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Evaluating the Intention and Behaviour of Private Sector Participation in Healthcare Service Delivery via Public-Private Partnership: Evidence from China

Evaluating the Intention and Behaviour of Private Sector Participation in Healthcare Service... Hindawi Journal of Healthcare Engineering Volume 2020, Article ID 5834532, 13 pages https://doi.org/10.1155/2020/5834532 Research Article Evaluating the Intention and Behaviour of Private Sector Participation in Healthcare Service Delivery via Public-Private Partnership: Evidence from China 1 1 2 1 3 1 Jie Yang, Lingchuan Song , Xiaoyi Yao, Qian Cheng, Zichao Cheng , and Ke Xu School of Management Engineering, Shandong Jianzhu University, Jinan 250101, Shandong, China School of Business, University of Leicester, Leicester LE3 5EB, UK Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing 100069, China Correspondence should be addressed to Lingchuan Song; songlc22@163.com Received 12 June 2019; Accepted 30 December 2019; Published 17 January 2020 Academic Editor: Emiliano Schena Copyright © 2020 Jie Yang et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Private sector participation in the healthcare market via public-private partnership (PPP) could be considered an available approach to narrow down the medical resource gap and improve the operational efficiency of healthcare facilities. Accordingly, this study aims to examine the influence and relative importance among critical factors for the intention and behaviour of the private sector towards participation in Chinese healthcare market (CHM) via PPP. We defined five hypotheses from previous literature and built a theoretical model based on modified theory of planned behaviour. (en, covariance-based structural equation modelling was applied to analyse the questionnaires provided by 248 respondents from construction companies, real estate developers, pharmaceutical companies, private hospitals, asset management companies, and medical industry property investment companies in China. Results indicated that attitude towards behaviour (β � 0.466, P< 0.001), subjective norm (β � 0.167, P< 0.05), perceived behavioural control (β � 0.231, P< 0.01), and facilitating conditions (β � 0.305, P< 0.001) are positively significant to behavioural intention; behavioural intention also shows a strong linkage with behaviour (β � 0.931, P< 0.001). Findings provide reference for governments and public authorities to exert additional efforts in implementing appropriate measures that will stimulate the private sector’s motivation to participate in CHM via PPP. public services account for 75.7% of total hospital beds and 1. Introduction 85.8% of outpatient visits at the end of 2017 [5]. Traditional Chinese healthcare market (CHM) has rapidly developed stereotyping predisposes people to seek services from ter- with economic growth in recent decades [1]. CHM has been tiary hospitals rather than primary care or private facilities one of the most involved fields to draw investments and even for chronic noncommunicable diseases. (e partici- efforts from the public sector [2]. In 2009, China started its pation of private capital in the market of healthcare via healthcare reform to establish basic medical and health public-private partnership (PPP) could be a feasible and system covering all residents from urban to rural areas [3]. sustainable approach to narrow down the gap between Achievements were made during the process of reform; to demand and supply of medical services effectively. illustrate, 93% of individuals were covered by insurance [4], In general, public institutions possess the dominant but the imbalanced distribution of resources between public position in the CHM [6], showing absolute advantages in general and private hospitals remains severe. Statistics from equipment, technical knowledge, and highly educated per- National Health Commission (NHC) indicates that ap- sonnel. Traditionally, benefits of public hospitals originate proximately 70% of medical service demand in China from financial subsidies and drug sales, resulting in over- currently comes from primary communities, and tertiary prescription and unnecessary procedures [7]. Moreover, the 2 Journal of Healthcare Engineering employed to investigate the intention and behaviour from number of public healthcare services reflects a mismatch with the huge market demand. (e excessive concentration private capital participation in CHM via PPP. Furthermore, we applied covariance-based structural equation modelling of patients to public hospitals resulted in the emergence of the “rent dissipation” phenomenon, such as queues and (CB-SEM) to analyse the data from questionnaire survey and scalped trading [8]. (us, waste of resources leads to effi- subsequently drew the conclusion. Finally, the findings and ciency defect of the entire society and damages the sus- limitations of this study were discussed. tainability of medical services in CHM. (is study could expand the research scope of intention Two typical routes exist for the implementation of and behaviour in CHM for the private sector and also de- private sector investment in the healthcare field, namely, velop an analytical framework as reference for other CHM stakeholders to make rational selections. privatisation and PPP. (ese two concepts must be distin- guished. Privatisation refers to the transfer of ownership and responsibilities from public services to private capital; it 2. Literature Review brings competition and market mechanism [9]. Opponents believe that a paradox exists between privatisation and 2.1. Critical Challenges in CHM. (ree notable challenges in welfare economic theory. Healthcare as public good related CHM are identified owing to the imbalance between de- to social responsibility should be equally accessible to all mand and supply of high-quality diagnosis [19]. Firstly, individuals without certain limitations [10]. Compared with doctors and patients were unsatisfied with the conditions of privatisation, PPP was interpreted as a long-term contrac- current practice [20]. Referral system remains absent in tual agreement between a public agency and a private sec- China [21], doctors in large-scale hospitals suffered from toral entity, through which each sector shares the skills, work overload and personal assaults [22, 23]. Approximately assets, risks, and rewards in the delivery of a service and 95.66% of doctors were reported to consider that a mismatch facility for use of the general public [11]. At the end of 2018, exists between efforts and salaries [24]. In addition, the debts of local governments in China reached 18.4 trillion healthcare practitioners held a tense relationship with pa- yuan [12]; public authorities were under huge pressure to tients. Several patients and their families even came into spend on social healthcare expenditures. Private capital conflict with doctors to protest against the insufficient involved in medical delivery via PPP could expand the medical resources and expensive fees of drugs and treat- source of funds, improve the operational efficiency of ments [25, 26]. Secondly, the phenomena of overprescrip- healthcare facilities [13], strengthen their own market tion and overdiagnosis were common in CHM [21], competitiveness, and acquire opportunities for future in- especially in primary or secondary cares of rural areas [27]. vestment. Emerging countries are considered a proper On the one hand, public hospitals were allowed to profit market in extensively promoting PPP to improve the quality from services and drugs to compensate for the low subsidies of medical infrastructures [14]. Four representative types are from governments [28, 29]. On the other hand, unnecessary applied for private sector investment in CHM via PPP diagnostic tests, drugs, and therapeutic interventions were modality, namely, build-operate-transfer (BOT), renovate- regarded as defensive actions for doctors to avoid potential operate-transfer (ROT), transfer-operate-transfer (TOT), disputes [30]. (irdly, the challenge is the resource shortage operation and management contracts (O&M) [15] (Table 1). and waste of primary healthcare institutions in CHM Despite PPP’s substantial contribution to creating high [31–33]. Li et al. indicated that low reimbursement caps and capacity and quality of health system in China [15], chal- limited coverage provided incentives for patients to overuse lenges remain. Firstly, numerous private capital entities, public hospitals and prevented primary medical institutions including construction companies and property developers, from providing first-contact care [34]. Researchers showed lack technical knowledge and experience to operate that a large room could be provided in the primary and healthcare facilities [16]. Secondly, considering certain dif- secondary healthcare markets in rural China, which could be ferences among medical entities, setting appropriate key made available for private capital investment [32]. indicators to evaluate performance for private participators Furthermore, traditional economic theory believed that as payment basis is difficult [14]. (irdly, private specialist efficiency and fairness are two major aims that social clinics are still not allowed to establish property relation with managers must consider in initiating policies and inter- public general hospitals in several core medical services vening in the market [35]. In China, establishing an adequate owing to policy restrictions [17]. Finally, the value conflict healthcare system to ensure that each individual gains access between public welfare and profit seeking in healthcare to medical services was a remarkable feature for achieving product remains harsh [18]. fair opportunities and a manifestation of healthcare de- (ese benefits and challenges will be difficult to ignore mocracy [36]. However, Yuan et al. argued that less than 5% for CHM participators during the decision-making process. of the financial burden on medical expenses had been cut (us, determining key factors for the intention of the private [37]. Most of the households in Mainland China still weakly sector to participate in CHM via PPP modality is necessary. resist expensive catastrophic or chronic diseases [38]; (is study aims to examine the influential factors that affect consequently, they must increase their savings as a pre- the intention and behaviour of private sector involvement in caution for the future burden of medical bills [39]. In ad- CHM via PPP. Firstly, five hypotheses are defined by lit- dition, findings from Kuan and Chen suggested that the erature research based on modified theory of planned be- prohibitive expenditure on healthcare has severely limited haviour (TPB). (en, the questionnaire survey method is family consumption in other daily activities [40]. Journal of Healthcare Engineering 3 Table 1: Representative types for private sector investment in CHM via PPP. Types of PPP in the Features Categories of private sector Empirical examples healthcare