Public-private partnerships in a decentralised NHS: the case of Italy

The paper analyzes the evolution of the Public Private Partnerships in Italy since their introduction in the 1990s, focusing on the “institutional PPPs”, which may “involve the establishment of an entity held jointly by the public partner and the private partner” (EU Commission, 2004, p. 18). In the Italian case, several Regions converted public hospitals into institutional PPPs, creating “joint-stock companies” or “foundations”. The majority of the boards of the new entities, which have private legal status, are controlled by the local health authorities, while the private partners are in charge of managing the hospitals. The paper focuses on the PPP experience carried out in Emilia-Romagna and Lombardy, two important Regions ruled by governments with different political orientations. Institutional PPPs are set up with a different aim and play a different role in the two Regions. In Emilia-Romagna, institutional PPPs are aimed mainly at solving local planning problems in a “public” NHS, due to excessive bed capacity. In Lombardy, PPPs are part of a long-term strategy aimed at progressively privatising the provision and therefore they contribute to determine an “internal system change” (Wendt, Frisina and Rothgang, 2009) in the Regional Health Service. Different PPP conceptions also emerge in the way the Regional governments dealt with the problems determined by the transition from the public NHS employment regulation to those adopted in the private healthcare sector: a shift, which is seen as crucial in order to ensure greater managerial flexibility to the PPPs. Within the institutional PPPs, the “old” public NHS employees enjoy rather different pay and working conditions from the “new” staff directly hired by the public-private entity. In the two Regions, the problem of managing a two-tier workforce found different solutions, which are consistent with the role and aims attributed to the PPPs.