Governments in Moscow, Mumbai, Manaus, and many other places face similar problems, and sources of problems, in their public hospitals. As in Brazil, the problems are often grounded in rigid and politicized governance arrangements. Many have attempted to improve hospital performance without addressing this underlying problem, with almost universally disappointing results. For these countries, the Brazilian PPP model is well worth considering.
This model requires the establishment of a long-term contract covering hospital services, which involves public officials in new and complex performance monitoring and verification. Many countries, especially low-income countries, would find this element of the reform challenging. Furthermore,
the São Paulo reform allowed only nonprofit organizations to run PPP hospitals. These organizations have social missions more closely aligned with the government's goals in the sector; thus, this choice was seen as reducing opportunism as well as being politically palatable. OSSs, unfortunately, have little access to capital, so this PPP model could not be used to expand capital in the sector. Even if capital is not a goal, many countries might not have a vibrant nonprofit hospital sector, which would limit the application of this model. Furthermore, the Brazilian PPP model has been evaluated only when applied to new hospitals, leaving open the question of how it would work with existing public hospitals-which constitute the bulk of the hospital sector in developing countries. However, we may learn more soon, since the state of São Paulo and a municipality in that state recently moved to apply the model to two existing hospitals.