Constructing: Relationships, Human Resource Management and Culture of Quality The Case of Hospital Do Suburbio, a Brazilian Healthcare Public Private Partnership.

Abstract

Public-Private Partnerships (PPPs) are an internationally proposed way to deal with perfunctory public administration by private sector management. Since 2010, the northern state of Bahia, Brazil has engaged in a PPP, Hospital do Subúrbio (HS), to provide urgency/emergency health services. While critics of public hospitals in Brazil report inadequate quality and safety, HS is the only public hospital that has reached the highest level of accreditation in the state. Given the management difficulties experienced by public administration in many countries, the challenges and best practices from HS can be used analytically to inform human resource management and hospital quality in Bahia, Brazil, as well as in countries that are seeking ways to deal with poor management of public hospitals. Between May-October, 2018 and July 2019-February 2020, I conducted an ethnographic case study which consisted of 107 semi-structured interviews, participant observation and document review in Salvador, Bahia, Brazil, to critically identify and evaluate the implementation of Hospital do Subúrbio. In Chapter 3, I seek to understand the external and shifting coalitions of support and opposition that should be identified and understood as part of evaluating the feasibility, implementation and sustainability of complex projects. I find that HS has established various levels of “embedded autonomy” with three main actors – the Secretary of Health, the local community and the Municipality of Salvador. Using evidence from my study, I conclude that care should be taken when advocating for PPPs under the assumption that the state is able to monitor project implementation. The case of HS also offers an opportunity to consider the importance of politics and the potential shifts in support and opposition that could occur over election cycles and leadership changes as well as opportunistic partisan behaviors that might arise given different sub-national arrangements and actors involved in service delivery. Furthermore, I conclude that creating opportunities to construct partnerships with local communities in grassroots ways can be instrumental for project implementation. In Chapter 4, I seek to understand the construction of Human Resource Management for healthcare organizations. I show that HS has managed to achieve low turnover and absenteeism through implementing various HRM approaches during the lifetime of the project. I organize my findings around four themes, namely 1) Hiring and Evaluation, 2) Professional Development and Actualization, 3) Empowerment and 4) Sense of Meaning. While scholars in the past have identified some of the same HRM practices as important elements in high performing organizations, especially in environments where they would not have been expected to do so, my research explores not the mere presence or absence of such HRM practices but their construction over time. This is important as my research could provide lessons about how to create more high-performing organizations, precisely through the identification of HRM processes of construction. In Chapter 5, I seek to understand the processes involved in constructing a culture of quality and quality improvement at HS. Similar to the construction of HRM processes in Chapter 4, this chapter explores not the mere presence or absence of a culture of quality and quality improvement but its construction over time. Considering Chapters 4 and 5 together, I also conclude that even though effective private sector management is the case at HS, caution must be taken when PPP assumptions are made about a taken-for-granted standard of effective private sector management.