field (is type has the widest scope of contract. In practice, the (1) Jinan Zhangqiu North Medical partnership concentrates on the (1) Construction companies Comprehensive Service Center BOT construction of healthcare services (2) Real estate developers (2) Xingyang People’s Hospital without depth in management and (3) Kunming Children’s Hospital operational stages. (is type is generally applied in existing medical services. Private sector undertakes all business (1) Pharmaceutical companies management aspects (drug and (1) Tongliao Zhongmeng Hospital TOT (2) Private hospitals medical equipment supply, (2) Nantong Rudong TCM Hospital (3)Asset management companies supermarket, canteen, and property), except core medical care (clinical work). (is type is also known as invest- (1) Medical industry property (1) Shenyang Fifth People’s Hospital operate-transfer (IOT). Private ROT investment companies (2) Hainan Ledong second People’s sector rebuilds and upgrades several (2) Construction companies Hospital equipment based on TOT. Governments remain the owner of public hospital and outsource (1) Private hospitals (1) Beijing Mentougou Hospital O&M nonclinical work (daily operation (2)Medical industry property (2) Qiannan Huishui Grade-A and management) to the private investment companies Tertiary Hospital sector. An overwhelming trend requiring emphasis is ageing. compared with other fields, the health landscape had been Scholars considered that China has reached the Lewis taking a period of enormous change, including clinical turning point and has become an ageing society [41]. Sta- technologies, models of care, and epidemiological trends; tistics showed that 20% to 33% of individuals will be aged 65 thus, the uncertainty was largely magnified [51]. years or older by 2050 [42]. (us, this change in demo- In effect, four approaches for private sector participation graphics will result in considerable levels of somatic disease in healthcare delivery via PPP were concluded by Barlow and and comorbidity [43]. (e booming demand for healthcare his colleagues [47, 52]. Firstly, private entities provide services and pension cares from the elderly heightened the medical facilities and nonclinical work without intensive cooperation. Secondly, a new project company is established shortage of medical resources [44]. Moreover, Niu et al. argued that community-based primary healthcare generates for the purpose of operating clinical services [53]. (e third poor performance, which scarcely met the satisfaction of the model is concession, which would be tightly supervised by elderly [45]. Existing literature suggested an urgent need to health authorities [54]. Finally, the private sector could increase the quality and quantity of CHM. deliver hospital services and primary care for individuals in their location [55]. (ese approaches have been used in numerous developed and emerging countries, especially in 2.2. PPP in Healthcare Service Delivery. As a typical category Europe. Chinese and foreign scholars hold a consensus that PPP of social infrastructures with increasing demand, healthcare was regarded as a suitable field for applying PPP [46]. is a combination of strength from public and private sectors for the fulfilment of cost efficiency and social policy [56, 57]. European countries had a relatively universal application of Since 2014, the new round of PPP tide has rapidly emerged this model to develop and deliver healthcare facilities [47]. Data from European PPP Expertise Center (EPEC) showed and has profoundly contributed to expanding the supply of urban infrastructures in China [58, 59]. Akin et al. con- that healthcare was the largest PPP sector, with huge market transaction volume [48]. Scholars collected 49 PPP hospital sidered that compared with municipal engineering or transportation, CHM embraces relatively low marketisation cases from the UK and developed an analytical model to emphasise that PPP hospital could achieve value for money [60]. PPP could be seen as a part of China’s healthcare reform to release the financial burden of medical facilities under stable political and economic circumstances [49]. However, considering the diversity of medical facilities and and introduce advanced management concept in CHM [61, 62]. In Guangdong, an empirical study was launched complexity of performance measurements, PPP in health- using grey relational analysis to build a research model and care was also confronted with challenges [50]. A previous compare the resource configuration and service ability study from Italy suggested that irrational and ill-advised among “Chaonan Minsheng Hospital” (which is a certain development could spoil the sustainability of PPP healthcare [14]. Torchia and Calabro` underlined a critical issue: PPP hospital in Guangdong), normal public hospitals, and 4 Journal of Healthcare Engineering conditions (FC) as a main indicator are identified and in- private hospitals. Accordingly, the PPP hospital has been found to have better resource allocation and service quality troduced in our modified TPB model from Venkatesh’s finding [78]. In this research, AB, SN, PBC, FC, BI, and B are than the other two types [63]. In addition, Zhang concluded several applicable forms in which the private sector could regarded as latent variables in the structural model participate in CHM via PPP and then emphasised that at- (Figure 1). tention should also be paid to cultivating the medical soft power, including the construction of key disciplines and 3.2. Hypothesis Development training of general practitioners [64]. Based on previous literature, no relevant research on the 3.2.1. Determinants of Private Sector’s BI to Participate in intention and behaviour of private sector participation in CHM via PPP. AB is defined as feeling on the target be- CHM exists, especially via PPP. (us, the question below haviour and could be regarded as individuals’ affective re- must be answered: action on the outcome of assuming a particular behaviour What are the influential factors and to what extent do [71, 78]. Boyne considered that the private sector is driven by they affect the intention and behaviour of private sector profit motives and self-interest [79]. (us, investment involvement in Chinese healthcare service delivery via PPP? benefits contribute to the decision-making process [80]; the existing research indicates that the public sector often in- 3. Theoretical Model and Hypotheses creases the return of investment to enhance the attractive- ness of PPP projects for the private sector [81]. Regarding the 3.1. 1eoretical Model Based on Modified TPB. TPB was healthcare domain, most private enterprises participate in developed by Ajzen in 1988 [65] as an expansion of theory of healthcare service delivery for profit as emphasised by reasoned action (TRA) [66]. Ajzen claimed that personal Mackintosh and his colleagues [82]. (e main concern of behaviour is affected by voluntary and various factors. TRA private equity investors involved in PPP hospitals was re- could not reasonably explain involuntary behaviour. (us, liable revenue [83]. In CHM, nonpublic healthcare services Ajzen put forward three indicators to analyse the decision- tend to be provided in large cities owing to the considerable making process and individual action, namely, attitude consuming market [84]. In addition, Chinese scholars towards behaviour (AB), subjective norm (SN), and per- claimed that the overemphasis on public welfare could ceived behavioural control (PBC). (ese three factors could frustrate the intention of private sector investment in CHM affect the behavioural intention (BI) and then behaviour (B) via PPP. (erefore, the following hypothesis is stated. [65]. In 1995, Taylor and Todd built an extended model, which Hypothesis 1 (H1). AB has significant positive effects on BI. introduced perceived usefulness as a critical factor based on SN is referred to as the behavioural perception of a the TPB model [67]. (ese scholars believed that the ex- decision-maker from important peers or groups [78]. In tended model could compensate the measurement of a CHM, the public sector (governments and public hospitals), certain group’s feeling towards a concept. consumers, and the private sector (private hospital, con- TPB was originally proposed to investigate a user’s struction companies pharmaceutical companies, real estate willingness to accept a certain technology. With its wide developers, and asset management companies) are three prevalence, TPB was also applied in numerous fields that typical stakeholders whose preference is crucial to each analyse human behaviour [68, 69]. Several studies were participant’s behaviour [4]. Ou and Jia stated that the private implemented on the BI of the private sector. East was the sector decides whether to participate in Chinese healthcare earliest researcher who used behaviour theory in the field of service delivery via PPP partly in consideration of social private investment [70]. Paetzold and Busch developed a image and public reputation [17]. Furthermore, researchers framework based on TPB to understand the decision- concluded that a positive correlation exists between SN and making process of the private sector towards sustainable BI [85]. China PPP Center reported a booming trend in investment [71]. Malaysian scholars applied a modified TPB CHM; that is, the number of commercial PPP projects in- model, which explained the effect of the private sector’s creased from 150 to 171 in two months [86, 87]. Considering intention and attitude to participate in socially responsible that the selection of investment objective from peers could investments [72]. In addition, TPB could be considered a provide an indirect suggestion into the decision-making framework to evaluate the willingness of private capital to process of the private sector [65], the imitation effect by invest in normal PPP projects and analyse the connection former private investors in CHM has influenced others’ between the private sector and PPP performance [73, 74]. In future behaviour. (us, the following hypothesis is stated. CHM, researchers applied TPB to examine the patients’ willingness to seek treatment [75], consuming intention on medical products and nurturing personal health behaviour Hypothesis 2 (H2). SN has significant positive effects on BI. [76, 77]. PBC is a perception, which reflects the resources and Considering the different approaches of PPP modality barriers of an expected behaviour [78]. It exhibits the confidence of controlling the resource, which is needed by and policy circumstance of CHM, the objective environment and competitive status should be emphasised whilst the the private capital. Wang and Zhang indicated that PPP has become a component of China’s medical reform; several private sector participates in CHM via PPP. (us, to build a research model with good explanatory effect, facilitating available approaches have emerged as references for private Journal of Healthcare Engineering 5 4. Research Method Attitude towards behaviour (AB) 4.1. CB-SEM. CB-SEM