Political accountability, incentives, and Contractual design of public private partnerships

Service adaptations, when there is changing demand or problems regarding the service provision, constitute a major issue in Public Private Partnerships (PPPs). So far, studies have explained the ex post adaptation problems by the distorted incentives for the private public-service provider to invest in adaptation efforts. However, as any PPP is between a public authority and a private public-service provider (no market price), public authorities have also an important role to play in the adaptation of the private public-service provision over time. This paper studies how the contractual design of PPPs affects accountability and incentives for contractually unanticipated service adaptations. More specifically, we observe worldwide two main different contracting out procedures: the concession contract and the availability contract. The main difference between these two contractual practices concerns the demand risk, which is borne by private providers in the first case and by public authorities in the second case. This paper shows that there are two main effects of the contractual design on accountability. (1) Concession contracts, compared to availability contracts, motivate more public authorities from investigating and responding to public demands. This is due to the fact that under a concession contract consumers are empowered, i.e. have the possibility to oust the private provider, which provides public authorities with more credibility in side-trading. (2) Concession contracts can give greater adaptation effort incentives to private providers than availability contracts, since, if private providers bear the demand risk, they can receive private gains from implementing the adaptation. The striking policy implication of this paper is then that the trend towards a greater resort to contracts where private providers bear little or no demand risk may not be optimal in terms of allocative efficiency

Political accountability, incentives, and Contractual design of public private partnerships

Service adaptations, when there is changing demand or problems regarding the service provision, constitute a major issue in Public Private Partnerships (PPPs). So far, studies have explained the ex post adaptation problems by the distorted incentives for the private public-service provider to invest in adaptation efforts. However, as any PPP is between a public authority and a private public-service provider (no market price), public authorities have also an important role to play in the adaptation of the private public-service provision over time. This paper studies how the contractual design of PPPs affects accountability and incentives for contractually unanticipated service adaptations. More specifically, we observe worldwide two main different contracting out procedures: the concession contract and the availability contract. The main difference between these two contractual practices concerns the demand risk, which is borne by private providers in the first case and by public authorities in the second case. This paper shows that there are two main effects of the contractual design on accountability. (1) Concession contracts, compared to availability contracts, motivate more public authorities from investigating and responding to public demands. This is due to the fact that under a concession contract consumers are empowered, i.e. have the possibility to oust the private provider, which provides public authorities with more credibility in side-trading. (2) Concession contracts can give greater adaptation effort incentives to private providers than availability contracts, since, if private providers bear the demand risk, they can receive private gains from implementing the adaptation. The striking policy implication of this paper is then that the trend towards a greater resort to contracts where private providers bear little or no demand risk may not be optimal in terms of allocative efficiency

Government Contracting with Faith-Based Providers: An Economic Perspective

This article analyses the policy debate surrounding the possible expansion of government contracting with faith-based providers of social services, from the perspective of recent developments in the economics of contracts. It presents a non-technical introduction to the economic tools used in the study of contracts, in particular the decision faced by governments of whether to provide services in-house or to contract out to a private nonprofit organization. In particular the paper looks at the problems of monitoring the quality of service provision and ensuring fairness in the procurement process. When the analysis is applied to the question of faith-based provision, the conclusion is that monitoring the terms of the contract is less of an issue than the debates that will arise over the distribution of contracts across different faith-based organizations. Working Paper 06-2

Performance-Based Financing: Report on Feasibility and Implementation Options Final September 2007

