INTRODUCTION

The health system in Peru is characterized by being fragmented, of low production, and of little coordination between the sectors that compose it, with very deficient stewardship¹; moving towards recuperative health and neglects the function of prevention and health promotion. One of the components is the Social Security of Peru (EsSalud), which covers 11.5 million people (30% of the Peruvian population), whose financing comes from the contribution of employers, which corresponds to 9% of the worker's salary and provides health services through its 409 health establishments distributed nationwide².

The main problem of EsSalud is the perception of the insured population of poor quality of service that does not find medical appointments when requesting them, either in person, by telephone, or through web platforms. Likewise, many appointments are provided one to two months after being requested, even in some cases, for example, in neurosurgery; they are granted after six months. This causes continuous claims from the population and a double expense for the insured, for having to go to private services, different from EsSalud, to be able to solve their acute health problems, and they end up going to various hospital centers for emergencies, generating overcrowding and long stays. in emergency rooms³.

It is necessary to consider that the population assigned to EsSalud is similar to that of developed countries since they have a life expectancy that exceeds the national average (> 76 years). This insured population suffers from chronic health problems that lead to repeated medical consultations and an over-demand of emergency services, requiring hospital management to perform optimally to meet the health demands of the population adequately. In addition, EsSalud lacks infrastructural planning, since in recent years it has gone from serving 8 to 11.5 million insured persons with the same infrastructure and a scant increase in human resources, generating an overload of care for health personnel, who it harms organizational performance, prevailing demotivation, adverse work environment and internal user dissatisfaction⁴.

To help solve these problems, the best international experiences are observed; This is how in Peru, since 2008, the model of Public-Private Health Associations (PPPs) has been worked on, the national legal framework is created and after the respective learning, two PPP contracts were signed in 2011⁵, one of them with the Alberto Leonardo Barton Thompson Hospital in Callao, constituting the first experience that works under this modality in Latin America. This hospital has 25 medical and surgical specialties; In addition, it has 215 beds, 07 operating rooms, 03 delivery rooms, a hemodialysis unit, 100 outpatient clinics, and state-of-the-art equipment, which has 250,000 affiliated insured persons⁶.

This APP was conceived as a pilot to seek the best performance of the health system before being applied in the rest of similar hospital centers of the Peruvian health system. Therefore, the objective of this research is to measure the impact of the public-private partnership management model in the hospital management system of Essalud level II, Callao region 2019, to serve as input in decision-making of Peruvian public policies. in health, likewise, as a benchmark in Latin American countries and other low-middle income countries that have deficient health systems with economic income from the state that do not cover the total financing of health, as occurs in developed countries. The objective of this study was to measure the impact of the PPP management model on the EsSalud level II-2 hospital management system.

METHODS

RESULTS

Concerning hospital efficiency, it is observed that the Negreiros Hospital attends to more patients per hour (performance per hour 4.77), the beds are occupied more frequently (replacement interval 0.48), the number of patients who occupy a bed is greater (bed performance 9.93), there is a greater number of surgical interventions (operating room performance 161.63) and a greater number of deliveries per room (delivery room performance 173.81). While the Alberto Barton Hospital has more care per patient (concentration per consultation 2.80), it keeps its patients more days (average stay 4.18), more cesarean sections were performed (41.3% cesarean section rate), more operations were suspended (892.67). Patients were kept in ICU beds for a longer time (8.03). Likewise, a similar trend is observed in bed occupancy between both hospitals (84.2% vs. 88.6%). (Table 1)

Regarding the management hospital, interviews were conducted, and from the responses provided by the public officials of the HLNV and the HABT in what corresponds to the annual procurement plan, the HLNV carried it out in advance according to the needs of each of its areas, it was consolidated by the Benefit Network and sent to the Headquarters for approval; Similarly, the HABT worked on its annual plan from the middle of the year to have a good programming of materials, supplies, equipment and personnel.