is used in this study. (is method was first adopted in the social sciences in 1970 and has been Subjective norm extensively applied in marketing, business, management, (SN) and behaviour research to identify the connections among Behavioural Behaviour (B) certain factors [94, 95]. In addition, several researchers often intention (BI) Perceived consider that SEM is as equal as CB-SEM [96]. However, behavioural PLS-SEM is another unique approach of SEM. Compared control (PBC) with PLS-SEM, CB-SEM should be generated with a high sample size [97]. Moreover, the objective of CB-SEM is Facilitating confirmation rather than prediction of PLS-SEM [98]. TPB conditions (FC) has been developed for decades with solid basis in theory. Figure 1: Structural model based on the modified TPB. CB-SEM could provide more robust estimations compared with PLS-SEM. (erefore, Amos 21.0 is adopted in our research to implement CB-SEM. sector investment in CHM [15]. To improve attractiveness, multiple barriers should be removed to establish an easy access by NHC, whilst private investors participate in elderly 4.2. Questionnaire. To collect first-hand information, a care and healthcare service delivery, including free provision questionnaire survey was formed containing six latent for certain procedures [88]. Existing research emphasises variables, AB, SN, PBC, FC, BI, and behaviour. (e re- that a reduced perceived impediment increases the will- spondents were asked to reply using a five-point Likert scale ingness to generate [74]. (erefore, the following hypothesis from 1 (strongly disagree) to 5 (strongly agree). (en, we is stated. invited six experts from the field of public health manage- ment and four scholars associated with PPP to test the Hypothesis 3 (H3). PBC has significant positive effects on reasonableness and comprehensiveness of the questionnaire. BI. Few items were modified on the basis of the corresponding FC could be defined as objective factors in an envi- suggestions from experts and scholars. Table 2 presents the ronment to support individual’s actual behaviour [89]. final questionnaire. Favourable measures in a situational context from organ- isational support could motivate a positive belief in BI [90]. 4.3. Data Collection. At the project level, the procedure of Certain opportunities with potential benefits provided by PPP healthcare project comprises construction (or renewal), public authorities contribute to the participation in social operation, and financing. (us, six groups were selected infrastructure delivery of private capital, including extra based on distinct stages: construction companies, real estate subsidies, financial support, and land acquiring priority [91]. developers, pharmaceutical companies, private hospitals, A large capital and technical rigor exist in the healthcare asset management companies, and medical industry prop- field; compared with full privatisation with high require- erty investment companies. Every group has become the ments on financial capacity and operational performance stakeholder by getting involved in CHM via different types [9], PPP could be regarded as an available method to be of PPP (Figure 1). involved in Chinese healthcare service delivery. Private Considering that the majority of projects in this round of capital has been largely encouraged by this favourable cir- PPP tide were executed contain the construction activity, cumstance [92]. (us, the following hypothesis is stated. about a quarter of the respondents were selected from construction companies related to the preoperational stage Hypothesis 4 (H4). FC has significant positive effects on BI. in this research. (en, pharmaceutical companies, private hospitals, and asset management companies were identified 3.2.2. Determinants of the Private Sector’s Behaviour to as the participators who hold dominant prevalence of ex- Participate in CHM via PPP. General theory believes that BI pertise and capacity in operational link. Meanwhile, medical is determined by AB, SN, and PBC. (is study brings FC as a industry property investment companies and real estate complementary variable in the modified model. (e developers were considered as the private investors with framework based on TPB could be used on investment commercial issues in the financing stage. behaviour to explain investors’ decision-making process (e criteria for selecting the sample respondents were as [72]. Intention is the closest determinant of behaviour [85]. follows: (1) they have expertise in their companies that Davies et al. considered that BI maintains a significantly participate in completed PPP or normal healthcare services; positive influence on usage [93]. (erefore, a strong BI raises (2) they come from multiple positions and departments; and the possibility of the actual behaviour to be performed [65]. (3) they are willing to participate in the survey. (erefore, (us, the following hypothesis is stated. 202 questionnaires were distributed online (WeChat), and 83 were distributed on the spot. All respondents were identified with working experience from the selected oc- Hypothesis 5 (H5). BI has significant positive effects on behaviour. cupations. (is data collection process lasted for four 6 Journal of Healthcare Engineering Table 2: Survey items and certain indices. Variables and survey items Cronbach’s α AVE Literature AB: AB1: I could obtain potential opportunities of investment by participating in CHM. AB2: Participating in CHM could increase operational benefits. AB3: Participating in CHM could obtain external 0.909 0.719 [71, 99, 100] political privileges. AB4: I can strengthen the competitiveness of nonclinical (or clinical) work by establishing partnership with public authorities. SN: SN1: Participating in Chinese healthcare service delivery could earn additional social reputation. SN2: An increasing number of my competitors is involved in CHM. 0.817 0.537 [74, 101] SN3: Investing in CHM helps me win recognition from public authorities. SN4: Investing in CHM helps me earn prestige from my competitors. PBC: PBC1: (e barriers to enter CHM is acceptable for me. PBC2: I could gain requisite knowledge and capital to invest in Chinese medical service delivery if I am 0.885 0.722 [102, 103] willing. PBC3: Given the necessary resources and knowledge, involvement in CHM would be easy for me. FC: FC1: Public authorities encourage private investors to participate in CHM. FC2: Supportive polices with potential benefits have been issued to make an easy approach for private capital investment in CHM. FC3: Official guidance is available to me to establish 0.899 0.735 [78, 104, 105] partnership with public authorities and invest in CHM. FC4: Employees in my company have received necessary training towards participating in Chinese healthcare service delivery. BI: BI1: I am willing to try to participate in CHM step by step. BI2: Investing in CHM by PPP rather than other fields or full privatisation is a good idea. 0.865 0.607 [71, 106] BI3: Personnel in my company would be glad to accept related training. BI4: CHM would be one of my favourite fields to invest by PPP. B: B1: I have engaged in Chinese healthcare resources supply via PPP. B2: I suggested other partners to also participate in 0.847 0.649 [78] CHM via PPP. B3: I will keep partnering with public authorities and investing in CHM. months from November 2018 to March 2019. Finally, 248 completion or perfunctory effort. (us, the effective rate is questionnaires were confirmed to be available for this re- 87%, which could meet the requirement of CB-SEM. Table 3 search by removing several questionnaires with low lists the demographic data of survey sample. Journal of Healthcare Engineering 7 Table 3: Sample demographics. Type Frequency Percentage (%) Male 166 66.9 Gender Female 82 33.1 3–5 years 53 21.4 6–10 years 122 49.2 Working experience 11–15 years 31 12.5 16–20 years 29 11.7 More than 20 years 13 5.2 Construction companies 64 25.8 Real estate developers 53 21.4 Pharmaceutical companies 27 10.9 Occupation Private hospitals 39 15.7 Asset management companies 41 16.5 Medical industry property investment companies 24 9.7 Administrative staff 173 69.8 Position Basic staff 75 30.2 Table 4: Goodness-of-fit test measure. 5. Result Analysis Goodness-of-fit Acceptable Value of 5.1. Reliability and Validity. Data reliability and validity Evaluation measure threshold model should be tested before implementing CB-SEM. SPSS 20.0 CMIN/DF <3.00 2.005 √ software was applied to calculate the Cronbach’ α value, GFI >0.90 0.906 √ which reflects the consistency level of the items. Cronbach’ α AGFI >0.90 0.886 √ value should be more than 0.7 [107]. In this study, the value RFI >0.90 0.911 √ scale ranges from 0.817 to 0.909; thus, the reliability of the NFI >0.90 0.936 √ questionnaire could be satisfied. (en, we used Amos 21.0 CFI >0.90 0.950 √ software to calculate average variance extracted (AVE) value RMSEA <0.08 0.064 √ for testing the validity. Fornell and Larcker believed that the PNFI >0.50 0.777 √ AVE value should be more than 0.5 [108]. (e six latent PCFI >0.50 0.815 √ PGFI >0.50 0.686 √ variables shown in Table 2 meet the standard, thereby confirming the excellent validity of our research. Table 5: CR value of latent variables. 5.2. Structural Model. After building the structural model, we used Amos 21.0 to test the goodness-of-fit. Multiple Latent variables Composite reliability value indices are connected with this procedure (Table 4). (e fit AB 0.911 value between our structural model and data meets the FC 0.917 acceptable standard. SN 0.820 In addition, composite reliability (CR) was applied to test PBC 0.886 BI 0.861 the internal consistency of the structural model. Hair in- B 0.847 dicated that the acceptable threshold should be 0.7 [109]; however, Fornell and Larcker believed that 0.6 could also be satisfactory as a standard [108]. In this research, the CR As seen from Table 6, the P value of all the five paths are values of all latent variables surpass 0.82 (Table 5). less than 0.05, including “AB” to “BI” (β � 0.466, P< 0.001), Figure 2 shows the finding of structural model on the “FC” to “BI” (β � 0.305, P< 0.001), “SN” to “BI” (β � 0.167, private sector’s intention and behaviours regarding partic- P< 0.05), “PBC” (β � 0.231, P< 0.01), and “BI” to “B” ipation in Chinese healthcare delivery via PPP. Each path (β � 0.931, P< 0.001). (ese five paths are statistically sig- among the latent variables corresponds to a certain hy- nificant and thus support H1 to H5. pothesis; the six β values display the path coefficients (standard regression weights), which are positively corre- lated with the effect degree. Moreover, we should verify if the 6. Discussion hypotheses are supported by calculating the critical ratio (is research established an analytical framework based on (CR) and the P value. When the CR is higher than 1.96, the P modified TPB to determine the influence and relative value should be less than 0.05. (is finding implies that the contribution among certain independent variables for the path is significant at the 0.05 level, and the hypothesis is private sector’s intention and behaviour towards partici- supported. Table 6 presents all the hypotheses’ testing pating in CHM via PPP. results. 