Abstract
The present study aimed to develop a Public-Private Partnership framework for managing the Adverse Health Effects of Environmental Disasters using the drying lake Urmia case study in Iran. This is a qualitative study with grounded theoretical approach. Data were collected through semi-structured interviews and analyzed using content analysis. To formulate the initial framework, an expert panel was formed. Delphi methodology was used to determine the validity of framework. The most critical infrastructure for private sector participation was designing a legal framework and providing adequate resources and facilities. Pollutant assessment and public education are among the essential areas in which the private sector can participate. To evaluate the performance of the private sector, periodic and short-term reports, and documentation should be used. Payments to the private sector should be for periodic objectives based on performance. Reimbursement should combine service fees, allocation per capita, and performance quality. One of the significant difficulties and challenges in the managing of AHEEDs is lack of resources, poor management and inter-departmental coordination. Policymakers can consider PPP as an effective policy for reducing the AHEEDs. To this end, the framework presented in this study can be used as a guide by national and local authorities and policymakers.
HIGHLIGHTS
Decades climate change have caused to different environmental disasters.
We conducted 20 semi-structured interviews with experts and came up with a proper insight on understanding different stakeholders in terms of private sector partnership management of adverse health effects of environmental disasters.
INTRODUCTION
The nature, theory, and conception of disasters are much debated and the subject of much academic deliberation. According to the Oxford English Dictionary, a disaster is something of a ‘ruinous or distressing nature; a sudden or great misfortune, mishap, or misadventure; a calamity.’ Perhaps this is something of an oversimplification of a complex concept. Health impacts are a significant reason for mainstreaming concern over environmental disasters (Dorling et al. 2007; Shamshirband et al. 2019; Reinert et al. 2021). There are different kinds of disasters, including natural or human-caused (technological, environmental, intentional/terrorism), rapid or slow onset, and short or long duration. In contrast to natural disasters, characterized by readily recognized physical injury with relatively predictable recovery periods, environmental disasters are characterized by slowly evolving and long-term adverse health consequences, not recognizable at a glance.
Different types of disasters have different health consequences (Cline et al. 2015). Drying lakes are one of the environmental disasters that have their own Adverse Health Effects (AHEs). Today, there are many global experiences of drying lakes, most notably Aral Lake in Central Asia, Salton Lake in California, Owens Lake in California, and Great Salt Lake in Utah (Nicholas 2016). The drying lakes can harm people's health. Respiratory diseases, increased cancers, hypertension, the prevalence of eye diseases, skin diseases, psychological hazards, and miscarriage are just a tiny part of the AHEs of drying lakes on public health (Falzon 2001; Crighton et al. 2003; Bennion et al. 2007; Herbst et al. 2008; Diusembayeva et al. 2015; Kouadri et al. 2021). One of the worst experiences of drying lakes is the drying of ‘Lake Urmia’ in northwestern Iran. Lake Urmia is Iran's largest inland lake and the second-largest saltwater lake in the world (Eimanifar & Mohebbi 2007). The lake began to dry out in the mid-2000s and is at risk of completely drying today. Examination of satellite images shows that since 2015, the lake has lost 88% of its area (Rezvantalab & Amrollahi 2011). Many environmental experts and government officials believe that Lake Urmia's drying up has irreparable consequences for the Iran provinces and the regional countries (Stone 2015). Incidence of various diseases in humans, animals, and plants, reduced fertility of agricultural lands, disruption of the quantitative and qualitative equilibrium of groundwater in the region, and irreparable economic losses will be other consequences of drought in Lake Urmia (Gholampour et al. 2015; Sadeghi-Bazargani et al. 2019).
