2015 Supplement in Health Policy and Planning
The role of the private sector in health systems
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An impact evaluation of medical insurance for poor in Georgia: preliminary results and policy implications
George Gotsadze, Akaki Zoidze, Natia Rukhadze, Natia Shengelia and Nino Chkhaidze Objective The objective of this article is to assess the impact of the new health financing reform in Georgia—‘medical insurance for the poor (MIP)’—which uses private insurance companies and delivers state-subsidized health benefits to the poorest groups of the Georgian population. Methods To evaluate the reform we looked at access to health care services and financial protection against health care costs, which are two key dimensions proposed for the universal coverage plans. The data from two nationally representative Health Utilization and Expenditure Surveys (2007 and 2010) were used, and a difference-in-difference method of evaluation was applied. Findings The MIP was not found to have a significant impact on service utilization growth nationwide, but in the capital city the MIP insured were 12% more likely to use formal health services and 7.6% more likely to use hospitals as compared with other areas of the country. The MIP impact on out-of-pocket health expenditures was greater in reducing costs of accessing services. The cost reductions were sizable and more pronounced among the poorest. Finally, the MIP significantly increased the odds of obtaining free benefits by insured individuals as compared with the control group. Such an increase was most noticeable for the poorest third of the population. Conclusions Marginal changes in access to services and the geographically diverse impact of the MIP on service utilization points to other factors affecting health-seeking behaviour of the insured. These other factors include private insurer behaviour that may have used strategies for reducing claims and managing utilization. Equity impact of the MIP and improved financial protection, especially for the poor, are benefits to be retained by government policies when universal health coverage is rolled out nationwide and all citizens will be covered. The role of private insurance companies as financial intermediaries of the publicly funded programme needs further evaluation before moving forward. Full Text (HTML)
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A total market approach for condoms in Myanmar: the need for the private, public and socially marketed sectors to work together for a sustainable condom market for HIV prevention
Han Win Htat, Kim Longfield, Gary Mundy, Zaw Win, and Dominic Montagu Background Concerns about appropriate pricing strategies and the high market share of subsidized condoms prompted Population Services International (PSI)/Myanmar to adopt a total market approach (TMA). This article presents data on the size and composition of the Myanmar condom market, identifies inefficiencies and recommends methods for better targeting public subsidy. Methodology Data on condom need and condom use came from PSI/Myanmar’s (PSI/M’s) behavioural surveys; data for key populations’ socioeconomic status profiles came from the same surveys and the National Tuberculosis Prevalence Survey. Data on market share, volumes, value and number of condoms were from PSI/M’s quarterly retail audits and Joint United Nations Programme on HIV/AIDS (UNAIDS). Results Between 2008 and 2010, the universal need for condoms decreased from 112.9 to 98.2 million while condom use increased from 32 to 46%. Free and socially marketed condoms dominated the market (94%) in 2009–11 with an increase in the proportion of free condoms over time. The retail price of socially marketed condoms was artificially low at 44 kyats ($0.05 USD) in 2011 while the price for commercial condoms was 119–399 kyats ($0.15–$0.49 USD). Equity analyses demonstrated an equal distribution of female sex workers across national wealth quintiles, but 54% of men who have sex with men and 55% of male clients were in the highest two quintiles. Donor subsidies for condoms increased over time; from $434 000 USD in 2009 to $577 000 USD in 2011. Conclusion The market for
male condoms was stagnant in Myanmar due to: limited demand for condoms
among key populations, the dominance
of free and socially marketed condoms on the market
and a neglected commercial sector. Subsidies for socially marketed and
free condoms have prevented the growth of the
private sector, an unintended consequence. A TMA is needed to grow and
sustain
the condom market in Myanmar, which requires close
co-ordination between the public, socially marketed and commercial
sectors.
