Investigating the performance of PPP in major healthcare infrastructure projects: the role of policy, institutions, and contracts

In the wake of the Covid-19 pandemic, public private partnerships (PPP) can prove useful to close the healthcare investment gap and accelerate long-term recovery, by matching public and private money. Despite their extensive application in the delivery of major infrastructure projects globally, their performance remains contested. Drawing on a unique set of data of PPP contracts for healthcare investments in Italy, the paper explores the antecedents (namely, policies, institutions, and contracts), that have influenced the capacity of PPP contracts to deliver performance, measured in terms of value for money (VfM), and contract stability. Results show that although explicit policy goals have a clear contribution, VfM can benefit from competent central PPP institutions, which should play a hands-on role in the planning, design, and project management activities. At the same time, centralised PPP units, if not combined with local competent authorities and strong governance mechanisms, may increase the risk of contract renegotiation.