The experience of healthcare stakeholders with hospital public-private-partnerships: a qualitative case study in China

Since the mid-1990s, many countries have introduced Public-Private Partnerships (PPPs) to build hospitals and deliver health services. While numerous studies have been conducted on the policies surrounding PPPs and their social and financial impacts, limited research has focused on the attitudes and perspectives of stakeholders who have experienced the reform– specifically their subject position-takings towards hospital PPPs. Even fewer studies have explored the situation in China, and the theoretical explanations underpinning this policy process remain underdeveloped. This paper aims to fill this gap by examining how healthcare stakeholders in China, particularly public and PPP/private hospital managers and administrators, experience hospital PPPs and investigating the social mechanisms that underpin these experiences. Based on Bourdieu’s concepts of field, capital, habitus, and the state, and a case-centred qualitative study, 33 key informant interviews were thematically analysed. The study reveals a field of struggle between the dominant public hospitals and the subordinate PPP hospital for state recognition. Rather than passively accept neoliberal changes in the healthcare field, our participants respond innovatively to hospital PPPs, where there are antagonistic understandings of the role of the state and its relations with the market regarding the financing, provision, and delivery of healthcare. These conflicting position-takings and dispositions reflect how differential power relations – manifested in the disparity in accumulated capital – between public and PPP hospitals materially and symbolically shape the struggling experiences of those working in the system. The study concludes that understanding hospital PPPs as existing in the healthcare field compensates the existing interpretation as a “political strategy” from the pluralist perspective or a “powerful discourse” in a Marxist tradition, and in doing so, the field struggles between public and private/PPP hospitals over state recognition and power differentials in resource allocation can be revealed. The findings also emphasise the importance of defining the boundaries between public and private hospitals, as well as determining the level of private capital involvement in health service delivery and funding.