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Private sector participation in delivering tertiary health care: a dichotomy of access and affordability across two Indian states
Anuradha Katyal, Prabal Vikram Singh, Sofi Bergkvist, Amit Samarth, and Mala Rao Poor quality care in public sector hospitals coupled with the costs of care in the private sector have trapped India's poor in a vicious cycle of poverty, ill health and debt for many decades. To address this, the governments of Andhra Pradesh (AP) and Maharashtra (MH), India, have attempted to improve people’s access to hospital care by partnering with the private sector. A number of government-sponsored schemes with differing specifications have been launched to facilitate this strategy. Aims This article aims to compare changes in access to, and affordability and efficiency of private and public hospital inpatient (IP) treatments between MH and AP from 2004 to 2012 and to assess whether the health financing innovations in one state resulted in larger or smaller benefits compared with the other. Methods We used data from household surveys conducted in 2004 and 2012 in the two states and undertook a difference-in-difference (DID) analysis. The results focus on hospitalization, out-of-pocket expenditure and length of stay. Results The average IP expenditure for private hospital care has increased in both states, but more so in MH. There was also an observable increase in both utilization of and expenditure on nephrology treatment in private hospitals in AP. The duration of stay recorded in days for private hospitals has increased slightly in MH and declined in AP with a significant DID. The utilization of public hospitals has reduced in AP and increased in MH. Conclusion The state of
AP appears to have benefited more than MH in terms of improved access to
care by involving the private sector.
The Aarogyasri scheme is likely to have contributed
to these impacts in AP at least in part. Our study needs to be followed
up with repeated evaluations to ascertain the
long-term impacts of involving the private sector in providing hospital
care. |
Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh
Alayne M Adams, Rubana Islam, and Tanvir Ahmed In Bangladesh, the health risks of unplanned urbanization are disproportionately shouldered by the urban poor. At the same time, affordable formal primary care services are scarce, and what exists is almost exclusively provided by non-government organizations (NGOs) working on a project basis. So where do the poor go for health care? A health facility mapping of six urban slum settlements in Dhaka was undertaken to explore the configuration of healthcare services proximate to where the poor reside. Three methods were employed: (1) Social mapping and listing of all Health Service Delivery Points (HSDPs); (2) Creation of a geospatial map including Global Positioning System (GPS) co-ordinates of all HSPDs in the six study areas and (3) Implementation of a facility survey of all HSDPs within six study areas. Descriptive statistics are used to examine the number, type and concentration of service provider types, as well as indicators of their accessibility in terms of location and hours of service. A total of 1041 HSDPs were mapped, of which 80% are privately operated and the rest by NGOs and the public sector. Phamacies and non-formal or traditional doctors make up 75% of the private sector while consultation chambers account for 20%. Most NGO and Urban Primary Health Care Project (UPHCP) static clinics are open 5–6 days/week, but close by 4–5 pm in the afternoon. Evening services are almost exclusively offered by private HSDPs; however, only 37% of private sector health staff possess some kind of formal medical qualification. This spatial analysis of health service supply in poor urban settlements emphasizes the importance of taking the informal private sector into account in efforts to increase effective coverage of quality services. Features of informal private sector service provision that have facilitated market penetration may be relevant in designing formal services that better meet the needs of the urban poor. Full Text (HTML) Full Text (PDF) |
Quality of inpatient care in public and private hospitals in Sri Lanka
Ravindra P Rannan-Eliya, Nilmini Wijemanne, Isurujith K Liyanage, Shanti Dalpatadu, Sanil de Alwis, Sarasi Amarasinghe, and Shivanthan Shanthikumar Objective To compare the quality of inpatient clinical care in public and private hospitals in Sri Lanka. Methods A retrospective, cross-sectional comparison was done of inpatient quality, in a sample of 11 public and 10 private hospitals in three of 25 districts. Data were collected for 55 quality indicators from medical records of 2523 public and 1815 private inpatient admissions. These covered treatment of asthma, acute myocardial infarction (AMI), childbirth and five other conditions, along with outcome indicators, and medicine prescribing indicators. Results Overall quality scores were better in the public sector than the private sector (77 vs 69%). Performance was similar for management of AMI and childbirth and somewhat better in the private sector for management of asthma. The public sector performed better in those indicators that are not constrained by resources (94 vs 81%), but worse in indicators that are highly resource intensive (10 vs 31%). Quality was comparable in assessment and investigation, but the public sector performed better in treatment and management (70 vs 62%) and drug prescribing (68 vs 60%), and modestly worse in terms of outcomes (92 vs 97%). Conclusions For a range
of indicators where comparisons were possible, quality of inpatient
clinical care in Sri Lanka was comparable
to levels reported from upper-middle income Asian
countries, and often approaches that in developed countries, although
the
findings cannot be generalized. Quality in the
public sector is better than in the private sector in many areas,
despite spending
being substantially less. Quality in public
hospitals is resource constrained, and needs greater government
investment for
improvement, but when resource limitations are not
critical, the public sector appears able to deliver equal or better
quality
than the private sector. Overall similarities in
quality between the two sectors suggest the importance of physician
training
and other factors. |
The quality of outpatient primary care in public and private sectors in Sri Lanka—how well do patient perceptions match reality and what are the implications?