In relation to the execution of expenses according to the activities programmed in the institutional operational plan and budget availability, according to the HLNV officials, there was an operational plan. However, it was not made known to them at the precise moment, the reason for which an adequate execution of the expenses was not carried out; The same thing happened with the Barton Hospital, the lack of knowledge of the operational plan was reflected in the shortage of materials, equipment, supplies, etc.

Regarding hospital infrastructure, HLNV workers mentioned limitations for staff such as lack of ergonomic chairs for administrative areas or uninstalled exhaust fans, while HABT workers stated that the hospital has good infrastructure, but there are problems in some environments such as the waiting room, where there is a risk of cross-infection due to lack of maintenance and ventilation.

Regarding epidemiological surveillance, Negreiros Hospital officials noted that the lack of budget and personnel limits the planning area, and the quality area, which is the only one that has epidemiology personnel. Barton Hospital officials considered that epidemiological surveillance is deficient because favorable behaviors are not complied with, such as submitting reports of nosocomial infections, emerging diseases, and mandatory notification, etc.

Regarding the reports of financial and budget information, according to the norm, the officials of the Negreiros Hospital agreed that there was a delay in the reports because the information after its elaboration goes through the head of services and then by the administration area in coordination with the hospital costs area, this contrasts with the reports issued by the HABT in its beginnings according to what its workers said since these were precise and fully approved. Currently, they believe that the regulations are still being complied with.

Regarding labor promotion, the HLNV workers affirmed that there are personnel training programs and that labor promotion is handled internally in the Human Resources area and in the Central Headquarters.

On the other hand, in the case of HABT, if there is a job promotion, they look for internal staff as the first option, and if they do not find someone with the desired profile, they proceed to external advertising.

As for applying the directives issued by MINSA and the Ministry of Economy and Finance, in terms of management and execution of funds, HLNV officials affirm that there is no direct management of the budget, but they do generate information on their income and hospital costs. Based on the ESSALUD directive, the HABT officials do not have clear knowledge on the subject but presume the existence of mandatory compliance with the issued directives.

Regarding the alternative measures for compliance with payment of debt service, installment of debts, work for service received, follow-up of third parties for the collection, the HLNV workers stated that there was no installment system since the patients served pay according to their possibilities, many of them with debts up to now, however, there is a follow-up by amounts and also a follow-up for the service work received. On the other hand, the workers at Barton Hospital are unaware of the issue.

Concerning the public-private partnership management model, HLNV officials consider that given the high demand from users, for example in the emergency area, the APP serves to meet this type of demand and they qualify the model as fair-good. In the same way, the HABT workers consider that it is a good model because it allows them to offer a better service to EsSalud patients.

Regarding user satisfaction,Figure 1describes user satisfaction, where it was found, globally, that the HABT (APP) showed a higher level of satisfaction than the HLNV (93.3% vs 66. 6%), in terms of user satisfaction according to services, it is evident that 12% of users treated at the HABT feel very satisfied with the outpatient service and 8.7% of those who are treated at the HLNV had the same perception of satisfaction, globally 72.7% of HLNV users and 72% of HABT users are satisfied with this service; With regard to satisfaction with the emergency service, 15.3% of users seen at the HABT are very satisfied, and 9.3% of those seen at the HLNV had the same perception of satisfaction. Globally, 63.3% of HLNV users and 64.6% of HABT users are satisfied with this service; On the other hand, in the hospitalization service, 66.7% of users treated at the HABT are delighted, and 55.3% of those who are treated at the HLNV had the same level of satisfaction. Found that 86.6% of HLNV users and 74.0% of HABT users are satisfied with the service.

Figure 1: Global satisfaction of external users according to the PPP management model (HABT) or under the traditional model (HLNV), 2016-2018 

DISCUSSION

The PPP between the public health sector and the private sector is based on a business model that aims to take advantage of the experience of the private sector to improve the clinical performance of health facilities. Although the financial implications of such partnerships have been explored⁸, few studies have examined the impact of PPPs on clinical performance outcomes.

In this research, we evaluate the impact of PPPs, using quantitative measures that reflect hospital efficiency, financial management, and user satisfaction.

