Public Hospital Facilities Development Using Build-Operate-Transfer Approach: Policy Consideration for Developing Countries


Hamid Pourasghari 1 , Mehdi Jafari ORCID 1 , * , Hasan Abolghasem Gorji 1 , 2 , Mohammadreza Maleki 1 , 3

1 Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran

2 Center of Excellence in Health Management and Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, IR Iran

3 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran

How to Cite: Pourasghari H, Jafari M, Abolghasem Gorji H, Maleki M. Public Hospital Facilities Development Using Build-Operate-Transfer Approach: Policy Consideration for Developing Countries, Iran Red Crescent Med J. 2016 ; 18(12):e39866. doi: 10.5812/ircmj.39866.


Iranian Red Crescent Medical Journal: 18 (12); e39866
Published Online: July 26, 2016
Article Type: Research Article
Received: June 9, 2016
Revised: June 14, 2016
Accepted: June 14, 2016




Background: Advantages and limitations of build-operate-transfer (BOT) contracts in various forms of public-private partnership (PPP) arrangements have not been studied.

Objectives: This study is the first of its kind to determine the framework, advantages, and limitations of BOT contracts for health care projects in selected countries.

Methods: A comparative design was employed to identify factors affecting the development of medical facilities through the adoption of PPPs and the implementation of BOT contracts. England, Spain, Australia, Turkey, and Canada were selected, and data were gathered through well-known databases for the relevant studies. Electronic databases were searched using the keyword terms, “build-operate-transfer,” “public-private partnerships,” “health sector/health system,” “health care facilities,” “Spain,” “Canada,” “England or United Kingdom,” “Turkey,” and “Australia.”

Results: The findings revealed that while there was insufficient information transparency for adoption of the BOT contract model in developing medical facilities and building new hospitals, some similarities were observed in its adoption in public fields. Adoption of the BOT contract model has been proven feasible in the selected countries for the health sector, in particular, for the development of new hospitals. These contracts are usually long-term in nature to provide the private sector with the chance to appropriately exploit the field. Different countries utilize this model to meet public regional and long-term health care needs, where the goal is not just a matter of seeking the private sector’s contribution.

Conclusions: This study suggests that more information transparency is required for these types of contracts. Factors such as the term of the contract, the maintenance of the facilities built and their post-completion ownership status, facilities and credits offered to the private sector during the construction and operation phases, and the provision of financial and non-financial incentives to the private sector require deeper examination and should also be adjusted to the local contexts of the developing country.


Public-Private Partnerships Health Care Sector Health Care Facilities

Copyright © 2016, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Neither the public nor the private sectors can meet health care service needs independent of each other. This has led to the beginning of a third way that emphasizes the partnership of these sectors (1, 2). Economic theories suggest that the private sector is not motivated enough to invest in health care services, while governments cannot provide sufficient health care services due to limited budgets (3). This situation has been aggravated by poor management, a lack of efficiency, a disproportionate use of funds and time, and low-quality services provided by the public sector (4). The low productivity of government agencies, their mostly unsatisfactory services, and budget constraints both in developed and developing countries have seriously challenged the assumption that health care organization must be administered by governments (5, 6). As an alternative, a public-private partnership (PPP) offers many advantages. Through this type of agreement, the skills and assets of the private sector are utilized in delivering services or facilities to provide general services (7). Indeed, it is very important to exploit PPP in health care services, especially for the financing, provision, and management of services where the public sector is facing serious difficulties (8). PPP in health care services takes many forms and covers varying degrees of shared responsibilities between these sectors, where each form can be adopted based on its conditions, objectives, and assumed benefits (9). All PPPs include agreements in which the roles and obligations of the partners have been specified and the financial reimbursement rates to the private partner are determined in regard to the risks undertaken by each sector (10). PPP arrangements are categorized by the Asian development bank as service contracts, management contracts, lease contracts, concessions, and build-operate-transfer (BOT) contracts (11).

