#46; &#8220;Privatization&#8221; does not mean the same in each of those countries&#59; not to say in USA&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally&#44; some analysts seem to move too quickly from the Hippocratic Oath of the health professional to the selfish behaviour of the <span class="elsevierStyleItalic">homo economicus</span>&#46; As Repullo puts it &#40;personal communication&#44; 2022&#41;&#58; &#8220;A good public management would be one that reduces the &#8216;privatization&#8217; promoted by public employees themselves when using their publicly contracted time for private activities&#59; when using public resources for private gain&#59; when conducting amicable or lucrative cuttings of waiting lists&#59; when fishing patients from the public to the private side&#59; when preferentially using public diagnostic tools for private patients&#59; when receiving payments to obtain public assistance&#59; or through the &#8216;dichotomy&#8217; with which a specialist or a laboratory unit or an imaging unit rewards referrals and tests with a percentage to the doctor who has prescribed them&#8221;&#46; As other authors have emphasized&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9</span></a> one must also ask oneself whether poor public governance allows welfare state servants to use the state for their own welfare&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In brief&#44; public-private partnership is an ambiguous&#44; polyvalent and equivocal concept&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9&#44;10</span></a> In a very recent paper&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> Fabre and Straub conclude that the existing evidence on public-private partnerships paints a rather mixed picture&#58; &#8220;The jury is still very much out regarding the efficiency gains provided by PPPs&#44; and more good-quality studies with convincing identification strategies are needed&#46; What is abundantly clear&#44; however&#44; is that the evidence is closely linked to the institutional context in which they are implemented&#44; to the historical and political landscape in which they take place&#44; and to the specific contracts and regulatory designs&#8221;&#46; Indeed&#44; as commented&#44; no normative theory allows expanding effects and prescriptions out of those environments&#46; In addition&#44; methodologies must be robust to endogeneity and adjust to case by case analysis&#46; Macro prescriptions <span class="elsevierStyleItalic">urbi et orbi</span> with aggregate data if associated to health outcomes to derive causality are particularly inadequate&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In Spain&#44; as in some other countries&#44; decisions regarding the collaboration or confrontation of public and private interests in the provision of healthcare services seem to be led more by ideology rather than by a well-founded debate&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">12-14</span></a> So far&#44; existing reviews do not clarify adequately the arena of the public-private debate&#44; due to lack of data&#59; and when information does exist&#44; it can also be biased&#46; We do not have moreover empirical evidence on data on different debt risk premium for private finance&#44; proper case-mix adjustments in comparing activity&#44; actual direct and indirect transaction costs&#44; public deficits overruns or time delays in care provision&#44; existing public finance restrictions&#44; short and long term effects of those policies&#44; and so on&#46; Without all these adjustments&#44; we argue that with such data lacking&#44; plus the absence of robust methodological approaches for the analysis&#44; the supposed <span class="elsevierStyleItalic">evidence-based</span> evaluation of public private partnerships becomes an act of faith under political premises&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Autorship contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">G&#46; L&#243;pez-Casasnovas is the sole author of the article&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Debate
The lack of data and the conceptual mistakes in assessing public-private partnerships as a form of healthcare privatization
La falta de datos y las equivocaciones conceptuales al evaluar los partenariados público-privados como un tipo de privatización sanitaria
Guillem López-Casasnovas
Corresponding author
guillem.lopez@upf.edu

Corresponding author.
