Case Study: France Public – Private Partnerships in the French healthcare 1. PPP Law/Legal Framework/PPP Policy in Health France is known for its’ long tradition of concession arrangements that grew significantly over the second half of the 20th century to place France among the most PPP prominent countries in the world (EPEC, 2012). In the health sector though PPPs had to wait important reforms allowing tenders of design, construction and maintenance aspects to be conducted by private providers and permit deferred payment mechanisms. These are among others: Public Health Code : ? Law n° 2003-850 of September 2003 on simplification of the structure and the functioning of health system in France; ? Law n° 2004-559 of June 2004 on partnership contracts; ? Law n° 2004-806 on public health policy: o Hospital leasing (Bail Emphytéotique Hospitalier – BEH) is governed by articles L. 6148-1 to 6148-1 6148-6 and R. 6148-1 to R. 6148-3 of the Public Health Code (CSP); o Administrative leasing (Bail Emphytéotique Administrative – BEA) is governed by Article L. 315-9 of the CASF (Code of Social action and families) and by Article L.1311-2 of the General Code for Territorial entities 2. Centralised PPP Unit on health at country level/ Decentralised decision making (devolved/decentralized approach used for management of PPP) At the national level the Ministry of health is supported by MNAIH (Mission nationale d’appui à l’investissement hospitalier) currently submerged under ANAP (Agence Nationale d’Appui à la Performance des établissements de santé et médico-sociaux) At the Regional level, PPPs are under the responsibility of regional hospitalization agency (ARH -Agence Régionale d’hospitalisation) incorporated in the regional public health authority (agence régionale de la santé – ARS) As per article L6113-10 of the Public Health Code (http://www.anap.fr/fileadmin/user_upload/01- ANAP/historique/ConventionConstitutiveANAP.pdf) the main tasks of ANAP are among others: – The development and dissemination of tools and services to help healthcare facilities improve their performance and quality of services; – The support and assistance for restructuring, reconstructions and property management; – Evaluation, audit and expertise of hospital projects especially in real estate and information systems; – The control and conduct audits on the performance of healthcare facilities; – Support to regional health agencies in their mission operational control and improved health facility performance; Health and Economics Analysis for an Evaluation of the Public Private Partnerships in Health Care Delivery across EU 112 – The support of the central government in its task of strategic management of the provision of healthcare and medical services. Therefore ANAP is responsible for technical supervision and support to the ARHs and public healthcare institutions (EPSs) from inception of individual schemes onwards and is responsible for the development of legal and financial framework. Thus parallel to the monitoring and control investment plans ANAP (or previously MAINH) has developed various methodological tools: a guide to PPP implementation (BEH guide), hospital revitalization guide, observatory hospital construction. On its part, ARS was set up in bid rationalize the provision of healthcare services. It is responsible for policy implementation regarding all public health services. It ensures and monitors compliance with the rules on behalf of the central government (Ministry of health). It is in charge of authorizing the establishment and operation of all health facilities and health services and participates in the control of these institutions. 3. First PPP Contract: (year, name) Following the legal framework the 1st PPP project was signed in 2005: Douai Logipôle Hospital signed – 05/09/2005. The project had the value € 30 milions for design, build, finance and operation of a logistical support platform (logipole) at the Douai Hospital. In the same year (2005) the ophthalmological hospital Quinze Vingts in Paris followed and soon after were PPPs for: ? Centre hospitalier universitaire de Caen; ? Centre hospitalier du Sud Francilien at Corbeil-Essonnes; ? Centre hospitalier universitaire de Rennes; ? Centre les Tilleroyes at Besançon. 4. Total Number of PPP Contracts Under the framework of Plan Hôpital 2007, the Ministry of Health launched a national call for project proposals from hospitals. 35 proposals were submitted in 2003 of which 20 were selected following discussions with the MAINH. First contracts were signed in 2005. A second wave of PPP projects was launched in 2006 (not only falling under Plan Hôpital 2007) among which about a dozen used the Partnership contracts –PC rather than BEH. By 2012 about 50 contracts (40 BEH and 10 PC) had been signed of which the construction of 35 hospitals were completed and already at the operational phase (EPEC, 2012). 5. Model Since PPPs were introduced most of awarded contracts are related to real estates, most case PPPs fall under DBFO (design, build, finance, operate) involving infrastructure, Electronic medical records and Hospital Management as well as logistics. A number of PPPs was concluded as leasing and partnership contracts. It is worth noting that in France the term ‘public – private partnership’ primarily refers to contracts based on fee payment by a public authority while contract based on revenue operations are known as ‘concessions’ or ‘delegations de service public’. The diagram below gives an overview of the two widely used PPP models in

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