A BOT is a concession in which a private entity (in the form of an agency or consortium) agrees to finance a new infrastructure project and commits to meet the performance standards set by the government (12). The private partner raises the necessary funds for the construction of new facilities and is entitled to retain the ownership of the facilities and buildings during the term of the contract. The term of the contract must be adjusted to allow for the return of the investment of the private entity (13). The public party commits to purchase a minimum level of the private partner’s products to allow the private partner to cover its expenses. The public administration either acquires the ownership of the project once it is completed or transfers it to a new partner through the conclusion of another contract (14). Designing BOT projects is a challenging process for both the public and private sectors. Both sectors have their own economic and social characteristics. While the public sector emphasizes accountability and the public interest, the private sector aims for maximum profits as a dynamic entity, emphases that have turned the conclusion of BOT contracts into a complex issue (15).

2. Objectives

As PPP arrangements have been proposed as a strategy to improve the efficiency of services while enabling the public sector to utilize the private sector’s resources, namely its financial resources and manual skills, several studies have been conducted to determine the appropriate form this partnership should take.

However, no research has investigated the conditions, advantages, and limitations of BOT contracts. Therefore, the purpose of this study, as a first study in this area, is to determine the framework, advantages, and limitations of BOT contracts for health care projects in selected countries.

3. Methods

3.1. Study Design

A comparative study approach was used, as this involves a structured approach to using in-depth research to study the development of hospital facilities using BOTs in selected countries. Through a comparative design, we adopted and allowed model identification across the five countries to provide issue-specific learning for developing countries. Variables included the regulatory framework, the scope of the law (act), private sector selection, the policy framework, the structural framework, the contract framework, financing methods, and use in the health sector. With our chosen variables, which have frequently been cited and debated in the literature and in policy discussions, we sought to maximize all the insight gained from the experiences of the selected countries in order to provide policy recommendations for developing countries.

Comparative tables were designed and used as the data gathering tool. The variables for the comparison were extracted from a review of the literature and included the following: legal framework, legal scope, health sector, policy framework, structural framework, contract framework, and funding procedure (16, 17). These variables were validated by the research team and two more experts in the area of PPP. Fish cards were used to gather data through library resources, reports published by the World Health Organization (WHO), research centers, and reputable databases such as Medline, PubMed, Elsevier, Index Copernicus, DOAJ, and EBSCO-CINAHL and Iranian search databases including SID and Iranmedex.

3.2. Country Selection

The studied countries were purposefully selected to display diverse experiences of hospital facility development through BOT; this selection allowed us to reach a comparison of the factors underlying the different attributes of hospital facility development and implementation. Using advanced search strategies, we collected qualitative data from the United Kingdom (the UK), Canada, Australia, Turkey, and Spain. The selected countries were developed collaboratively by the research team and were then adapted by the national consortium from the Management and Planning Organization of Iran (MPO) to fit the context of developing countries.

3.3. Data Collection and Analysis

Nine scientific bibliographic databases, PubMed, Springer, Index Copernicus, SCI-expanded, Scopus, Emerald, Proquest, and Google scholar, were selected because they are large databases of peer-reviewed literature. A data extraction form designed on the basis of the study variables was used to gather the data. The electronic databases were searched using the keyword terms, “build-operate-transfer,” “public-private partnerships,” “health sector/health system,” “health care facilities,” “Spain,” “Canada,” “England or United Kingdom,” “Turkey,” and “Australia.” Country-specific details reported in the databases were gathered for the period 1990–2015. We identified 16 papers requiring more careful scrutiny (Figure 1). Country-specific details were analyzed using comparative tables, which allowed us to compare the countries based on the variables.

Flow Chart of the Literature Review
Figure 1. Flow Chart of the Literature Review

3.4. Ethical Consideration

The study was approved by the ethics committee of the Iran University of Medical Sciences (IUMS) (Rec: IR.IUMS.1394.9211557201).

4. Results

The information for each selected country has been presented separately from the variables (18-33).

