Introduction

Hospitals play critical roles in health systems, delivering essential care for routine conditions and specialty care for complex and critical patients. In low- and middle-income countries (LMICs), which generally have fewer physicians per capita [1,2], public hospitals hold an even more prominent position. However, persistent health system challenges in LMICs coupled with limited resources, call for innovations in service delivery and funding.

A public-private partnership (PPP), a long-term, formalized cooperation between the public- and private-sectors, combines the competencies of both partners to achieve specific outcomes, allowing governments to address challenges and shift risk, while leveraging private sector financing and capacity [3,4]. Advocates promote them as a potential solution for health funding shortages due to fiscal constraints, while promising better quality of services with greater efficiency [5]. Opponents argue that this arrangement can result in inequity in access to care [6]. While hospital PPPs have been implemented with some successes in countries including Australia, the United Kingdom, Canada, Iran, and Turkey, there is mixed acceptance [5–9]. In 2014, an expert panel from the European Commission concluded there was, overall, insufficient evidence to determine if PPPs are an efficient mechanism to finance health systems of member states [10]. There is even less evidence from LMICs [5–9].

The integrated PPP model includes financing, construction, facility operation, and clinical service provision [4]. Some hospitals using this model have shown improved clinical outcomes. For example, hospitals in Finland and Spain have experienced reduced infection rates, lengths of stay, wait times for surgery, and readmission rates, among other improvements [5]. Yet, little longitudinal data exist on the clinical performance of integrated PPPs. Given the limited evidence on PPPs as an effective mechanism to improve quality and finance health systems, the Organization for Economic Cooperation and Development (OECD) has called for more measurement of PPP results [11].

In October 2011, the Queen ‘Mamohato Memorial Hospital (QMMH) replaced Lesotho’s 100-year-old national referral hospital, Queen Elizabeth II (QEII) in the capital city of Maseru. QMMH and its affiliated primary care clinics–collectively known as the QMMH Integrated Network (QMMH-IN)–is one of sub-Saharan Africa’s first and most well-known healthcare PPPs, constructed and operated under an integrated model [12]. QMMH is operated by Ts’epong, a consortium of Netcare Hospital Group, a private South African health care provider, and several South African and Basotho-owned businesses. Ts’epong was selected as the private partner by the Government of Lesotho (GoL) through a competitive tender process.

The first goal of the partnership was to replace the aging QEII and upgrade the filter clinics to provide high quality, publicly funded care to the greater Maseru district and referral services for the country. The second goal was to engage the private sector to increase efficiency, accountability, and quality of care while maintaining the government’s role as steward of the health sector and promulgator of policies and standards. Under the 18-year PPP contract, Ts’epong would operate QMMH-IN. Ts’epong would receive monthly payments from GoL for initial loan repayment and operating costs, including clinical services up to an agreed-upon annual threshold of 20,000 inpatient stays and 350,000 ambulatory visits.

Previous evaluations of QMMH-IN examined indicators on capacity, utilization, quality, and patient outcomes. A 2012 evaluation found that, compared to QEII, QMMH-IN provided more services, increased quality of care, and produced better patient outcomes, including a 41% reduction in overall mortality during its first year [12,13]. Ts’epong implemented management improvements, including computerized information systems, hiring and supervision systems for human resources, preventive maintenance, and other backbone systems essential for accountability and achieving efficiency, quality, and patient outcomes [12–14].

Despite these successes, the operation of QMMH-IN has been controversial [15]. The partnership itself has been strained with disagreements between the public and private partners, and between shareholders within the private consortium. These have resulted in litigations, some still under arbitration in 2021 [16]. Payments from the GoL have frequently been delayed, and payments for services above the contract threshold have been withheld [13,16]. Within this context, we sought to understand if early successes seen in 2012 quality metrics persisted into 2018, approximately halfway through the 18-year contract.

Materials and methods

Results

Capacity & utilization

Hospital beds increased between 2012 and 2018 from 390 to 410 (5.1%); filter clinic beds remained constant at 24 (Table 1). Increases in the Short Stat Medical/Surgical (35.0%), Orthopedic (16.7%), and Gynecology (40.0%) wards offset substantial decreases in the Female Surgical (-51.4%), and Pediatric Surgical (-41.2%) wards (Table 2).