In recent years, humans have made many plans to identify and control the side effects and damages of natural phenomena and disasters and have achieved good results (Ruijten 2007). One of these plans is the use of existing capabilities and potentials in the private sector in the form of a Public-Private Partnership (PPP) policy. In general, PPP is a mechanism whereby the public sector (government and other governmental entities) to provide the infrastructure services (Water and water treatment, transportation, health, education, etc.) utilizes the capacity of the private sector (cooperatives, private companies, charities, and non-governmental organizations (NGOs)) including knowledge, experience, and financial resources. In PPP, a contract is agreed upon between the public and private sectors to share the risk, responsibility, and benefits and synchronize the resources and expertise of both sectors in the provision of infrastructure services (Davies 2011). In PPP, the role of government changes from the investor, implementer, and beneficiary of infrastructure in the first instance to policy maker, regulator, and supervisor of the quality and quantity of services provided (Ghobadian et al. 2004; Gharaee et al. 2013). Governments also use PPP as a critical efficient, and cost-effective mechanism in implementing policies and achieving goals (Osborne 2002).
Despite recent studies on the effects of drying lakes on public health, there is a need to redesign health services and, if needed, provide new services to reduce the degree of AHEs caused by the crisis. Therefore, one of the significant challenges in facing adverse health effects of environmental disasters (AHEEDs) is developing creative and new methods to face this new phenomenon. On the other hand, the health sector, like other sectors, is facing limited resource problems, so the presence of the private sector as a partner to the health sector to mitigate the health problems caused by drying lakes is highly beneficial. Therefore, the present study aimed to develop a PPP framework for managing the AHEEDs in the form of a case study of the drying and shrinking of Lake Urmia in Iran.
MATERIALS AND METHODS
This qualitative study with a grounded theoretical approach was conducted in 2022. Considering the Lack of insufficient knowledge and evidence in this area and the researchers’ goal to provide a new framework, the grounded theory approach was selected as a suitable approach for this study to reach reliable results. Grounded theory is a systematic and qualitative procedure for generating theory directly from data that has been systematically collected and analyzed (Creswell 2002; Strauss & Corbin 2012). The present study was conducted in Iran, and the drying Lake Urmia selected as the case study. Choosing Lake Urmia as the study case help researcher to be focused and structured, and as a result, more practical results obtained and presented. The study participants were experts in the field of study, including experts, officials, and vice chancellors from schools of medical science, universities, private organizations and institutions, experts and informants working in health centers, experts from research centers, and other stakeholders in the field under study. To summarize the feedbacks of the participants and with the aim of resolving the conflicts between the participants regarding the results of the study and the obtained framework, the respondent validity was used and also to create a consensus among the participants, the Delphi method was applied. Inclusion criteria comprised having at least five years of relevant work experience in the health system and having the desire and ability to participate in the study.
Purposive sampling was used to select participants. This sampling method is the most dominant and widely used sampling method in qualitative studies and has many advantages compared to other methods. By this method, people with the most and richest information and who can appropriately provide their information to researchers were selected as participants. Sampling continues until the information saturation stage is reached and the researchers feel that new information is no longer available (Attride-Stirling 2001). This phase was achieved with 15 participants in the present study, but the researchers continued sampling up to 20 individuals to ensure excellent reliability.
To collect in-depth data, semi-structured interviews were used. Because the use of semi-structured interviews provides sufficient opportunity for the participants to present their opinions and researchers can obtain extensive and deep information in different fields. For the convenience of the participants, interviews were conducted in a suitable location at the participants’ workplaces. During the interviews, guiding questions were used, which were designed using the literature review and expert opinions. The duration of each interview varied from 60 to 90 minutes. With the interviewees’ consent, their statements were recorded using an audio recorder, and the interviewers also took notes during the interview. Recorded interviews were immediately transcribed after each interview by researchers.
Considering the approach of the study and in order to obtain valid and accurate results, content analysis was used to analyze the data, which is a method for identifying, analyzing, and reporting patterns within the text and is widely used in qualitative data analysis. Two researchers coded 24 Data. The steps for analyzing and coding the data were as follows: gaining familiarity with the text, identifying and extracting primary codes (identifying and extracting more data related to primary codes), identifying themes (inserting extracted primary codes into related themes), reviewing and completing identified themes, naming and defining themes, ensuring the reliability of the extracted codes and themes (with the agreement between the two coders being achieved through discussion and resolving any disagreements).