Table 1. Matrix of the Comparison of Candidate Countries in Terms of Legal Framework, Legal Scope, and Selection of Private Sector, Policy Framework, and Structural Framework
Legal frameworkIs there any special law introduced for BOT?YesYesIs integrated in other modelsYesYes
Are the BOT concepts defined in the laws?YesYesIs integrated in other modelsYesYes
Are there any special laws for the types of PPP?YesYesYesIn some typesYes
Legal scopeIn what sectors has implementation of BOT been considered permissible?All sectors except for information, security, and militaryService and higher education sectorsServiceService and energy sectorsHas not been clearly defined
Is PPP also used in the health sector?YesYesYesYesYes
Which forms of PPP contracts are most used?Outsourcing, DBFO, lease contractOutsourcing, BOT, turnkey contractsOutsourcing, services, design, build, and operationOutsourcing, lease contract, BOTDBFO
Selection of the private sectorAre the conditions of the private sector specified for participating in projects?Has not been clearly definedYesYesTo some extentHas not been clearly published
Can foreign companies also take part in projects?Has not been clearly definedHas not been clearly definedYesYesHas not been clearly published
Is it possible to select the private sector without competitive conditionsHas not been clearly definedNoHas not been clearly definedHas not been clearly definedHas not been clearly published
Policy frameworkIs there any policy document regarding BOT?YesYesYesYesYes
Is there any transparent and clear process for a competitive atmosphere?Has not been mentionedYesHas not been clearly definedIs ambiguousHas not been clearly published
Are BOT project decisions made in a central way?Has not been clearly definedNoNoHas not been clearly definedNo
Are local governments for municipalities also able to lead BOT projects?YesYesYesYesYes
Structural frameworkIs there any central unit for BOT?YesYesExists for all PPP typesYesYes
If there is a central BOT unit, where is it?English Health MinistryThe health sectors of local governmentsLocal governmentsHealth ministry of Turkey and the health sector in provincesThe local governments have public-private participation units
Is there any BOT unit in various sectors (executive agencies)?Exists in educational and transportation sectorsHas not been mentionedYesExists in the energy sectorExists
Funding procedureIs there any standard format for the contracts?Has not been mentionedHas not been mentionedHas not been mentionedHas not been mentionedHas not been mentioned
What is the normal duration of the contracts?20 - 30 yearsMostly 25 years20 - 30 YearsUp to 49 years10 - 15 Years
Which sector is responsible for making a contract with the private sector?The local health sectorThe health sector of local governmentsThe health sector of local governmentsThe health sector in each province or stateRegional government
Is the government’s contract separate for each design-build-implementation, or is carried out by a company?Is mostly done by a complexIs mostly done by a complexIs mostly done by a complexIs mostly done by a complexIs mostly done by a complex
Funding procedureHow is the project cost compensated for the private sector?Operation within an agreed time periodOperation can be done under approved tariffsOperation within an agreed time periodOperation considering the facilitiesAccording to the payment based on population per capita
Are there any laws for the procedure and authority for tariff setting for public services done through BOT?Approved tariffs are usedIs not clearIs not clearHas not been mentionedHas not been mentioned
Health sectorIs BOT applied in the hospital sector?YesYesYesYesYes
Is delivery of clinical services also included in BOT?YesYesYesAll sectorsYes
Which institution is responsible for BOT in this sector?The trust is responsible for decision makingThe health sector of local governmentsThe health sector of local governmentsTurkey’s health ministry and health sector in provincesThe local government is in charge of decision making

4.1. Legal Framework

Although England, Canada, and Turkey have regulated and transparently defined BOT, it is still unregulated and yet to be defined in Spain. BOT regulations have been integrated into other models in Australia. The selected countries also have specific regulations for different types of PPP.