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Table 1. Capacity and Utilization Measures at Queen ‘Mamohato Memorial Hospital Integrated Network Managed by a Public-Private Partnership in 2012 and 2018.

https://doi.org/10.1371/journal.pone.0272568.t001

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Table 2. Ward-level Utilization Measures at Queen ‘Mamohato Memorial Hospital Integrated Network Managed by a Public-Private Partnership in 2012 and 2018.

https://doi.org/10.1371/journal.pone.0272568.t002

Though not statistically significant, the number of clinical staff increased by 3.4%, driven heavily by physicians, increasing from 70 to 85 (p = 0.23; Table 1). Registered nurses comprised 50% of clinical staff at both timepoints. Non-clinical staff significantly decreased by 56 (17.6%, p<0.02).

Inpatient admissions decreased by 2,176 (-8.0%, p<0.0001; Table 2). The largest decreases occurred in the Female Surgical (-52.1%, p<0.0001), Pediatric Surgical (-33.3%, p<0.0001), and Adult Medical wards (Male: -34.1%, p<0.0001; Female: -27.8%, p<0.0001) as well as the filter clinics (-25.7%, p<0.0001; Table 1). The decrease in NICU admissions (-67.9%) was offset by the addition of a Neonatal ward. Admissions to the Neonatal/Nursery increased by 72.4% between 2012 (Nursery = 789) and 2018 (Neonatal = 1,243; Nursery = 117). The ICU (23.1%, p = 0.01), Step Down (25.0%, p<0.0001), and Maternity (5.7%, p = 0.0021) wards experienced the largest increases in admissions (Table 2).

Outpatient ambulatory visits increased by over 14,000 visits (3.8%, p<0.0001; Table 1), primarily at the hospital specialty outpatient clinics (25.6%, p<0.0001). Increases in visits at the A&E Department (7.0%, p<0.0001) and filter clinics (4.1%, p<0.0001) were largely offset by substantial decreases in Gateway Clinic visits (-36.8%, p<0.0001).

Hospital inpatient days increased by 21.2%, due to increased ALOS from 5.1 to 6.5 days (27.5%). ALOS increased in all wards except Short Stay Medical/Surgical (-12.2%) and ICU (-12.1%; Table 2). The longer hospital ALOS observed in 2018 was largely driven by the addition of the long-stay Neonatal ward which treated 5.5% of all hospital inpatients in 2018 but accounted for 17.3% of all hospital days. Excluding the long-stay NICU and Neonatal wards, 2018 ALOS was 5.7 days compared to 5.0 in 2012.

Hospital bed occupancy increased from 82% to 99% in 2018 (19.5%, p<0.0001; Table 1), with more than half of the wards (n = 8) having occupancy rates of 90% or more (Table 2). The Neonatal ward had 209% occupancy; when beds were unavailable, neonates were shifted between the wards catering to neonates (NICU, Neonatal ward, and Nursery). Gynecology (126%) and Maternity (107%) wards also had greater than 100% occupancy.

Clinical quality

Crash carts were better equipped during Timepoint 1 observations (82.9%) compared to Timepoint 2 (73.8%; Table 3). Among missing stock during Timepoint 2, no carts stocked Heparin or the required amounts of Dopamine, Dobutamine, or Ringers Lactate. Four carts were missing electrocardiogram (ECG) leads.

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Table 3. Clinical Quality and Patient Outcome Measures at Queen ‘Mamohato Memorial Hospital Integrated Network Managed by a Public-Private Partnership in 2012 and 2018.

https://doi.org/10.1371/journal.pone.0272568.t003

During Timepoint 1, 75 patients were observed for time to triage over a total of 9 hours; during Timepoint 2, 29 patients were observed over a total of 14 hours. The proportion of patients triaged within five minutes of arrival dropped from 84.0% at Timepoint 1 to 27.6% at Timepoint 2. Average time to triage observed at Timepoint 2 was 15 minutes; this was not calculated at Timepoint 1.