Regarding the hospital indicators, it is observed that the behavior is variable in both hospitals. Compared to the national averages, they are below the average in most indicators but with more advantageous results in the HLNV⁷.

It has been observed that the health establishment under the public-private association modality has a physician-hour performance below the national standard, with a decreasing trend in recent years, and is lower compared to the HLNV⁷. The average number of consultations in both hospitals is below the standard, less than 3.5 consultations on average⁷. Regarding the average length of stay or days of stay, this is much higher in the HABT than the HLNV (close to 2 extra days on average).

In both hospitals, programs were developed for job promotion, where the first option is sought among the internal staff and in the case of not finding the person with the profile sought, the external promotion is made. However, there were aspects that were not optimally managed in both hospitals, such as the annual procurement plan, the program to strengthen capacities and skills for the administrative systems (budget, treasury, and accounting), lack of knowledge of the operating plan, and lack of knowledge of the board of directors. issued by MINSA and the Ministry of Economy and Finance in matters of management and execution of funds.

The officials of both health establishments considered that the public-private partnership model was good, since it offers adequate service to EsSalud patients. These results are in agreement with those reported by Pérez et al.⁹, who carried out an investigation entitled "Multilevel analysis of the technical efficiency of hospitals in the Spanish National Health System by type of ownership and management", the results suggested that traditional hospitals have a lower average efficiency index compared to hospitals with public-private collaboration. For their part, Franco and Fullana¹⁰, found that PPP management models have greater assistance and spending efficiency than other forms of management. While, traditionally managed hospitals have better research efficiency results compared to other forms of management.

These results correspond to those observed by Jorge et al.¹¹who carried out an investigation entitled "Efficient Management of Primary Health Care at the first level of care and its impact on the level of user satisfaction: EsSalud Case" and where it was found that the PPP management model Based on management in Primary Health Care, it improves the satisfaction of the insured, determined by accessibility to appointments, delivery of medicines and medical and non-medical care. For his part, Paripancca¹²found that there was a significant relationship between the dimensions of quality of care and the satisfaction of external users referred in a public-private association hospital.

The results of this research do not confirm the results observed in the international context, where health establishments are administered by a PPP, as in another study by Franco and Fullana¹³where they compare three types of establishments: private management, public-public association private and public management, the former being the one with the best efficiency rates. There are several favorable elements that support the traditional management model as in the Negreiros Hospital, first of all, with more efficient hospital indicators such as medical hour performance, occupancy percentage and performance per bed, operating room performance, suspended operations , delivery room performance and average ICU stay. In the second instance, it is related to financial and budget information, with similar results in both models, however, the hospital by PPP modality spends three times more than one by traditional modality, and, finally, a higher level of global satisfaction to 60% and in many cases as an outpatient clinic and hospitalization with higher satisfaction indicators than the APP model.

The differences are not revealing in both models of hospital management, with weaknesses and strengths in both formats, it is appropriate to establish corrective actions or measures to address these critical aspects and strengthen the favorable aspects, focused on improving the quality of care of the insured patient and consequently raise the quality of life of the same. Likewise, the establishment of a human resource needs plan is recommended to provide sufficient assistance personnel and adequately condition the environments such as the expansion of these in many areas such as waiting, emergency, administrative, epidemiological surveillance, among others, in both hospitals, to meet the great demand of patients in such a way as to optimize hospital efficiency.

Within the limitations of the study, it is found that, having carried out a qualitative analysis and a descriptive quantitative comparison, without carrying out inferential analysis; there is no empirical evidence to show that one model is superior to another; however, what has been observed could make us think that there are no revealing differences between both management models.

CONCLUSIONS

The results showed that a PPP modality health facility such as the HABT does not seem to present better results than a traditional format facility such as the HLNV. The hospital efficiency indicators seem slightly more favorable in a traditional format model compared to the PPP management model, highlighting the hourly medical performance. The financial management indicators favored both models, however, the PPP management modality showed a budget execution three times higher compared to the traditional management model. Finally, the general satisfaction of the user of a health establishment with a PPP management model was higher compared to the traditional model.