To increase the rigor and accuracy of results, we used four criteria proposed by Guba and Lincoln (Lincoln & Guba 1985), which is the most comprehensive approach for improving rigor in qualitative studies. Because it includes almost most of the methods of improving the regor of the findings of qualitative studies:
Credibility and Confirmability: using long-term engagement and reviews by colleagues and also the comments provided by the experts. Also, to resolve the participants’ conflicting feedback and summarize the feedback, respondent validity was used, such that after each session, the opinions of the interviewee were summarized and sent to the interviewees so that any errors and ambiguities could be corrected;
Dependability: two researchers were involved in the coding process;
Transferability: experts’ opinions and also purposive sampling was used. In addition to the above, the study design used integrated mixed methods (quantitative and qualitative and data collection methods), as well as researcher agreement and transparency.
After extracting the results of interviews, a panel of 12 experts was formed to design the initial framework for PPPs in managing the AHEs of drying lakes. The research team drafted the framework components, and the panel members’ expert opinions were used to design the initial framework. In the expert panel, each of the framework's components was discussed and agreed upon based on the experts’ consensus.
After determining the principal dimensions and structure of the initial framework, achieving a consensus among participants based on their feedback, and determining the validity of the framework, the Delphi methodology was used. A summary of the objectives, along with the initial framework developed in the earlier stages, was prepared in the form of a Delphi questionnaire containing policy options and was sent to 15 experts in the field, resulting in 12 forms being completed and submitted to the researchers. Using this questionnaire, each stakeholder rated each policy option in the two dimensions ‘importance’ (whether this option is essential and should be considered) and ‘implementability’ (whether the health system can implement it). The Delphi questionnaire consisted of a 9-point Likert scale, in which options with a median higher than 7 were accepted, options with a median of 4–7 were entered in the second phase and options with a median less than four were excluded.
Ethical approval
The Ethics Committee had approved the study of the authors’ institute. Ethical Number: IR.TBZMED.REC.1397.774.
The authors fully respect ethical issues (including the informed consent of the participants, plagiarism, duplication, etc.).
RESULTS
Overall opinions of participants on PPP in management of adverse health effects of environmental disasters
There were differing views among the interviewees regarding the participation of the private sector in managing the AHEEDs. Most participants saw the use of private sector power as a necessity. Most participants saw the use of private sector potential as a necessity.
Participant No. 7: ‘In my opinion, the public sector and the health system alone cannot manage the AHEs of the lake (drying lake) … so has to get help from the private sector.’
However, a limited number of participants considered not only the private sector participation in this area unhelpful but also considered the presence of the private sector as a disorder in managing the adverse effects. However, some of these dissenters believed that, provided that the private sector does not directly manage disaster relief, services could be purchased from the private sector, outsourced to the private sector, or sought as services provided through projects and contracts.
Essential prerequisites for PPP in management of adverse health effects of environmental disasters
Most participants believed that the private sector's participation in the health sector had not been defined, and there is currently no legal infrastructure or required resources to implement it. Thus, given the increasing population and the inability of the public sector to perform this task, the private sector's abilities can be utilized. In order to formulate a legal framework, protective requirements and legal deterrents must be considered. Also, resources must be allocated according to actual priorities and needs after providing resources and facilities.
Some participants considered changing the public sector's negative view of the private sector and the public sector's readiness for monitoring and evaluation as the prerequisites for participation with the private sector.
Participant No. 3: ‘We should not look at the private sector with a negative view, and there should be a benefit to the private sector to be willing to participate … ’.
Participants believed that by holding meetings with private sector management and attracting their support, the ability and capacity of this sector could be used to control adverse effects in the form of PPP. The contracts should also be such that payments to the private sector are based on the process and the obtained results. In one participant's opinion, there are two prerequisites for outsourcing some services to the private sector. First, the private sector would have sufficient capacity, and second, the public sector would be able to monitor and evaluate the services provided. Participants believed that a committee for the AHEs of the drying lake should be set up, composed of experts from different relevant fields, which would be responsible for the monitoring system of AHEs caused by the drying lake.