Patient outcomes

Overall hospital mortality decreased from 8.0% to 6.5% (-18.8%, p<0.0001; Table 3); no deaths were reported in the filter clinics. When excluding the adult and neonatal ICUs, which treat the most critical patients and may be expected to have higher deaths, hospital mortality decreased from 7.1% to 5.4% (-23.9%, p<0.0001). Mortality rates increased significantly in the Female Surgical ward from 7.6% to 12.8% (68.4%, p<0.0001; Table 4). Mortality decreased substantially in the Nursery (-81.0%, p = 0.0006), shifting the location of death to the new Neonatal ward (13.7%).

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Table 4. Ward-level Patient Deaths at Queen ‘Mamohato Memorial Hospital Integrated Network Managed by a Public-Private Partnership in 2012 and 2018.

https://doi.org/10.1371/journal.pone.0272568.t004

While the number of pediatric patients admitted to the hospital with pneumonia as their primary diagnosis increased by 22.7% (2012: n = 286; 2018: n = 351; Table 3), the mortality rate nearly halved from 11.9% to 6.0% (-49.6%, p = 0.0083). Though not statistically significant, NICU mortality increased between the timepoints overall (31.7% to 36.1%, p = 0.31) and specifically among very low birthweight neonates (30.2% to 36.8%, p = 0.50). In 2018, very low birthweight neonates admitted first to the Neonatal ward had the highest mortality (48.9%; Fig 1). However, neonatal mortality overall (including all wards serving neonates; Table 3) decreased by 9.1% (p = 0.28).

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Fig 1. Neonatal intensive care unit (NICU) deaths by birthweight and admitting ward in 2018.

https://doi.org/10.1371/journal.pone.0272568.g001

Discussion

We examined one of the first and largest healthcare PPPs in sub-Saharan Africa to understand if the performance achievements observed in the first full year of QMMH-IN operations persisted approximately six years later. We analyzed key indicators of capacity, utilization, quality, and patient outcomes and found evidence that some continued to improve while others worsened.

Though hospital bed capacity increased and admissions decreased between the timepoints, bed occupancy rates increased significantly overall and in most wards. Half of the wards had occupancies at or above 90% in 2018, with 5 wards over 100% occupancy. Hospitals with bed occupancy rates above 85% have been associated with increased mortality compared to lower occupancy hospitals [21,22]. The combination of increased occupancy and limited increases in clinical staff may have overstretched resources, potentially compromising QMMH’s ability to respond to infectious outbreaks or emergencies [22], a relevant concern given the current COVID-19 pandemic.

High occupancy and outpatient demand have been concerns since QMMH first opened. This has strained relations between the government and the private partner overpayment for services provided in over contract maximums [15,19]. Substantial utilization could be due to insufficient capacity or the perceived or actual reduced scope of services provided at district hospitals. Assessment of the bed and clinical service capacity at the district level, reviewing of referral practices could help redirect non-critical patients to more appropriate levels and decongest QMMH’s wards.

Neonatal mortality in sub-Saharan Africa is among the highest in the world, with one recent meta-analysis reporting an incidence density rate of neonatal mortality of 24.5 in NICU wards compared to 1.2 within the larger population [23]. The addition of a NICU, first brought to Lesotho through the PPP, was important and likely drove initial increases in neonatal admissions (246 in 2012). A less intensive Neonatal ward was then opened and experienced a surge in admissions (1,439 combined NICU, Neonatal ward, and Nursery admissions in 2018). While neonatal mortality overall decreased between the timepoints, NICU mortality rate at QMMH remains far above those achieved in most high-income countries, though similar to other LMICs including Uganda, India, Iran, and Nepal [24]. Mortality reviews may help determine causes for increasing NICU death rates and should include a focus on gestational age, an important factor affecting mortality rates [24]. The high Neonatal ward utilization in 2018 (209%) suggests that population need for neonatal care far outpaces QMMH capacity; 33 incubators appear insufficient. Though not highly comparable, data from the United States suggests NICU bed rates of approximately 7.2 NICU beds per 100 births in the population, or 83–94 per 100 births under 1500 grams, are needed [25]. The need in Lesotho is likely even higher given high rates of maternal and neonatal risk factors associated with neonatal mortality including inadequate ANC care and high rates of low or very low birthweight infants [23,26]. Neonatal disorders remain the third leading cause of disability adjusted life years (DALYs) in Lesotho, driven by preterm births [27]. Antenatal, intrapartum, and postnatal interventions could reduce preterm births, neonatal trauma, and illness, decreasing the country’s demand for specialty neonatal health services [28]. A systems-level approach to treat uncomplicated neonates at district hospitals and reduce demand overall for specialty neonatal health services may be needed.