Departament d’Economia i Empresa, Universitat Pompeu Fabra; Centre for Research in Health and Economics, Barcelona Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Very often&#44; the literature on public-private partnerships in healthcare assimilates public outsourcing&#44; public-private management competition&#44; market emulation&#46;&#46;&#46; with privatization&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;2</span></a> And from any of these managerial formulas some authors jump to political views on consequences such as an eventual reduction of finance &#40;austerity&#44; budget cuts&#41;&#44; elimination of services or inequity&#46; This is supposed to be driven by lower utilization&#44; which is always assumed to be related to a poorer quality&#44; leading to worse outcomes for the population in terms of mortality often under very short latency times anchored to some convenient political horizon&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The process is empirically measured by private spending&#44; more than by funding&#46; The private sector expenditure however aggregates data from a wide range of situations&#58; different contracts with a wide extent of policies<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#44; including in some cases cleaning&#44; security or catering services&#59; legal and accounting management tasks&#59; consulting services&#59; IT support&#59; ambulances and transfers&#59; social workers and certain home care services&#46; To the miscellany of content must be added the diversity of recipients&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">3</span></a> including transfers to charities and private not-for-profit organizations&#46; And when data are compared&#44; it is common to make <span class="elsevierStyleItalic">tabula rasa</span> of the legitimate healthcare policy actions&#44; according to the limits of the public responsibilities&#59; for example&#44; mixing up the case of the English regions &#8212;with no political autonomy&#8212; with the Spanish autonomous communities&#44; or the Italian local authorities &#8212;with quite large political decentralisation&#8212;&#44; or even inside countries &#8212;say between England and the rest of nations in the United Kingdom&#33;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In assessing impacts&#44; commonly language does not help either&#58; in Spanish&#44; &#8220;could affect&#8221; sounds similar to &#8220;might affect&#8221;&#46; That semantic dissociation emerges when one reads the abstract of some papers&#44; or the implications derived from the results&#44; with the complete more enriched content of the analysis&#46; By forgetting the associations that are not statistically significant in alternative measures to those chosen&#44; or the endogeneity of the relations that impede causality&#44; the policy-making purposes of the exercise seems to neglect the study&#59; particularly on the disclaims that the authors make when discuss the results&#44; or on the required future research agenda to &#8220;know better&#8221;&#46; These caveats usually come too late to be considered for political recommendations&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Having acknowledged this&#44; it is true that if we want to emulate in Spain such a nonsense approach in judging the effects of public-private partnerships&#44; even a daring analyst cannot do so properly due to lack of data &#40;risk premium for private finance&#44; proper case-mix adjustments in comparing activity&#44; actual direct and indirect transaction costs&#44; public deficits overruns or time delays in care provision&#44; existing public finance restrictions&#44; short and long term effects of those policies&#44; etc&#46;&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">What are we talking about when we speak about privatization&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">First of all&#44; in order to put the debate on the right track&#44; it is necessary to clarify the meaning of privatization<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#46; There is often an abuse of concepts&#44; including indirect public management services &#40;medium-long term &#8220;administrative concessions&#8221; or year by year contracting-out or <span class="elsevierStyleItalic">conciertos</span>&#41;&#44; private collaboration in building infrastructures&#44; running some facilities&#44; the logistical management of some equipments or publicly delegated management know-how of some public healthcare services&#46; All of them are forms of public management&#44; under budgetary finance and public regulation&#58; not a pure privatization of a social service&#46; This should be identified by limited access just to those individuals who can pay for it with no risk mutualisation&#46; Without this clear-cut clarification&#44; any public vs&#46; private analysis in my view loses academic interest from the beginning&#46; The cards are marked when any form of public provision with public responsibility but no public production is labelled as &#8220;privatisation&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Second&#44; translating all the forms and modalities of public-private partnerships in a unique variable does not make sense&#46; If all the contractual diversity is quantified in an item of expenditure&#44; the account unit cannot be interpreted thereafter for efficiency analysis&#58; the one who spends is not necessarily the same one who has financed the service&#44; or who is ultimately responsible for it&#46; From this it does not seem plausible to derive a pure coefficient that measures &#8220;the marginal impact of the resources utilisation&#8221;&#44; say