Areas that the private sector can participate
In the opinion of some participants, there is little incentive for the private sector to participate in the management of AHEEDs. However, some other participants believe that if the areas, tasks, and services in which the private sector can participate are identified, this will be beneficial and effective for the public and private sectors. In this case, the control and treatment of the AHEs of drying lakes can be assigned to the private sector to reduce the burden on the public sector to some extent, and the private sector will also achieve its goal of increasing revenue. The second is for the private sector to do so on behalf of the public sector and for the public sector to buy these services from them.
The private sector can participate in education, research, consultation, management, monitoring, and surveillance (monitoring and evaluation of pollutants, monitoring and reporting of the symptoms of AHEs, and control measures, including diagnosis and treatment). According to the interviewees, the private sector can effectively identify patients, refer patients to treatment centers, follow up treatment until full recovery, educate families to avoid the AHEs of dust exposure, and follow up treatment, among others. Participants believed that private sector knowledge could also be applied to executive function and research in the form of contracts and agreements. They also saw the supply of human resources (including specialist and expert personnel) as another task that could be achieved through partnership with the private sector.
Participants believe that the private sector's involvement in assessing the status quo and analyzing the statistical data collected through the surveillance system will be helpful, such that the public sector would have the opportunity to manage and strengthen the surveillance system. One participant believed that to determine the appropriate areas for private sector participation, a preliminary assessment should be carried out to identify the AHEs caused by environmental disasters accurately. The results of the initial implementation of the surveillance system should also be introduced.
Participant No. 4: ‘ … if the results of the evaluation are extracted, and the results of the initial implementation of the surveillance system are provided, it is easy to determine in which sectors the private sector can participate.’
Monitoring and evaluation of private sector performance
Participants believe that private sector monitoring and evaluation should be systematic. The services provided must be documented, indexed, and indicators must be developed and reported regularly. Inputs, processes, and outputs should be considered in monitoring and evaluation. Monitoring and evaluation should be performed by public sector staff.
Participant No. 18: ‘Monitoring and evaluation should be done with agreed and predetermined monitoring and evaluation checklists with specific dates … Monitoring and evaluation should be implemented continuously and consistently, in accordance with a pre-established schedule …’.
How to pay the private sector for managing adverse health effects
In the interviewees’ view, payments should be based on the result and effectiveness of the partnership. Rigorous and justified goals, indicators, and standards should be determined, and proper checklists for monitoring and evaluation should be developed to make payments based on them for achieving periodic milestones. Indicators and milestones should be based on the work process, the activities’ outcome, and effectiveness. Payments should also be based on the level of performance and assessed through post-performance appraisal and approval by the appropriate experts and entities.
Most participants stated that a combination of per-service, per capita, and performance-based pay calculation methods could be used. However, most participants considered paying in return for identifying and referring patients as the best payment method. Participants also believed that payments should be based on specific tariffs in line with the policies of the Ministry of Health as determined by the expert team. Several participants also believed that payments should be made based on agreements between the private and public sectors and be clearly and precisely included in the contract. Quality of service and assessment methods used should be specified in the contract and directly impact payments.
Achievements and implications of PPP to manage adverse health effects caused by environmental disasters
Study participants highlighted the following as the most critical potential outcomes and achievements of private sector participation in managing the AHEEDs:
- 1.
Avoid waste of resources: Participants believed that partnership with the private sector can help to prevent the waste of resources;
- 2.
Improving service coverage: In this regard, participant No. 1 stated: ‘ … private-sector participation can lead to increased identification of at-risk individuals, community-based education in districts and families, and advancement of public health goals … ’;
- 3.
Greater efficiency: By waste reduction and better management of resources;
- 4.
Access to more information: Where the community refers to the private sector for the treatment, data from the private sector can be used to influence health interventions and management of AHEs.
- 5.
Opportunity for the public sector to perform stewardship tasks: Its most important achievement, given the extent of the affected areas and the diversity of health effects in need of treatment, will be to provide managers with an opportunity to address the more critical issues and develop the monitoring system.
- 6.
