Public-private partnerships in the Spanish National Health System: The reversion of the Alzira model.

In the statutory Spanish National Health System (SNHS), the role of public provision is prominent. Nonetheless, since the inception of the SNHS, Regional Health Authorities have also purchased hospital care from private not-for-profit or for-profit providers, usually complementing public provision. Over the years, the autonomous community of Valencia has championed the use of Public Private Partnerships (PPP) in the form of administrative concessions (AC) awarded to private providers. In the La Ribera Health Department, which includes Alzira, the company Ribera Salud held the concession to provide hospital and primary care to the registered population since 1999 - and this became known as the Alzira model. In April 2018, when the administrative concession was expected to be renewed, Valencia's Health Authority decided to terminate the concession and to revert to direct public provision. While most stakeholders - and in particular the left-wing regional government - were in favour of reverting to public provision, advocates of the Alzira model argued that it was superior in terms of productivity, per capita expenditure and quality. The termination of the Alzira model led to further regulatory changes enacted in the Law for Health 8/2018, which clearly states that public provision is the preferred model of service delivery and new (tighter) requirements are defined for any future PPPs aiming to settle in the autonomous community of Valencia. This paper describes the process and provides background information to understand the underlying reasons of this policy development.