8 Journal of Healthcare Engineering Potential opportunities (AB1) a1 = 0.86 Revenue from healthcare services (AB2) a2 = 0.83 Better Willingness Willingness Willingness External political privileges AB choice than a3 = 0.83 of applying of personnel of investing (AB3) full gradually training in CHM a4 = 0.86 privatization Competitiveness of nonclinical (or (BI1) (BI3) (BI4) (BI2) clinical) work (AB4) Public authority encouragement a16 = 0.77 a18 = 0.78 (FC1) a5 = 0.77 β1 = 0.47 ∗∗∗ a17 = 0.77 a19 = 0.80 Supportive policies a6 = 0.84 (FC2) FC a7 = 0.86 Available guidance (FC3) a8 = 0.87 β2 = 0.31 ∗∗∗ Professional personnel in healthcare (FC4) BI Social reputation β3 = 0.17 (SN1) β4 = 0.93 ∗∗∗ a9 = 0.61 Competitors’ intention a10 = 0.81 SN (SN2) a11 = 0.81 a22 = 0.81 a20 = 0.80 Recognition from public authorities β4 = 0.23 ∗∗ a21 = 0.81 (SN3) a12 = 0.68 Prestige from private sectors (SN4) Participating Maintaining Suggestions Market barriers of chinese healthcare in CHM by partnership for other (PBC1) PPP with public partners a13 = 0.87 actually hospitals (B2) Capability of resource acquisition (B1) (B3) a14 = 0.82 PBC (PBC2) a15 = 0.86 Capability of resource utilization (PBC3) Figure 2: Structural model with path coefficients (β) and factor loading (a). Table 6: Hypothesis assessments. industry property investment companies are provided huge potential and market volume in China to build large-scale Hypothesis Path β CR (t) P Result clinical trials of new medicines, devices, and surgical pro- ∗∗∗ H1 BI⟵ AB 0.466 8.712 Supported cedures via PPP [113]. In addition, real estate developers ∗∗∗ H2 BI⟵ FC 0.305 5.999 Supported attempt to enter into CHM, such as Vanke, China Resources, H3 BI⟵ SN 0.167 2.466 Supported ∗∗ and Tahoe and Wanda [114]. Several embraced motivation H4 BI⟵ PBC 0.231 3.136 Supported ∗∗∗ to invest in healthcare service delivery and subsequently H5 B⟵ BI 0.931 12.588 Supported obtain an easy access to land acquisition or integrate medical ∗∗∗ ∗∗ ∗ P< 0.001; P< 0.01; P< 0.05. facilities to increase added residential value. (erefore, di- rect incentives were provided to the private sector, estab- lishing a positive attitude towards participating in CHM via Conventional theory suggests that path coefficient was PPP. based on standardised regression data [110]; thus, it could be FC holds the second strongest significant effect on BI has used to compare the relative importance of the independent been verified, with the standard path coefficient of 0.305 in variables in OLS regression [95]. (e degree of four latent our findings. External facilitators directly contribute to BI, variables’ contribution to BI can be identified from this such as technical support and favourable CHM policies perspective. [115]. Since Premier Li Keqiang solemnly emphasised the AB has a significant positive effect on BI with the necessity of promoting private capital into CHM [116], standard path coefficient of 0.466. (is effect could show the numerous supportive policies have been approved, in- closest linkage between attitude and intention in the deci- cluding the expansion of market space, broadening the sion-making process of private capital involvement in CHM reimbursement coverage of nonpublic hospitals, and tax via PPP. AB is conducted directly by the feeling on per- relief on primary healthcare facilities by PPP [117]. Fur- formance of target behaviour [111]. (e need for medical thermore, new technical fields are encouraged to initiate a resource supply is literally urgent in China given the chal- transformation from outsource contract to PPP, such as lenges of ageing, increasing prevalence of chronic diseases, telemedicine and E-health system [113]. (e internal fa- and incompleteness of healthcare delivery [112]. Alternately, cilitators are equally critical. Participation in CHM could be Wang and Zhang pointed out that CHM contains several highly viable for those private sector entities with experi- opportunities for the private sector, where most individuals enced personnel, financing channels, and advanced man- are willing to pay for PPP healthcare services at a reasonable agement framework. An increasing number of public level [15]. Pharmaceutical corporations and medical Journal of Healthcare Engineering 9 hospitals tend to share human resource and medical devices From this research, the importance of prospective with eligible private sector entities [17]. Evidence from benefits and supportive measures is emphasised. Public authorities should provide official guidelines for private “Beijing Children’s Hospital–New Century International Children’s Hospital” PPP project confirms this availability. capital involvement in CHM, which could effectively de- PBC is positively significant to BI, with a relatively low crease the transaction cost in information searching and path coefficient of 0.23. Zheng et al. researched on the contract signing. (us, additional analysis is made from willingness of private capital to engage in sustainable per- these two perspectives. formance in PPP infrastructure and confirmed that PBC On the one hand, most PPP healthcare projects were holds a positive effect on BI [74]. In this study, PBC is also newly built, and the integration of stock facilities was less significant to specific intention. (e confidence of risk re- applied. BOT concession could promote the enthusiasm of sponse on specific behaviour directly contributes to BI of private capital participation in CHM, considering that participating in CHM. PPP contains more feasibility than several private sector companies in CHM are from the traditional public procurement owing to the efficiency- construction industry [122]. However, a long-term insti- tutional inertia of the BT in China causes the construction oriented governance structure [118], which could strengthen the confidence and decrease the uncertainty of private stage to be a major source of profit and private participants capital participation in Chinese healthcare delivery. SN also to be scarcely motivated to accept other types of PPP. has a significant effect on BI, with the lowest path coefficient (erefore, the private entities should be encouraged to es- of 0.167, which shows a limited effect. Previous findings tablish partnership with public authorities in TOT, ROT, suggested that SN holds a strong influence on BI in the and OM through integration, transformation, or leasing of decision-making process of the private sector regarding existing healthcare facilities. (e financing risks of these socially responsible investment [72]. (e evidence shows a types are distinctly lower than BOT, and private investors reverse result in our research; the size of standardised direct might broaden the scope of cooperation and market in a new effect of SN on BI is approximately 1/3 times that of AB. approach. (e Second Social Welfare Center of Beijing has Considering that social reputation is regarded as one of the successfully upgraded and integrated medical resources in ROT, which achieved the value between the public and key factors in hospital selection of patients and most of the nonpublic medical facilities hold unsatisfied prestige in private. In addition, the social sector should be encouraged CHM [119], improving the condition in a short time is to participate in CHM in the form of consortium, which difficult. (us, public reputation and social image were could magnify the advantages of construction enterprises in deemed as subordinate targets behind business benefit for financing, construction, and external relations, as well as the several private entities in CHM. To a certain extent, these strength of medical industry property investment companies factors cause the lowest effect from SN to BI. and private hospitals in service performance. Behaviour is significantly influenced by BI, with the On the other hand, considering the knowledge rigor of highest path coefficient of 0.931. Numerous studies re- the medical field, private sector faces considerable uncer- peatedly confirmed this close linkage between BI and actual tainty in CHM. A standard and feasible exit mechanism behaviour [120, 121]. Although several findings showed that should be established. No official guideline exists as a ref- BI holds a relatively lower effect on behaviour than with our erence for the private sector in exiting PPP. Existing result, it would be totally acceptable considering the dif- common approaches have obvious limitations in effect, such ference of context in various studies. as expired handover, equity transfer, public listing, bond issuance, and asset-backed securities. We suggest that re- strictions on equity transfer of special purpose vehicle could 7. Conclusions and Implications be appropriately liberalised in the Chinese healthcare field. Previous studies have been conducted regarding the will- Although governments and public agencies should not be ingness of the private sector to invest in economic infra- the subject of equity transfer, they may properly allow equity structure via PPP. However, the critical factors related to flows among various private capital entities in CHM. To a certain extent, equity flow would help in dispelling the intention and behaviour of private sector participation in CHM via PPP and the relative importance to which AB, FC, misgivings of the investors and strengthen the intention. (is study contains certain limitations despite its use- PBC, and SN affect BI were neglected in the relevant lit- erature. (is study’s innovation is the analysis of the fulness on the intention and behaviour research of private sector involvement in CHM via PPP. Most of the data from influencing factors of BI and the identification of the level of effect on BI based on modified TPB and CB-SEM. (e our selected respondents are provided from the question- naire. Additional studies could be generated via face-to-face finding shows that AB, FC, PBC, and SN are positively significant to BI, and that BI has a significant effect on interview to acquire highly accurate information and strong behaviour. Moreover, AB and FC hold a relatively stronger explanation. linkage to BI than with others, which provides reference for governments and public authorities to implement appro- Data Availability priate policies for stimulating the private sector’s motivation to participate in CHM via PPP and subsequently narrow (e data used to support the findings of this study are down the gap of medical resources and ameliorate the available from the corresponding author upon reasonable quality of Chinese healthcare services. request. 10 Journal of Healthcare Engineering risk could be wholely controlled, in Chinese, http://finance. Disclosure people.com.cn/GB/n1/2019/0220/c1004-30806607.html. (e founding sponsors had no role in the design of the study; [13] B. James, R. Jens, and W. 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Evaluating the Intention and Behaviour of Private Sector Participation in Healthcare Service Delivery via Public-Private Partnership: Evidence from China