Public participation: In this regard, participant No. 8 said: ‘The only area where the private sector can participate is to attract people and volunteers participation. This is where we have serious problems … ’.
Designing and validating the framework
The initial designed framework in this study consists of 24 subjects in 4 main sections as follows. The first phase of the Delphi included (i) essential infrastructures and backgrounds for PPPs, (ii) areas and services that the private sector can participate in, (iii) how to monitor and evaluate private sector performance, and (iv) how to pay to the private sector. After analyzing the experts’ opinions, two subjects were omitted in this first phase due to low scores, eight entered the second phase (scores of 4–7), and 14 were finally accepted (scores greater than 7).
Public-private partnership framework for managing adverse health effects of drying lakes.
Public-private partnership framework for managing adverse health effects of drying lakes.
DISCUSSION
The present study aimed to develop a PPP framework for managing AHEEDs (the case study of Lake Urmia in Iran) that was achieved through interviews with experts, expert panel meetings, and Delphi methodology.
Although the results of many studies and experiences in other countries depict the positive results and achievements of private sector participation in the health sector (Bailey 2014; van der Berg 2015), some participants did not have a positive attitude toward the private sector's partnership with the public sector in managing the AHEEDs. One of the possible reasons for this may be the weaknesses and difficulties in privatization in different sectors of Iran. Some weaknesses and difficulties include Lack of infrastructure, weak management, faulty monitoring and evaluation, bad contracts with the private sector, the weak structure of reimbursement, the intervention of politicians in health, interference of the public sector in the processes after the outsourcing, unwillingness of the public sector to hand over to the private sector, etc. (Gharaee et al. 2019, 2022; Azami-Aghdash et al. 2020; Tabrizi et al. 2020; Hojatolah & Saber 2021; Saber Azami et al. 2022).
Given the positive achievements and results of PPP in different sectors, especially the health sector in other countries (Comendeiro-Maaloe et al. 2019; Hamalainen et al. 2019; Palaco et al. 2019), officials, policymakers, and experts in the field are expected to plan and make a great effort to utilize the potential and capacities of the private sector.
In the view of the expert panel, designing a legal framework for PPP was one of the most critical infrastructure prerequisites for private sector participation. In many studies, it has been suggested that the public sector should design the initial legal framework, and the private sector's views are used to complete and finalize it. This legal framework should at least include a clear definition of the duties of each sector (public and private), a clear definition of objectives, how to monitor and evaluate performance and standards, how to pay to the private sector, and how to handle disputes and legal issues (Busch & Givens 2013; Chen et al. 2013). In high-income countries, such legal frameworks are well-defined, but in low- and middle-income countries, this is not usually the case (Lassa 2013). Therefore, applying the experience and knowledge of high-income countries could help develop such frameworks.
Also, from the experts’ perspective, providing the required facilities and financial resources is one of the essential areas in which the private sector can collaborate. The occurrence of any disaster, especially environmental disasters, imposes enormous costs on the public sector. In the study of Gharaee et al. (2022), which was conducted to design a surveillance system for managing AHEs of drying of Urmia lake, the diseases that could be created included mental disorders, respiratory diseases, eye problems, hypertension, cardiovascular diseases, cancers, allergic reactions, goiter, malnutrition, anemia, vector-borne diseases, soil-borne diseases, liver diseases, systemic diseases, water and foodborne diseases, neurological problems, epigenetic effects and airborne diseases respectively (Gharaee et al. 2022). Many governments, especially in low- and middle-income countries, cannot afford and pay for such costs. One of the effective strategies in such situations is to utilize the resources available in the private sector (Khan & Rahman 2007). In many high-income countries, the primary approach to using private sector resources for disaster management is insurance plans. In the US, flood insurance companies have been established since 1968 and play a prominent role in providing resources and policy making. In France, insurance companies are obliged to provide people with different kinds of disaster and accident insurance and play critical roles in this field (Linnerooth-Bayer & Mechler 2007). However, due to structural, policy, and economic weaknesses in low- and middle-income countries, such approaches have been less developed, and insurance companies are less inclined to do so, while many disasters and accidents happen in these countries (Atmanand 2003).