This study examines the feasibility of introducing a performance-related bonus scheme in the health sector. After describing the Tanzania health context, we define “Performance-Based Financing”, examine its rationale and review the evidence on its effectiveness. The following sections systematically assess the potential for applying the scheme in Tanzania. On the basis of risks and concerns identified, detailed design options and recommendations are set out. The report concludes with a (preliminary) indication of the costs of such a scheme and recommends a way forward for implementation. We prefer the name “Payment for Performance” or “P4P”. This is because what is envisaged is a bonus payment that is earned by meeting performance targets1. The dominant financing for health care delivery would remain grant-based as at present. There is a strong case for introducing P4P. Its main purpose will be to motivate front-line health workers to improve service delivery performance. In recent years, funding for council health services has increased dramatically, without a commensurate increase in health service output. The need to tighten focus on results is widely acknowledged. So too is the need to hold health providers more accountable for performance at all levels, form the local to the national. P4P is expected to encourage CHMTs and health facilities to “manage by results”; to identify and address local constraints, and to find innovative ways to raise productivity and reach under-served groups. As well as leveraging more effective use of all resources, P4P will provide a powerful incentive at all levels to make sure that HMIS information is complete, accurate and timely. It is expected to enhance accountability between health facilities and their managers / governing committees as well as between the Council Health Department and the Local Government Authority. Better performance-monitoring will enable the national level to track aggregate progress against goals and will assist in identifying under-performers requiring remedial action. We recommend a P4P scheme that provides a monetary team bonus, dependent on a whole facility reaching facility-specific service delivery targets. The bonus would be paid quarterly and shared equally among health staff. It should target all government health facilities at the council level, and should also reward the CHMT for “whole council” performance. All participating facilities/councils are therefore rewarded for improvement rather than absolute levels of performance. Performance indicators should not number more than 10, should represent a “balanced score card” of basic health service delivery, should present no risk of “perverse incentive” and should be readily measurable. The same set of indicators should be used by all. CHMTs would assist facilities in setting targets and monitoring performance. RHMTs would play a similar role with respect to CHMTs. The Council Health Administration would provide a “check and balance” to avoid target manipulation and verify bonus payments due. The major constraint on feasibility is the poor state of health information. Our study confirmed the findings of previous ones, observing substantial omission and error in reports from facilities to CHMTs. We endorse the conclusion of previous reviewers that the main problem lies not with HMIS design, but with its functioning. We advocate a particular focus on empowering and enabling the use of information for management by facilities and CHMTs. We anticipate that P4P, combined with a major effort in HMIS capacity building – at the facility and council level – will deliver dramatic improvements in data quality and completeness. We recommend that the first wave of participating councils are selected on the basis that they can first demonstrate robust and accurate data. We anticipate that P4P for facilities will not deliver the desired benefits unless they have a greater degree of control to solve their own problems. We therefore propose - as a prior and essential condition – the introduction of petty cash imprests for all health facilities. We believe that such a measure would bring major benefits even to facilities that have not yet started P4P. It should also empower Health Facility Committees to play a more meaningful role in health service governance at the local level. We recommend to Government that P4P bonuses, as described here, are implemented across Mainland Tanzania on a phased basis. The main constraint on the pace of roll-out is the time required to bring information systems up to standard. Councils that are not yet ready to institute P4P should get an equivalent amount of money – to be used as general revenue to finance their comprehensive council health plans. We also recommend that up-to-date reporting on performance against service delivery indicators is made a mandatory requirement for all councils and is also agreed as a standard requirement for the Joint Annual Health Sector Review. P4P can also be applied on the “demand-side” – for example to encourage women to present in case of obstetric emergencies. There is a strong empirical evidence base from other countries to demonstrate that such incentives can work. We recommend a separate policy decision on whether or not to introduce demand-side incentives. In our view, they are sufficiently promising to be tried out on an experimental basis. When taken to national scale (all councils, excepting higher level hospitals), the scheme would require annual budgetary provision of about 6 billion shillings for bonus payments. This is equivalent to 1% of the national health budget, or about 3% of budgetary resources for health at the council level. We anticipate that design and implementation costs would amount to about 5 billion shillings over 5 years – the majority of this being devoted to HMIS strengthening at the facility level across the whole country

The private finance initiative (PFI) and finance capital: A note on gaps in the "accountability" debate

During recent years, a wide spectrum of research has questioned whether public services/infrastructure procurement through private finance, as exemplified by the UK Private Finance Initiative (PFI), meets minimum standard of democratic accountability. While broadly agreeing with some of these arguments, this paper suggests that this debate is flawed on two grounds. Firstly, PFI is not about effective procurement, or even about a pragmatic choice of procurement mechanisms which can potentially compromise public involvement and input; rather it is about a process where the state creates new profit opportunities at a time when the international financial system is increasingly lacking in safe investment opportunities. Secondly, because of its primary function as investment opportunity, PFI, by its very nature, prioritises the risk-return criteria of private finance over the needs of the public sector client and its stakeholders. Using two case studies of recent PFI projects, the paper illustrates some of the mechanisms through which finance capital exercises control over the PFI procurement process. The paper concludes that recent proposals aimed at “reforming” or “democratising” PFI fail to recognise the objective constraints which this type of state-finance capital nexus imposes on political process

Financing and Managing Public Services: An Assessment

Public services can be, and are, delivered according to a variety of different arrangements. The public sector can finance and provide a service itself, or contract with the private sector to participate in provision, or its role may be limited to regulating a private provider. In this paper we examine the features determining the effectiveness of public-service delivery, including incentives for employees and teams within organizations providing public services, the structure of the organization and the competitive framework that it faces, and the role of the private sector. We assess the reform programme in the UK, which has involved substantial reorganization of public services and increasing involvement of the private sector. Reforms focus on the improvement of incentives; but while incentives are critical, the special characteristics of public services (and the people who provide them) must be recognized in the implementation of new structures and incentive schemes.public services, public management

On the Road to Better Value: State Roles in Promoting Accountable Care Organizations

Outlines how accountable care organizations can deliver value through incentives to manage utilization, improve quality, and curb cost growth. Profiles states supporting the model with data, new payment methods, accountability measures, and other efforts