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Copyright © 2020 Jie Yang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Healthcare Engineering Volume 2020, Article ID 5834532, 13 pages https://doi.org/10.1155/2020/5834532 Research Article Evaluating the Intention and Behaviour of Private Sector Participation in Healthcare Service Delivery via Public-Private Partnership: Evidence from China 1 1 2 1 3 1 Jie Yang, Lingchuan Song , Xiaoyi Yao, Qian Cheng, Zichao Cheng , and Ke Xu School of Management Engineering, Shandong Jianzhu University, Jinan 250101, Shandong, China School of Business, University of Leicester, Leicester LE3 5EB, UK Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing 100069, China Correspondence should be addressed to Lingchuan Song; songlc22@163.com Received 12 June 2019; Accepted 30 December 2019; Published 17 January 2020 Academic Editor: Emiliano Schena Copyright © 2020 Jie Yang et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Private sector participation in the healthcare market via public-private partnership (PPP) could be considered an available approach to narrow down the medical resource gap and improve the operational efficiency of healthcare facilities. Accordingly, this study aims to examine the influence and relative importance among critical factors for the intention and behaviour of the private sector towards participation in Chinese healthcare market (CHM) via PPP. We defined five hypotheses from previous literature and built a theoretical model based on modified theory of planned behaviour. (en, covariance-based structural equation modelling was applied to analyse the questionnaires provided by 248 respondents from construction companies, real estate developers, pharmaceutical companies, private hospitals, asset management companies, and medical industry property investment companies in China. Results indicated that attitude towards behaviour (β � 0.466, P< 0.001), subjective norm (β � 0.167, P< 0.05), perceived behavioural control (β � 0.231, P< 0.01), and facilitating conditions (β � 0.305, P< 0.001) are positively significant to behavioural intention; behavioural intention also shows a strong linkage with behaviour (β � 0.931, P< 0.001). Findings provide reference for governments and public authorities to exert additional efforts in implementing appropriate measures that will stimulate the private sector’s motivation to participate in CHM via PPP. public services account for 75.7% of total hospital beds and 1. Introduction 85.8% of outpatient visits at the end of 2017 [5]. Traditional Chinese healthcare market (CHM) has rapidly developed stereotyping predisposes people to seek services from ter- with economic growth in recent decades [1]. CHM has been tiary hospitals rather than primary care or private facilities one of the most involved fields to draw investments and even for chronic noncommunicable diseases. (e partici- efforts from the public sector [2]. In 2009, China started its pation of private capital in the market of healthcare via healthcare reform to establish basic medical and health public-private partnership (PPP) could be a feasible and system covering all residents from urban to rural areas [3]. sustainable approach to narrow down the gap between Achievements were made during the process of reform; to demand and supply of medical services effectively. illustrate, 93% of individuals were covered by insurance [4], In general, public institutions possess the dominant but the imbalanced distribution of resources between public position in the CHM [6], showing absolute advantages in general and private hospitals remains severe. Statistics from equipment, technical knowledge, and highly educated per- National Health Commission (NHC) indicates that ap- sonnel. Traditionally, benefits of public hospitals originate proximately 70% of medical service demand in China from financial subsidies and drug sales, resulting in over- currently comes from primary communities, and tertiary prescription and unnecessary procedures [7]. Moreover, the 2 Journal of Healthcare Engineering employed to investigate the intention and behaviour from number of public healthcare services reflects a mismatch with the huge market demand. (e excessive concentration private capital participation in CHM via PPP. Furthermore, we applied covariance-based structural equation modelling of patients to public hospitals resulted in the emergence of the “rent dissipation” phenomenon, such as queues and (CB-SEM) to analyse the data from questionnaire survey and scalped trading [8]. (us, waste of resources leads to effi- subsequently drew the conclusion. Finally, the findings and ciency defect of the entire society and damages the sus- limitations of this study were discussed. tainability of medical services in CHM. (is study could expand the research scope of intention Two typical routes exist for the implementation of and behaviour in CHM for the private sector and also de- private sector investment in the healthcare field, namely, velop an analytical framework as reference for other CHM stakeholders to make rational selections. privatisation and PPP. (ese two concepts must be distin- guished. Privatisation refers to the transfer of ownership and responsibilities from public services to private capital; it 2. Literature Review brings competition and market mechanism [9]. Opponents believe that a paradox exists between privatisation and 2.1. Critical Challenges in CHM. (ree notable challenges in welfare economic theory. Healthcare as public good related CHM are identified owing to the imbalance between de- to social responsibility should be equally accessible to all mand and supply of high-quality diagnosis [19]. Firstly, individuals without certain limitations [10]. Compared with doctors and patients were unsatisfied with the conditions of privatisation, PPP was interpreted as a long-term contrac- current practice [20]. Referral system remains absent in tual agreement between a public agency and a private sec- China [21], doctors in large-scale hospitals suffered from toral entity, through which each sector shares the skills, work overload and personal assaults [22, 23]. Approximately assets, risks, and rewards in the delivery of a service and 95.66% of doctors were reported to consider that a mismatch facility for use of the general public [11]. At the end of 2018, exists between efforts and salaries [24]. In addition, the debts of local governments in China reached 18.4 trillion healthcare practitioners held a tense relationship with pa- yuan [12]; public authorities were under huge pressure to tients. Several patients and their families even came into spend on social healthcare expenditures. Private capital conflict with doctors to protest against the insufficient involved in medical delivery via PPP could expand the medical resources and expensive fees of drugs and treat- source of funds, improve the operational efficiency of ments [25, 26]. Secondly, the phenomena of overprescrip- healthcare facilities [13], strengthen their own market tion and overdiagnosis were common in CHM [21], competitiveness, and acquire opportunities for future in- especially in primary or secondary cares of rural areas [27]. vestment. Emerging countries are considered a proper On the one hand, public hospitals were allowed to profit market in extensively promoting PPP to improve the quality from services and drugs to compensate for the low subsidies of medical infrastructures [14]. Four representative types are from governments [28, 29]. On the other hand, unnecessary applied for private sector investment in CHM via PPP diagnostic tests, drugs, and therapeutic interventions were modality, namely, build-operate-transfer (BOT), renovate- regarded as defensive actions for doctors to avoid potential operate-transfer (ROT), transfer-operate-transfer (TOT), disputes [30]. (irdly, the challenge is the resource shortage operation and management contracts (O&M) [15] (Table 1). and waste of primary healthcare institutions in CHM Despite PPP’s substantial contribution to creating high [31–33]. Li et al. indicated that low reimbursement caps and capacity and quality of health system in China [15], chal- limited coverage provided incentives for patients to overuse lenges remain. Firstly, numerous private capital entities, public hospitals and prevented primary medical institutions including construction companies and property developers, from providing first-contact care [34]. Researchers showed lack technical knowledge and experience to operate that a large room could be provided in the primary and healthcare facilities [16]. Secondly, considering certain dif- secondary healthcare markets in rural China, which could be ferences among medical entities, setting appropriate key made available for private capital investment [32]. indicators to evaluate performance for private participators Furthermore, traditional economic theory believed that as payment basis is difficult [14]. (irdly, private specialist efficiency and fairness are two major aims that social clinics are still not allowed to establish property relation with managers must consider in initiating policies and inter- public general hospitals in several core medical services vening in the market [35]. In China, establishing an adequate owing to policy restrictions [17]. Finally, the value conflict healthcare system to ensure that each individual gains access between public welfare and profit seeking in healthcare to medical services was a remarkable feature for achieving product remains harsh [18]. fair opportunities and a manifestation of healthcare de- (ese benefits and challenges will be difficult to ignore mocracy [36]. However, Yuan et al. argued that less than 5% for CHM participators during the decision-making process. of the financial burden on medical expenses had been cut (us, determining key factors for the intention of the private [37]. Most of the households in Mainland China still weakly sector to participate in CHM via PPP modality is necessary. resist expensive catastrophic or chronic diseases [38]; (is study aims to examine the influential factors that affect consequently, they must increase their savings as a pre- the intention and behaviour of private sector involvement in caution for the future burden of medical bills [39]. In ad- CHM via PPP. Firstly, five hypotheses are defined by lit- dition, findings from Kuan and Chen suggested that the erature research based on modified theory of planned be- prohibitive expenditure on healthcare has severely limited haviour (TPB). (en, the questionnaire survey method is family consumption in other daily activities [40]. Journal of Healthcare Engineering 3 Table 1: Representative types for private sector investment in CHM via PPP. Types of PPP in the Features Categories of private sector Empirical examples healthcare field (is type has