on &#8220;mortality&#8221;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Third&#44; to translate resources from the &#8220;healthcare industry&#8221; into population health outcomes is a triple somersault&#59; even more if they are measured as mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a> It is well known that mortality is affected by so many and such diverse factors&#44; like education&#44; lifestyles&#44; income or social capital&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;7</span></a> that the <span class="elsevierStyleItalic">caeteris paribus</span> assumption either in cross sectional studies or over time is systematically violated&#44; leaving causality and the implications for health policy in speculative grounds&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Fourth&#44; comparisons across countries are impossible without fully accounting the institutional settings&#46; Even beyond the label of National Health Services&#44; the health systems of Greece&#44; Italy&#44; Spain or England &#40;not to say countries within UK&#41; are very different realities&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a> Think of the English GP &#40;basically&#44; self-employed professionals&#41; and the Spanish statutory staff &#40;salaried public servants&#41;&#59; or with respect to some East European countries&#44; still with serious <span class="elsevierStyleItalic">under-the-table</span> pay problems&#46; &#8220;Privatization&#8221; does not mean the same in each of those countries&#59; not to say in USA&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally&#44; some analysts seem to move too quickly from the Hippocratic Oath of the health professional to the selfish behaviour of the <span class="elsevierStyleItalic">homo economicus</span>&#46; As Repullo puts it &#40;personal communication&#44; 2022&#41;&#58; &#8220;A good public management would be one that reduces the &#8216;privatization&#8217; promoted by public employees themselves when using their publicly contracted time for private activities&#59; when using public resources for private gain&#59; when conducting amicable or lucrative cuttings of waiting lists&#59; when fishing patients from the public to the private side&#59; when preferentially using public diagnostic tools for private patients&#59; when receiving payments to obtain public assistance&#59; or through the &#8216;dichotomy&#8217; with which a specialist or a laboratory unit or an imaging unit rewards referrals and tests with a percentage to the doctor who has prescribed them&#8221;&#46; As other authors have emphasized&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;9</span></a> one must also ask oneself whether poor public governance allows welfare state servants to use the state for their own welfare&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In brief&#44; public-private partnership is an ambiguous&#44; polyvalent and equivocal concept&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">9&#44;10</span></a> In a very recent paper&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> Fabre and Straub conclude that the existing evidence on public-private partnerships paints a rather mixed picture&#58; &#8220;The jury is still very much out regarding the efficiency gains provided by PPPs&#44; and more good-quality studies with convincing identification strategies are needed&#46; What is abundantly clear&#44; however&#44; is that the evidence is closely linked to the institutional context in which they are implemented&#44; to the historical and political landscape in which they take place&#44; and to the specific contracts and regulatory designs&#8221;&#46; Indeed&#44; as commented&#44; no normative theory allows expanding effects and prescriptions out of those environments&#46; In addition&#44; methodologies must be robust to endogeneity and adjust to case by case analysis&#46; Macro prescriptions <span class="elsevierStyleItalic">urbi et orbi</span> with aggregate data if associated to health outcomes to derive causality are particularly inadequate&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In Spain&#44; as in some other countries&#44; decisions regarding the collaboration or confrontation of public and private interests in the provision of healthcare services seem to be led more by ideology rather than by a well-founded debate&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">12-14</span></a> So far&#44; existing reviews do not clarify adequately the arena of the public-private debate&#44; due to lack of data&#59; and when information does exist&#44; it can also be biased&#46; We do not have moreover empirical evidence on data on different debt risk premium for private finance&#44; proper case-mix adjustments in comparing activity&#44; actual direct and indirect transaction costs&#44; public deficits overruns or time delays in care provision&#44; existing public finance restrictions&#44; short and long term effects of those policies&#44; and so on&#46; Without all these adjustments&#44; we argue that with such data lacking&#44; plus the absence of robust methodological approaches for the analysis&#44; the supposed <span class="elsevierStyleItalic">evidence-based</span> evaluation of public private partnerships becomes an act of faith under political premises&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Autorship contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">G&#46; L&#243;pez-Casasnovas is the sole author of the article&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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ISSN: 02139111
Original language: English
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