4.2. Legal Scope

BOT projects have been authorized in England in all sectors except the information, security, and military sectors. BOT has been adopted in Canada for the service and higher education sectors and adopted in the service and energy sectors in Turkey. There is no definite information about Spain. BOT has been adopted in all selected countries for healthcare services. PPP contracts in England come in the form of outsourcing, DBFO, and lease contracts, in Canada as outsourcing, BOT, and turnkey contracts, in Australia in the form of outsourcing, services, and DBO contracts, in Turkey as outsourcing, lease, and BOT, and in Spain as DBFO contracts.

4.3. Selection Procedure of Private Sector

Canada and Australia have completely defined and Turkey has partially defined the requirements the private sector has to meet before starting projects, while England and Spain have yet to do so in clear terms. International private enterprises and corporations are authorized to execute projects in Australia and Turkey. However, this has not been clearly defined in other countries. Canada has forbidden the selection of the private sector for projects without competition from other sectors, while other selected countries have not defined this issue clearly.

4.4. Policy Framework

Apart from Spain, all the selected countries have adopted specific policies for BOT projects. While the process of business competition in Canada is transparent, it is unclear in Turkey and has not been addressed in England. Nor have Australia or Spain made this competition process clear. The decision-making process in Australia and Canada is decentralized in the case of BOT projects, while it has no clear definition in the other countries. While Australia has banned local governments and municipalities from negotiating BOT projects with the private sector, other countries are not specific in this regard.

4.5. Structural Framework

Australia has designated a central unit for different PPP arrangements with agencies in all local governments. There is also a BOT unit in all administrative agencies across the country. Again, other countries are not specific in this regard.

4.6. Contract Framework

None of the selected countries has developed a standard format for PPP contracts (not mentioned). The duration of these contracts in England and Australia is 20 - 30 years, in Canada is 25 years in most cases, is 49 years in Turkey, and is 10 - 15 years in Spain. Apart from Spain, where the regional governments are entitled to negotiate and conclude contracts with the private sector, this authority in other countries has been vested with the health sector of local governments. In almost all countries, each phase (designing- building-operation) is completed by a different company.

4.7. Funding Procedure

In England and Australia, the costs of the private sector are covered through revenues obtained from operation of the project during a certain period. This covering of private-sector costs occurs in Canada through revenues obtained from the operation of the project based on charging fixed tariffs, in Turkey through the operation of the project while considering the facilities provided for the private sector, and in Spain through per capita-based reimbursement. England charges fixed tariffs for BOT-based public service contracts. This has not been defined in clear terms in Canada and Australia and has not been specified in Turkey and Spain.

4.8. Application in Health Sector

The BOT arrangement is practiced in all the selected countries for hospital development projects as well as in clinical settings. The agency in charge of concluding BOT contracts for health care services in England, Turkey, and Spain has not been clearly specified, while Canada and Australia have delegated this authority to the health sector of local and regional governments.

5. Discussion

Various PPP arrangements have been introduced around the world since the 1970s (2). The PPP approach has sometimes produced successful results, while at other times, it has encountered serious challenges. There is no single policy to be adopted for the administration of hospitals under this model of partnership. Each country adopts a specific model in consideration of its prevailing socioeconomic context and makes some gains. But almost every country has faced difficulties and stern challenges while practicing this model of partnership (32).

As the health sector requires the contributions of diverse sectors due to its nature and also due to the fact that various interested entities are involved in different hospital departments, this sector is fertile ground for the private sector to make investments (32). Service departments encourage the involvement of the private sector by their promising nature. As the results suggest, the selected countries are obviously open to diverse PPP arrangements, but they do not limit BOT applications to health care services. These countries are characterized by the adoption of a wide range of PPP models with attention paid to the conditions, the diverse advantages of the various models in different situations, and the lowering of risks of uncertain models. The findings indicated that while there was insufficient information transparency for the adoption of the BOT contract model to increase hospital beds and build new hospitals in the selected countries, some similarities were observed in public fields. These countries have done the groundwork for the application of PPP models, particularly for hospitals. Also, although European countries are setting great store by PPP modes of financing (34), PPP is yet to be practiced on a large scale in developing countries (35).