the widest scope of contract. In practice, the (1) Jinan Zhangqiu North Medical partnership concentrates on the (1) Construction companies Comprehensive Service Center BOT construction of healthcare services (2) Real estate developers (2) Xingyang People’s Hospital without depth in management and (3) Kunming Children’s Hospital operational stages. (is type is generally applied in existing medical services. Private sector undertakes all business (1) Pharmaceutical companies management aspects (drug and (1) Tongliao Zhongmeng Hospital TOT (2) Private hospitals medical equipment supply, (2) Nantong Rudong TCM Hospital (3)Asset management companies supermarket, canteen, and property), except core medical care (clinical work). (is type is also known as invest- (1) Medical industry property (1) Shenyang Fifth People’s Hospital operate-transfer (IOT). Private ROT investment companies (2) Hainan Ledong second People’s sector rebuilds and upgrades several (2) Construction companies Hospital equipment based on TOT. Governments remain the owner of public hospital and outsource (1) Private hospitals (1) Beijing Mentougou Hospital O&M nonclinical work (daily operation (2)Medical industry property (2) Qiannan Huishui Grade-A and management) to the private investment companies Tertiary Hospital sector. An overwhelming trend requiring emphasis is ageing. compared with other fields, the health landscape had been Scholars considered that China has reached the Lewis taking a period of enormous change, including clinical turning point and has become an ageing society [41]. Sta- technologies, models of care, and epidemiological trends; tistics showed that 20% to 33% of individuals will be aged 65 thus, the uncertainty was largely magnified [51]. years or older by 2050 [42]. (us, this change in demo- In effect, four approaches for private sector participation graphics will result in considerable levels of somatic disease in healthcare delivery via PPP were concluded by Barlow and and comorbidity [43]. (e booming demand for healthcare his colleagues [47, 52]. Firstly, private entities provide services and pension cares from the elderly heightened the medical facilities and nonclinical work without intensive cooperation. Secondly, a new project company is established shortage of medical resources [44]. Moreover, Niu et al. argued that community-based primary healthcare generates for the purpose of operating clinical services [53]. (e third poor performance, which scarcely met the satisfaction of the model is concession, which would be tightly supervised by elderly [45]. Existing literature suggested an urgent need to health authorities [54]. Finally, the private sector could increase the quality and quantity of CHM. deliver hospital services and primary care for individuals in their location [55]. (ese approaches have been used in numerous developed and emerging countries, especially in 2.2. PPP in Healthcare Service Delivery. As a typical category Europe. Chinese and foreign scholars hold a consensus that PPP of social infrastructures with increasing demand, healthcare was regarded as a suitable field for applying PPP [46]. is a combination of strength from public and private sectors for the fulfilment of cost efficiency and social policy [56, 57]. European countries had a relatively universal application of Since 2014, the new round of PPP tide has rapidly emerged this model to develop and deliver healthcare facilities [47]. Data from European PPP Expertise Center (EPEC) showed and has profoundly contributed to expanding the supply of urban infrastructures in China [58, 59]. Akin et al. con- that healthcare was the largest PPP sector, with huge market transaction volume [48]. Scholars collected 49 PPP hospital sidered that compared with municipal engineering or transportation, CHM embraces relatively low marketisation cases from the UK and developed an analytical model to emphasise that PPP hospital could achieve value for money [60]. PPP could be seen as a part of China’s healthcare reform to release the financial burden of medical facilities under stable political and economic circumstances [49]. However, considering the diversity of medical facilities and and introduce advanced management concept in CHM [61, 62]. In Guangdong, an empirical study was launched complexity of performance measurements, PPP in health- using grey relational analysis to build a research model and care was also confronted with challenges [50]. A previous compare the resource configuration and service ability study from Italy suggested that irrational and ill-advised among “Chaonan Minsheng Hospital” (which is a certain development could spoil the sustainability of PPP healthcare [14]. Torchia and Calabro` underlined a critical issue: PPP hospital in Guangdong), normal public hospitals, and 4 Journal of Healthcare Engineering conditions (FC) as a main indicator are identified and in- private hospitals. Accordingly, the PPP hospital has been found to have better resource allocation and service quality troduced in our modified TPB model from Venkatesh’s finding [78]. In this research, AB, SN, PBC, FC, BI, and B are than the other two types [63]. In addition, Zhang concluded several applicable forms in which the private sector could regarded as latent variables in the structural model participate in CHM via PPP and then emphasised that at- (Figure 1). tention should also be paid to cultivating the medical soft power, including the construction of key disciplines and 3.2. Hypothesis Development training of general practitioners [64]. Based on previous literature, no relevant research on the 3.2.1. Determinants of Private Sector’s BI to Participate in intention and behaviour of private sector participation in CHM via PPP. AB is defined as feeling on the target be- CHM exists, especially via PPP. (us, the question below haviour and could be regarded as individuals’ affective re- must be answered: action on the outcome of assuming a particular behaviour What are the influential factors and to what extent do [71, 78]. Boyne considered that the private sector is driven by they affect the intention and behaviour of private sector profit motives and self-interest [79]. (us, investment involvement in Chinese healthcare service delivery via PPP? benefits contribute to the decision-making process [80]; the existing research indicates that the public sector often in- 3. Theoretical Model and Hypotheses creases the return of investment to enhance the attractive- ness of PPP projects for the private sector [81]. Regarding the 3.1. 1eoretical Model Based on Modified TPB. TPB was healthcare domain, most private enterprises participate in developed by Ajzen in 1988 [65] as an expansion of theory of healthcare service delivery for profit as emphasised by reasoned action (TRA) [66]. Ajzen claimed that personal Mackintosh and his colleagues [82]. (e main concern of behaviour is affected by voluntary and various factors. TRA private equity investors involved in PPP hospitals was re- could not reasonably explain involuntary behaviour. (us, liable revenue [83]. In CHM, nonpublic healthcare services Ajzen put forward three indicators to analyse the decision- tend to be provided in large cities owing to the considerable making process and individual action, namely, attitude consuming market [84]. In addition, Chinese scholars towards behaviour (AB), subjective norm (SN), and per- claimed that the overemphasis on public welfare could ceived behavioural control (PBC). (ese three factors could frustrate the intention of private sector investment in CHM affect the behavioural intention (BI) and then behaviour (B) via PPP. (erefore, the following hypothesis is stated. [65]. In 1995, Taylor and Todd built an extended model, which Hypothesis 1 (H1). AB has significant positive effects on BI. introduced perceived usefulness as a critical factor based on SN is referred to as the behavioural perception of a the TPB model [67]. (ese scholars believed that the ex- decision-maker from important peers or groups [78]. In tended model could compensate the measurement of a CHM, the public sector (governments and public hospitals), certain group’s feeling towards a concept. consumers, and the private sector (private hospital, con- TPB was originally proposed to investigate a user’s struction companies pharmaceutical companies, real estate willingness to accept a certain technology. With its wide developers, and asset management companies) are three prevalence, TPB was also applied in numerous fields that typical stakeholders whose preference is crucial to each analyse human behaviour [68, 69]. Several studies were participant’s behaviour [4]. Ou and Jia stated that the private implemented on the BI of the private sector. East was the sector decides whether to participate in Chinese healthcare earliest researcher who used behaviour theory in the field of service delivery via PPP partly in consideration of social private investment [70]. Paetzold and Busch developed a image and public reputation [17]. Furthermore, researchers framework based on TPB to understand the decision- concluded that a positive correlation exists between SN and making process of the private sector towards sustainable BI [85]. China PPP Center reported a booming trend in investment [71]. Malaysian scholars applied a modified TPB CHM; that is, the number of commercial PPP projects in- model, which explained the effect of the private sector’s creased from 150 to 171 in two months [86, 87]. Considering intention and attitude to participate in socially responsible that the selection of investment objective from peers could investments [72]. In addition, TPB could be considered a provide an indirect suggestion into the decision-making framework to evaluate the willingness of private capital to process of the private sector [65], the imitation effect by invest in normal PPP projects and analyse the connection former private investors in CHM has influenced others’ between the private sector and PPP performance [73, 74]. In future behaviour. (us, the following hypothesis is stated. CHM, researchers applied TPB to examine the patients’ willingness to seek treatment [75], consuming intention on medical products and nurturing personal health behaviour Hypothesis 2 (H2). SN has significant positive effects on BI. [76, 77]. PBC is a perception, which reflects the resources and Considering the different approaches of PPP modality barriers of an expected behaviour [78]. It exhibits the confidence of controlling the resource, which is needed by and policy circumstance of CHM, the objective environment and competitive status should be emphasised whilst the the private capital. Wang and Zhang indicated that PPP has become a component of China’s medical reform; several private sector participates in CHM via PPP. (us, to build a research model with good explanatory effect, facilitating available approaches have emerged as references for private Journal of Healthcare Engineering 5 4. Research Method Attitude towards behaviour (AB) 4.1. CB-SEM. CB-SEM is used