Overall Opinions of Participants on PPP in Management of Adverse Health Effects of Environmental Disasters
There were different views among the interviewees regarding the participation of the private sector in managing AHE of environmental disaster. Most participants saw the use of private sector power as a necessity. Most participants saw the use of private sector potential as a necessity.
Participant No. 7: "In my opinion, the public sector and the health system alone cannot manage the adverse health effects of the lake (drying lake) ... so has to get help from the private sector."
However, a limited number of participants considered not only the private sector participation in this area unhelpful, but also considered the presence of the private sector as a disorder in managing the AHEs. However, some dissenters believed, provided that disaster not managed by the private sector, the services could be purchased from private sector and outsourced some services as project and through contract.
Essential Prerequisites for PPP in Management of Adverse Health Effects of Environmental Disasters
The majority of participants believed that the private sector's participation in health sector had not been defined so far, and given the increasing population and the inability of the public sector to perform this task, the abilities of the private sector can be utilized, which currently the legal infrastructure and required resources to implement it, are not provided. In order to formulate a legal framework, protective and deterrent legal requirements must be considered. Also, after the provision of resources and facilities, resources must be allocated according to actual priorities and needs.
Some participants considered changing the public sector's negative view of the private sector, and the public sector's readiness for monitoring and evaluation as the prerequisites for participation with the private sector.
Participant No. 3: "We should not look at the private sector with a negative view and there should be a benefit to the private sector to be willing to participate ...".
Participants believed that by holding meetings with private sector and attracting their support, the ability and energy of this sector could be used to control AHEs in the form of PPP. The contracts should also be such that payments to private sector were based on the process and the obtained results. In the opinion of one participant, there are two prerequisites for outsourcing some services to the private sector: firs the private sector would had sufficient ability and the second the public sector had monitoring and evaluation ability. Participants believed that a committee for AHEs of drying lake should be set up, composed of experts from different related fields, which would be responsible for the surveillance system of AHEs caused by the drying lake.
Areas that the private sector can participate
In the opinion of some participants, there is little incentive for private sector to participate in the management of AHEs of environmental disasters. But some other participants believe that if the areas, tasks and services in which the private sector can participate are clearly identified, this will be beneficial and effective for the public sector and the private sector itself. In this case, the control and treatment of AHEs of drying lakes can be assigned to the private sector to reduce the burden on the public sector to some extent, and the private sector will also achieve its goal of earning money. The second is for the private sector to do so on behalf of the public sector, and the public sector to buy these services from them.
Areas that the private sector can participate to include education, research, consultation, management, monitoring and surveillance (monitoring and evaluation of pollutants, monitoring and reporting of AHEs' symptoms, control measures including diagnosis and treatment). According to the interviewees, the private sector can be effective in identifying patients, referring patients to treatment centers, following up treatment to the full recovery, educating families to prevent AHEs caused by dusts, follow up treatment, and so on. Participants believed that private sector knowledge could also be applied in the areas of executive and research in the form of contracts and agreements. They also saw the supply of human resources (especially specialist and experts) as another task that could be done by private sector through partnership.
Participants believe that the involvement of the private sector in the assessment the status quo and analyzing the statistical data collected through the surveillance system will be helpful, so that public sector have the opportunity to manage and strengthen the surveillance system. One participant believed that to determine the appropriate areas for private sector participation, a preliminary assessment should be carried out to accurately identify the AHEs caused by environmental disaster. The results of the initial implementation of the surveillance system should also be introduced.
Participant No. 4: "... if the results of the evaluation are extracted and the results of the initial implementation of the surveillance system are provided, it is easy to determine in which sectors the private sector can participate."
Monitoring and evaluation of private sector performance
Participants believe that private sector monitoring and evaluation should be systematic. The services provided must be documented and indexes and indicators developed and reported periodically and at short intervals. Inputs, processes, and outputs should be considered in monitoring and evaluation. Monitoring and evaluation should be performed by public sector staff.
Participant No. 18: "Monitoring and evaluation should be done with agreed and predetermined monitoring and evaluation checklists with specific dates ... Monitoring and evaluation should be implemented on a continuous and consistent basis, in accordance with a pre-established schedule ...".
How to pay to the private sector for managing adverse health effects
In the interviewees' view, payments should be based on the result and effectiveness of the partnership. In fact, rigorous and rationale goals, indicators and standards should be determined and proper checklists for monitoring and evaluation should be developed, so that payments should be made based on them and for achieving periodic goals. Indicators and goals of evaluation should be based on the work process, the outcome of the activities and their effectiveness. Payments should also be based on the level of performance and after performance appraisal and approval by the appropriate experts and entities.
Most participants stated that a combination of fee for services, per capita and pay for performance methods could be used. However, the majority of participants considered paying in return for identifying and referring patients, as the best method of payment. Participants also believed that payments should be based on specific tariffs in line with the policies of the Ministry of Health as determined by the expert team. A number of participants also believed that payments should be made on the basis of agreements between the private and public sectors and be clearly and precisely included in the contract. Quality of service is also one of the things that how to measure it should be specified in the contract and have a direct impact on payments.
Achievements and implications of PPP to manage adverse health effects caused by environmental disasters
Study participants highlighted the following as the most important potential outcomes and achievements of private sector participation in managing the AHEs of environmental disasters:
- Avoid waste of resources: Participants believed that partnership with the private sector can help to prevent waste of resources;
- Improving service coverage: In this regard, participant No. 1 stated: "... private-sector participation can lead to increased identification of at-risk individuals, community-based education in districts and families, and advancement of public health goals ...";
- Greater efficiency: By waste reduction and better management of resources;
- Access to more information: Considering the part of the community referring to the private sector for the treatment, a considerable amount of data can be obtained from the private sector, which can therefore influence health interventions and management of AHEs.
- Opportunity for the public sector to perform stewardship tasks: Its most important achievement, given the extent of the affected areas and the diversity of health effects in need of care, will be to provide managers with an opportunity to address the more important issues and develop the surveillance system.
- Public participation: In this regard, participant No. 8 said: "The only area where the private sector can participate is to attract people and volunteers participation. This is where we lame ...".
Designing and validating the framework
The initial framework consists of 24 options in 4 sections including: Essential infrastructures and backgrounds for PPPs, areas and services that the private sector can participate to, how to monitor and evaluate private sector performance and how to pay to the private sector, entered into the first phase of Delphi. In the first phase, after analyzing the experts' opinion, 2 options were omitted due to low scores, 8 were entered to the second phase, and 14 were finally accepted. In the second Delphi phase, 8 forms were responded, and due to the high agreement of the first and second phase, the Delphi was stopped, and at the end, 20 options were accepted and 4 options were excluded. Based on the results of the study, the PPP framework for Management of AHEs caused by drying lake, compose of 20 options in the 4 sections including essential infrastructure and backgrounds for PPPs, areas and services that the private sector can participate, how to monitor and evaluate the private sector performance (figure 1).
Figure 1: Public-private partnership framework for managing adverse health effects of drying lakes