BOT contracts are usually long-term in nature to provide the private sector with the chance to appropriately exploit the field. Different governments utilize this mode of financing to meet public regional and long-term health care needs, where this goal is not just a matter of seeking the private sector’s contribution. PPP models could be applied in a wide range of fields, and building a hospital could be seen as entailing the inclusion of different departments to offer clinical and non-clinical services in the form of a single package.

The findings of this study indicate that the mechanisms put in place to control and monitor the activities of the private sector to execute BOT projects are not transparent. Bearing in the mind that information about these mechanisms in most countries is not adequate, the importance of health issues and medical products makes it necessary to address these mechanisms carefully. This necessity is further highlighted by McKee et al.’s study, which demonstrated that health care PPP projects are faced with four main challenges: costs, quality, flexibility, and complexity (32).

The economic issues of the health care sector and especially the development of new hospitals with respect to geographical demands have long been considered by regional and national policymakers in different countries. Infrastructure projects play a vital part in the development of the economy. As governments are expected to improve the quality and efficiency of their services on a regular basis, they usually take special measures to facilitate and expedite the execution of these projects to serve their purpose. Considering the public domains of each country and their current challenges and shortcomings, the completion of infrastructure projects in different sectors tends to be drawn-out and largely inefficient as a result of awkward bureaucracies and crippling governmental policies. Governments also have difficulties in raising funds sufficient for these projects. However, the potentials and capacities of every country highlight the importance of utilizing the specialties and innovation of the private sector to complete infrastructure projects in the form of BOTs, outsourcing, services, management contracts etc. (36).

The results of our study suggest that more information transparency is required for these types of contracts. Factors such as the term of the contract, the maintenance of the facilities built and their post-completion ownership status, the facilities and credits offered to the private sector during the construction and operation phases, and the provision of financial and non-financial incentives to the private sector require deeper examination.

The most important issues to take into account while applying this mode of financing and which must be transparently specified before the conclusion of any contracts are the exact terms of the contract, the procedure for transferring the ownership of the hospital once the contract expires, the process of providing facilities (if any) for the private party, the risk-sharing procedure, how doctors will work in the hospitals and what fees will be paid to them, and the procedure of calculating costs that must be paid by patients. Transparent regulations for the transfer of ownership and providing for numerous requirements are very important in these contracts. As the private sector uses public facilities and must abide by the government’s regulations, the policy-makers must be careful in the adoption of certain policies. It is clear that the design of PPP models should ultimately result in improved health care services for the patients. Failure to observe the defined standards and requirements will cause disagreements between the partners and will also doom a project.

5.1. Conclusion

Studying PPP models, and BOT in particular, for the development of hospitals in most countries shows that BOT-based projects are hard to implement. This is because PPP models in general and the BOT model in particular require the development and definition of specific institutions, processes, and stages. The following policies are proposed to tackle this issue in developing countries:

1. Development of a national strategic instrument or a road map for PPP. It is necessary to prepare an instrument that can recognize risk factors and impediments to the implementation of PPP models through examining and analyzing current legal, political, and regulatory frameworks. Through recognizing risks and designating certain entities to deal with them, road maps help government officials place a project within its proper legal, political, and regulatory frameworks; road maps also offer guidelines for the development of PPPs. Officials can also contribute to the success of BOT projects through the proactive management of existing and potential risk factors.

2. Establish a specialized institution or organization to monitor PPPs across the country. Such a monitoring entity is recommended if one takes into account the experimental findings and multisectoral characteristics of the factors that are influential in the creation, development, and success of public-private partnerships. PPPs demand a powerful public sector with managers who have mastered the skills of negotiation and the conclusion of contracts as well as risk analysis. The public sector must have the authority to recognize appropriate projects and negotiate and finalize BOT contracts on behalf of the government. It must also supervise the projects and offer and implement practical solutions in case of need.

3. Facilitate public-private partnerships. Two ways of facilitating PPPs are first, to demand that the users of hospital services make payments in order to secure the necessary resources and second, to draw up standard instruments for BOT contracts.



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