in this study. (is method was first adopted in the social sciences in 1970 and has been Subjective norm extensively applied in marketing, business, management, (SN) and behaviour research to identify the connections among Behavioural Behaviour (B) certain factors [94, 95]. In addition, several researchers often intention (BI) Perceived consider that SEM is as equal as CB-SEM [96]. However, behavioural PLS-SEM is another unique approach of SEM. Compared control (PBC) with PLS-SEM, CB-SEM should be generated with a high sample size [97]. Moreover, the objective of CB-SEM is Facilitating confirmation rather than prediction of PLS-SEM [98]. TPB conditions (FC) has been developed for decades with solid basis in theory. Figure 1: Structural model based on the modified TPB. CB-SEM could provide more robust estimations compared with PLS-SEM. (erefore, Amos 21.0 is adopted in our research to implement CB-SEM. sector investment in CHM [15]. To improve attractiveness, multiple barriers should be removed to establish an easy access by NHC, whilst private investors participate in elderly 4.2. Questionnaire. To collect first-hand information, a care and healthcare service delivery, including free provision questionnaire survey was formed containing six latent for certain procedures [88]. Existing research emphasises variables, AB, SN, PBC, FC, BI, and behaviour. (e re- that a reduced perceived impediment increases the will- spondents were asked to reply using a five-point Likert scale ingness to generate [74]. (erefore, the following hypothesis from 1 (strongly disagree) to 5 (strongly agree). (en, we is stated. invited six experts from the field of public health manage- ment and four scholars associated with PPP to test the Hypothesis 3 (H3). PBC has significant positive effects on reasonableness and comprehensiveness of the questionnaire. BI. Few items were modified on the basis of the corresponding FC could be defined as objective factors in an envi- suggestions from experts and scholars. Table 2 presents the ronment to support individual’s actual behaviour [89]. final questionnaire. Favourable measures in a situational context from organ- isational support could motivate a positive belief in BI [90]. 4.3. Data Collection. At the project level, the procedure of Certain opportunities with potential benefits provided by PPP healthcare project comprises construction (or renewal), public authorities contribute to the participation in social operation, and financing. (us, six groups were selected infrastructure delivery of private capital, including extra based on distinct stages: construction companies, real estate subsidies, financial support, and land acquiring priority [91]. developers, pharmaceutical companies, private hospitals, A large capital and technical rigor exist in the healthcare asset management companies, and medical industry prop- field; compared with full privatisation with high require- erty investment companies. Every group has become the ments on financial capacity and operational performance stakeholder by getting involved in CHM via different types [9], PPP could be regarded as an available method to be of PPP (Figure 1). involved in Chinese healthcare service delivery. Private Considering that the majority of projects in this round of capital has been largely encouraged by this favourable cir- PPP tide were executed contain the construction activity, cumstance [92]. (us, the following hypothesis is stated. about a quarter of the respondents were selected from construction companies related to the preoperational stage Hypothesis 4 (H4). FC has significant positive effects on BI. in this research. (en, pharmaceutical companies, private hospitals, and asset management companies were identified 3.2.2. Determinants of the Private Sector’s Behaviour to as the participators who hold dominant prevalence of ex- Participate in CHM via PPP. General theory believes that BI pertise and capacity in operational link. Meanwhile, medical is determined by AB, SN, and PBC. (is study brings FC as a industry property investment companies and real estate complementary variable in the modified model. (e developers were considered as the private investors with framework based on TPB could be used on investment commercial issues in the financing stage. behaviour to explain investors’ decision-making process (e criteria for selecting the sample respondents were as [72]. Intention is the closest determinant of behaviour [85]. follows: (1) they have expertise in their companies that Davies et al. considered that BI maintains a significantly participate in completed PPP or normal healthcare services; positive influence on usage [93]. (erefore, a strong BI raises (2) they come from multiple positions and departments; and the possibility of the actual behaviour to be performed [65]. (3) they are willing to participate in the survey. (erefore, (us, the following hypothesis is stated. 202 questionnaires were distributed online (WeChat), and 83 were distributed on the spot. All respondents were identified with working experience from the selected oc- Hypothesis 5 (H5). BI has significant positive effects on behaviour. cupations. (is data collection process lasted for four 6 Journal of Healthcare Engineering Table 2: Survey items and certain indices. Variables and survey items Cronbach’s α AVE Literature AB: AB1: I could obtain potential opportunities of investment by participating in CHM. AB2: Participating in CHM could increase operational benefits. AB3: Participating in CHM could obtain external 0.909 0.719 [71, 99, 100] political privileges. AB4: I can strengthen the competitiveness of nonclinical (or clinical) work by establishing partnership with public authorities. SN: SN1: Participating in Chinese healthcare service delivery could earn additional social reputation. SN2: An increasing number of my competitors is involved in CHM. 0.817 0.537 [74, 101] SN3: Investing in CHM helps me win recognition from public authorities. SN4: Investing in CHM helps me earn prestige from my competitors. PBC: PBC1: (e barriers to enter CHM is acceptable for me. PBC2: I could gain requisite knowledge and capital to invest in Chinese medical service delivery if I am 0.885 0.722 [102, 103] willing. PBC3: Given the necessary resources and knowledge, involvement in CHM would be easy for me. FC: FC1: Public authorities encourage private investors to participate in CHM. FC2: Supportive polices with potential benefits have been issued to make an easy approach for private capital investment in CHM. FC3: Official guidance is available to me to establish 0.899 0.735 [78, 104, 105] partnership with public authorities and invest in CHM. FC4: Employees in my company have received necessary training towards participating in Chinese healthcare service delivery. BI: BI1: I am willing to try to participate in CHM step by step. BI2: Investing in CHM by PPP rather than other fields or full privatisation is a good idea. 0.865 0.607 [71, 106] BI3: Personnel in my company would be glad to accept related training. BI4: CHM would be one of my favourite fields to invest by PPP. B: B1: I have engaged in Chinese healthcare resources supply via PPP. B2: I suggested other partners to also participate in 0.847 0.649 [78] CHM via PPP. B3: I will keep partnering with public authorities and investing in CHM. months from November 2018 to March 2019. Finally, 248 completion or perfunctory effort. (us, the effective rate is questionnaires were confirmed to be available for this re- 87%, which could meet the requirement of CB-SEM. Table 3 search by removing several questionnaires with low lists the demographic data of survey sample. Journal of Healthcare Engineering 7 Table 3: Sample demographics. Type Frequency Percentage (%) Male 166 66.9 Gender Female 82 33.1 3–5 years 53 21.4 6–10 years 122 49.2 Working experience 11–15 years 31 12.5 16–20 years 29 11.7 More than 20 years 13 5.2 Construction companies 64 25.8 Real estate developers 53 21.4 Pharmaceutical companies 27 10.9 Occupation Private hospitals 39 15.7 Asset management companies 41 16.5 Medical industry property investment companies 24 9.7 Administrative staff 173 69.8 Position Basic staff 75 30.2 Table 4: Goodness-of-fit test measure. 5. Result Analysis Goodness-of-fit Acceptable Value of 5.1. Reliability and Validity. Data reliability and validity Evaluation measure threshold model should be tested before implementing CB-SEM. SPSS 20.0 CMIN/DF <3.00 2.005 √ software was applied to calculate the Cronbach’ α value, GFI >0.90 0.906 √ which reflects the consistency level of the items. Cronbach’ α AGFI >0.90 0.886 √ value should be more than 0.7 [107]. In this study, the value RFI >0.90 0.911 √ scale ranges from 0.817 to 0.909; thus, the reliability of the NFI >0.90 0.936 √ questionnaire could be satisfied. (en, we used Amos 21.0 CFI >0.90 0.950 √ software to calculate average variance extracted (AVE) value RMSEA <0.08 0.064 √ for testing the validity. Fornell and Larcker believed that the PNFI >0.50 0.777 √ AVE value should be more than 0.5 [108]. (e six latent PCFI >0.50 0.815 √ PGFI >0.50 0.686 √ variables shown in Table 2 meet the standard, thereby confirming the excellent validity of our research. Table 5: CR value of latent variables. 5.2. Structural Model. After building the structural model, we used Amos 21.0 to test the goodness-of-fit. Multiple Latent variables Composite reliability value indices are connected with this procedure (Table 4). (e fit AB 0.911 value between our structural model and data meets the FC 0.917 acceptable standard. SN 0.820 In addition, composite reliability (CR) was applied to test PBC 0.886 BI 0.861 the internal consistency of the structural model. Hair in- B 0.847 dicated that the acceptable threshold should be 0.7 [109]; however, Fornell and Larcker believed that 0.6 could also be satisfactory as a standard [108]. In this research, the CR As seen from Table 6, the P value of all the five paths are values of all latent variables surpass 0.82 (Table 5). less than 0.05, including “AB” to “BI” (β � 0.466, P< 0.001), Figure 2 shows the finding of structural model on the “FC” to “BI” (β � 0.305, P< 0.001), “SN” to “BI” (β � 0.167, private sector’s intention and behaviours regarding partic- P< 0.05), “PBC” (β � 0.231, P< 0.01), and “BI” to “B” ipation in Chinese healthcare delivery via PPP. Each path (β � 0.931, P< 0.001). (ese five paths are statistically sig- among the latent variables corresponds to a certain hy- nificant and thus support H1 to H5. pothesis; the six β values display the path coefficients (standard regression weights), which are positively corre- lated with the effect degree. Moreover, we should verify if the 6. Discussion hypotheses are supported by calculating the critical ratio (is research established an analytical framework based on (CR) and the P value. When the CR is higher than 1.96, the P modified TPB to determine the influence and relative value should be less than 0.05. (is finding implies that the contribution among certain independent variables for the path is significant at the 0.05 level, and the hypothesis is private sector’s intention and behaviour towards partici- supported. Table 6 presents all the hypotheses’ testing pating in CHM via PPP. results. 