Most participants believed that frequent, regular written reports and documentation should be used for monitoring and evaluation, and the tool should also include agreed and predetermined monitoring and evaluation checklists with scheduled dates. In a study by Berezin & colleagues (2018) in Russia aimed at providing a practical framework for assessing PPPs and ranking countries in this area, they used five indicators based on software designed for this purpose (Berezin et al. 2018). In 2014, the World Bank provided a checklist for evaluating PPP projects, which can be used to provide native and practical checklists for various sectors (The World Bank Group 2014). Other studies have used checklists or similar tools to evaluate PPP projects (Kurniawan 2013; Marx 2017). Three critical points must be considered when designing and using such evaluation tools. First, their validity and reliability should be approved. Second, the public and private sectors should agree on the content and evaluation process. The tools should localize based on each country and even in different regions within a country context.
Most experts believe that payments should be a combination of the fee for services, per capita, and performance pay. Various methods have been proposed in the existing literature for payment to the private sector (Lawther & Martin 2014; Liu et al. 2015). There are several essential points to consider when designing a private sector payment method. First, payments should be commensurate with the quantity and quality of private sector work performed and motivate the private sector to improve performance and quality. Second, the payment method should be such that it divides the risk between the public and private sectors. Third, it must be commensurate with each region and country's economic and social conditions. The payment methods and their theoretical bases discussed by the experts in this study cover most of these points well. The critical concept in this regard is the excellent design and implementation of these payment methods because, in many cases, many difficulties arise in the implementation stage despite the proper design and theory. On the other hand, given the limited experience of PPPs in managing AHEEDs, more attention is needed in this area.
From the perspective of the study participants, preventing waste of resources, improving service coverage, greater efficiency, access to more information, creating opportunities for the public sector for stewardship tasks, and attracting public participation are the essential benefits of PPPs in the field of AHEEDs. Many studies have highlighted the benefits mentioned in the present study amongst other benefits (Sapri et al. 2016; Azami-Aghdash et al. 2019). It should be noted that each benefit is only achieved if the PPP is implemented well. Otherwise, not only will there be no benefits, but there may be harmful results. Among the most important of these are the increased costs of providing services by the private sector (Lassa 2013).
Strengths and limitations
Based on the results of the literature review and researchers’ experiences, the present study has presented a new approach to better manage the AHEs of drying up lakes and other environmental crises for the first time. One of the significant limitations of the present study was the lack of related evidence (in regards to drying lakes) which therefore did not allow comparisons of findings. As such, researchers relied on relevant field management. Further, due to the novelty of the subject and the low experience of PPP in Iran, there were few experts whose opinions were appropriate to draw on in this field. Despite the mentioned limitations, the researchers did their best to reduce the effects of the limitations as much as possible to obtain comprehensive and practical results. For example, obtaining the opinions of experts and different groups, considering different methods to improve the consistency of the results, and using different methods to make the results comprehensive.
CONCLUSIONS
Considering the adverse effects posed by environmental disasters (especially the drying up of lakes) on the health of the local population and the limited capacity and abilities of the public sector to manage and prevent these effects, using the capacity and potential of the private sector can be very helpful. PPP policy can be considered an effective solution by senior officials and policymakers. To this end, the framework presented in this study can be used as a guide for national and local policymakers. The designed framework needs to be more complete and improved by conducting more studies in different regions and countries.
AUTHORSHIP
H.GH and S.AA designed the project, collected data, and drafted the first version of the manuscript. R.R, N.D collected data and analyzed the data. H.GH and S.AA revised the manuscript.
ACKNOWLEDGEMENTS
At this moment, we appreciate the research vice chancellor of Tabriz University of Medical Sciences as the funder and all the experts from the private and public sectors who participated in this study.
FUNDING
The study was supported by the Tabriz University of Medical Sciences (IR.TBZMED.REC.1397.774).
DATA AVAILABILITY STATEMENT
All relevant data are included in the paper or its Supplementary Information.
CONFLICT OF INTEREST
The authors declare there is no conflict.