Similar to experiences of other PPP hospitals such as in Brazil and Iran, where ALOS reduced by 0.6 days each to 4.8 and 4.5 days, respectively, the transition from public to PPP-governance initially resulted in a decrease in ALOS [12]. Though ALOS has increased since 2012, an ALOS of 6.5 is acceptable, particularly for a hospital meant to take the most critical cases [29,30]. QMMH’s ALOS matches South Africa’s 2017 country-level ALOS and is under the average of 7.7 among 36 countries in the OECD [2]. The NICU and Neonatal wards had particularly long ALOS as they treat neonates who undergo the most intensive treatments. The remaining increases in general ALOS (from 5.1 in 2012 to 5.7 in 2018 after excluding the long-stay wards) may reflect a shift in focus to treating more complicated patients as QMMH down-referred uncomplicated cases to district hospitals, though inefficient discharge procedures may also contribute.

Improvements in specific quality measurements at the PPP hospital were major findings of the 2012 study; however, our results show these started to slide in key areas. In 2020, when the direct observations took place, crash carts were less well stocked and there were longer waits for triage in the A&E Department. Though there are variety of factors that affect patient outcomes, these reduced quality measures do not appear to have affected hospital mortality rates. Quality improvement processes that focus on availability of essential emergency drugs and equipment, patient triage and patient flow, staffing, and continuous training on emergency care should be explored by hospital administrators.

Overall and in many wards, the improvements in mortality are encouraging, particularly in the ICU where ALOS also decreased. The adult medical wards accounted for 56% of hospital deaths in 2012 and 43% in 2018; focusing on these two high-volume wards may further reduce mortality. The continued improvement in the proportion of children dying of pneumonia (from 11.9% to 6.0%), might be associated with improved management of pneumonia and other infections.

Overall, QMMH-IN’s performance continued halfway through the PPP contract, though with some concerning backward slides. The contentious context over the preceding years, with increasingly strained partner relationships and unpredictable cash flow, could have hampered QMMH’s operations [16]. In early 2021, the GoL announced the termination of the PPP contract and intended transition of QMMH-IN to GoL management [16]. While recent events indicate the partnership itself is in serious jeopardy, our evaluation suggests that generally the hospital under the PPP was providing high-level, critically needed services in the country, and continued to improve patient outcomes. Quality at QMMH remains substantially higher than when the GoL-operated QEII experienced hospital mortality rates of 12.0%, had no triage system, and had only one crash cart [12]. The strategy of utilizing a PPP to operate the only referral hospital in Lesotho improved the range and quality of services available within the country.

Strong concerns remain over the cost of the PPP [15]. Though beyond the scope of this paper, a cost-effectiveness analysis would be beneficial to determine the cost per outcome of deaths and disability adjusted life years averted by operating QMMH-IN under the PPP. Resolution of disagreements over payment delays, extra service rates and payments, and potentially renegotiation of contract maximums would have been important to secure the partnership for the remainder of the contract and stabilize hospital performance.

Conclusion

Healthcare PPPs may be a promising mechanism to finance healthcare systems in LMICs. This study has added to scarce evidence on longitudinal performance. Within the context of a strained partnership, QMMH-IN has continued to operate, providing secondary and tertiary-level services to the country, and continuing to improve patient outcomes. Since QMMH operates like other public facilities, low-cost, high-quality, specialized medical care is, in principle, available to all Lesotho residents. This is a critical dimension of achieving universal health coverage.

Supporting information

Acknowledgments

We would like to thank the administrators and staff at QMMH for providing access to patient records, administrative data, wards, and patients for this evaluation. We appreciate the Ministry of Health directors and officers for supporting our data collection efforts. We thank the Lesotho-Boston Health Alliance staff in Maseru, Lesotho for their assistance and support. We would like to acknowledge our colleagues at the International Finance Corporation and the World Bank Group for providing introductions and background information.