8 Journal of Healthcare Engineering Potential opportunities (AB1) a1 = 0.86 Revenue from healthcare services (AB2) a2 = 0.83 Better Willingness Willingness Willingness External political privileges AB choice than a3 = 0.83 of applying of personnel of investing (AB3) full gradually training in CHM a4 = 0.86 privatization Competitiveness of nonclinical (or (BI1) (BI3) (BI4) (BI2) clinical) work (AB4) Public authority encouragement a16 = 0.77 a18 = 0.78 (FC1) a5 = 0.77 β1 = 0.47 ∗∗∗ a17 = 0.77 a19 = 0.80 Supportive policies a6 = 0.84 (FC2) FC a7 = 0.86 Available guidance (FC3) a8 = 0.87 β2 = 0.31 ∗∗∗ Professional personnel in healthcare (FC4) BI Social reputation β3 = 0.17 (SN1) β4 = 0.93 ∗∗∗ a9 = 0.61 Competitors’ intention a10 = 0.81 SN (SN2) a11 = 0.81 a22 = 0.81 a20 = 0.80 Recognition from public authorities β4 = 0.23 ∗∗ a21 = 0.81 (SN3) a12 = 0.68 Prestige from private sectors (SN4) Participating Maintaining Suggestions Market barriers of chinese healthcare in CHM by partnership for other (PBC1) PPP with public partners a13 = 0.87 actually hospitals (B2) Capability of resource acquisition (B1) (B3) a14 = 0.82 PBC (PBC2) a15 = 0.86 Capability of resource utilization (PBC3) Figure 2: Structural model with path coefficients (β) and factor loading (a). Table 6: Hypothesis assessments. industry property investment companies are provided huge potential and market volume in China to build large-scale Hypothesis Path β CR (t) P Result clinical trials of new medicines, devices, and surgical pro- ∗∗∗ H1 BI⟵ AB 0.466 8.712 Supported cedures via PPP [113]. In addition, real estate developers ∗∗∗ H2 BI⟵ FC 0.305 5.999 Supported attempt to enter into CHM, such as Vanke, China Resources, H3 BI⟵ SN 0.167 2.466 Supported ∗∗ and Tahoe and Wanda [114]. Several embraced motivation H4 BI⟵ PBC 0.231 3.136 Supported ∗∗∗ to invest in healthcare service delivery and subsequently H5 B⟵ BI 0.931 12.588 Supported obtain an easy access to land acquisition or integrate medical ∗∗∗ ∗∗ ∗ P< 0.001; P< 0.01; P< 0.05. facilities to increase added residential value. (erefore, di- rect incentives were provided to the private sector, estab- lishing a positive attitude towards participating in CHM via Conventional theory suggests that path coefficient was PPP. based on standardised regression data [110]; thus, it could be FC holds the second strongest significant effect on BI has used to compare the relative importance of the independent been verified, with the standard path coefficient of 0.305 in variables in OLS regression [95]. (e degree of four latent our findings. External facilitators directly contribute to BI, variables’ contribution to BI can be identified from this such as technical support and favourable CHM policies perspective. [115]. Since Premier Li Keqiang solemnly emphasised the AB has a significant positive effect on BI with the necessity of promoting private capital into CHM [116], standard path coefficient of 0.466. (is effect could show the numerous supportive policies have been approved, in- closest linkage between attitude and intention in the deci- cluding the expansion of market space, broadening the sion-making process of private capital involvement in CHM reimbursement coverage of nonpublic hospitals, and tax via PPP. AB is conducted directly by the feeling on per- relief on primary healthcare facilities by PPP [117]. Fur- formance of target behaviour [111]. (e need for medical thermore, new technical fields are encouraged to initiate a resource supply is literally urgent in China given the chal- transformation from outsource contract to PPP, such as lenges of ageing, increasing prevalence of chronic diseases, telemedicine and E-health system [113]. (e internal fa- and incompleteness of healthcare delivery [112]. Alternately, cilitators are equally critical. Participation in CHM could be Wang and Zhang pointed out that CHM contains several highly viable for those private sector entities with experi- opportunities for the private sector, where most individuals enced personnel, financing channels, and advanced man- are willing to pay for PPP healthcare services at a reasonable agement framework. An increasing number of public level [15]. Pharmaceutical corporations and medical Journal of Healthcare Engineering 9 hospitals tend to share human resource and medical devices From this research, the importance of prospective with eligible private sector entities [17]. Evidence from benefits and supportive measures is emphasised. Public authorities should provide official guidelines for private “Beijing Children’s Hospital–New Century International Children’s Hospital” PPP project confirms this availability. capital involvement in CHM, which could effectively de- PBC is positively significant to BI, with a relatively low crease the transaction cost in information searching and path coefficient of 0.23. Zheng et al. researched on the contract signing. (us, additional analysis is made from willingness of private capital to engage in sustainable per- these two perspectives. formance in PPP infrastructure and confirmed that PBC On the one hand, most PPP healthcare projects were holds a positive effect on BI [74]. In this study, PBC is also newly built, and the integration of stock facilities was less significant to specific intention. (e confidence of risk re- applied. BOT concession could promote the enthusiasm of sponse on specific behaviour directly contributes to BI of private capital participation in CHM, considering that participating in CHM. PPP contains more feasibility than several private sector companies in CHM are from the traditional public procurement owing to the efficiency- construction industry [122]. However, a long-term insti- tutional inertia of the BT in China causes the construction oriented governance structure [118], which could strengthen the confidence and decrease the uncertainty of private stage to be a major source of profit and private participants capital participation in Chinese healthcare delivery. SN also to be scarcely motivated to accept other types of PPP. has a significant effect on BI, with the lowest path coefficient (erefore, the private entities should be encouraged to es- of 0.167, which shows a limited effect. Previous findings tablish partnership with public authorities in TOT, ROT, suggested that SN holds a strong influence on BI in the and OM through integration, transformation, or leasing of decision-making process of the private sector regarding existing healthcare facilities. (e financing risks of these socially responsible investment [72]. (e evidence shows a types are distinctly lower than BOT, and private investors reverse result in our research; the size of standardised direct might broaden the scope of cooperation and market in a new effect of SN on BI is approximately 1/3 times that of AB. approach. (e Second Social Welfare Center of Beijing has Considering that social reputation is regarded as one of the successfully upgraded and integrated medical resources in ROT, which achieved the value between the public and key factors in hospital selection of patients and most of the nonpublic medical facilities hold unsatisfied prestige in private. In addition, the social sector should be encouraged CHM [119], improving the condition in a short time is to participate in CHM in the form of consortium, which difficult. (us, public reputation and social image were could magnify the advantages of construction enterprises in deemed as subordinate targets behind business benefit for financing, construction, and external relations, as well as the several private entities in CHM. To a certain extent, these strength of medical industry property investment companies factors cause the lowest effect from SN to BI. and private hospitals in service performance. Behaviour is significantly influenced by BI, with the On the other hand, considering the knowledge rigor of highest path coefficient of 0.931. Numerous studies re- the medical field, private sector faces considerable uncer- peatedly confirmed this close linkage between BI and actual tainty in CHM. A standard and feasible exit mechanism behaviour [120, 121]. Although several findings showed that should be established. No official guideline exists as a ref- BI holds a relatively lower effect on behaviour than with our erence for the private sector in exiting PPP. Existing result, it would be totally acceptable considering the dif- common approaches have obvious limitations in effect, such ference of context in various studies. as expired handover, equity transfer, public listing, bond issuance, and asset-backed securities. We suggest that re- strictions on equity transfer of special purpose vehicle could 7. Conclusions and Implications be appropriately liberalised in the Chinese healthcare field. Previous studies have been conducted regarding the will- Although governments and public agencies should not be ingness of the private sector to invest in economic infra- the subject of equity transfer, they may properly allow equity structure via PPP. However, the critical factors related to flows among various private capital entities in CHM. To a certain extent, equity flow would help in dispelling the intention and behaviour of private sector participation in CHM via PPP and the relative importance to which AB, FC, misgivings of the investors and strengthen the intention. (is study contains certain limitations despite its use- PBC, and SN affect BI were neglected in the relevant lit- erature. (is study’s innovation is the analysis of the fulness on the intention and behaviour research of private sector involvement in CHM via PPP. Most of the data from influencing factors of BI and the identification of the level of effect on BI based on modified TPB and CB-SEM. (e our selected respondents are provided from the question- naire. Additional studies could be generated via face-to-face finding shows that AB, FC, PBC, and SN are positively significant to BI, and that BI has a significant effect on interview to acquire highly accurate information and strong behaviour. Moreover, AB and FC hold a relatively stronger explanation. linkage to BI than with others, which provides reference for governments and public authorities to implement appro- Data Availability priate policies for stimulating the private sector’s motivation to participate in CHM via PPP and subsequently narrow (e data used to support the findings of this study are down the gap of medical resources and ameliorate the available from the corresponding author upon reasonable quality of Chinese healthcare services. request. 10 Journal of Healthcare Engineering risk could be wholely controlled, in Chinese, http://finance. Disclosure people.com.cn/GB/n1/2019/0220/c1004-30806607.html. (e founding sponsors had no role in the design of the study; [13] B. James, R. Jens, and W. 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