Ravindra P Rannan-Eliya, Nilmini Wijemanne, Isuru K Liyanage, Janaki Jayanthan, Shanti Dalpatadu, Sarasi Amarasinghe, and Chamara Anuranga Objective To compare the quality of clinical care and patient satisfaction in public and private outpatient primary care services in Sri Lanka. Methods A prospective, cross-sectional comparison was done by direct observation of patient encounters and exit interviews of outpatients in 10 public hospital general outpatient clinics and 66 private practitioner clinics in three districts of Sri Lanka. A total of 1027 public sector patients and 944 private sector patients were surveyed. Data were collected for 39 quality indicators covering diarrhoea, cough, hypertension, diabetes, asthma, upper respiratory tract infections (URTI) and five other conditions, along with prescribing indicators. The exit interviews collected data for 10 patient satisfaction indicators. Results The public sector performed better for some conditions (diarrhoea, cough and asthma) and the private sector performed better for others (hypertension, diabetes, URTI and tonsillitis). Overall quality was similar between the sectors in the domains of history taking, examination and investigations and management, but the private sector performed much better on patient education (57 vs 12%). Overall patient satisfaction was high in both sectors (98%), although the private sector performed much better in interpersonal satisfaction (94 vs 84%) and system-related indicators (95 vs 84%). Comparisons with studies from other countries suggest that both sectors perform considerably better than India, and similarly in many indicators to high-income countries. Conclusions Quality of
outpatient primary care in Sri Lanka is generally high for a
lower-middle income developing country. The public
and private sectors perform similarly, except that
private sector patients have longer consultations, are more likely to
receive
education and advice, and obtain better
interpersonal satisfaction. The public system, with its limited funding,
is able to
deliver care in diagnosis and management that is
similar to the private sector, while private sector patients, who spend
more
on their healthcare receive better quality care in
non-clinical areas. |
Mortality outcomes in hospitals with public, private not-for-profit and private for-profit ownership in Chile 2001–2010
Camilo Cid Pedraza, Cristian A. Herrera, Lorena Prieto Toledo, and Felipe Oyarzún Public, private not-for-profit (PNFP) and private for-profit (PFP)
hospitals may have different behaviour and performance
in different indicators such as health outcomes,
cost-efficiency and quality. Chile has a mixed healthcare system both in
financing and service delivery. The public National
Health Fund (Fondo Nacional de Salud) covers 76% of the
population—poorer
and with higher health risks—whereas private health
insurers cover 16% of the population—richer and with lower health
risks.
The aim of the study was to analyse the in-patient
mortality outcomes by hospital ownership in Chile. Methods: We use
hospital
discharge data in Chile for the period 2001–10 with
a total of 16 205 314 discharges in 20 public, 6 PNFP and 15 PFP
hospitals.
We analyse in-patient mortality considering all
diagnoses and a subsample considering only myocardial infarction and
stroke
diagnoses. Using a probit regression, we estimate
how hospital ownership explains in-patient mortality controlling for
other
confounding variables like health and socioeconomic
status, and hospital characteristics. Results: The discharge condition
was reported as death in 3.5% of the public
hospitals’ discharges, 1.3% in PNFP and 0.7% in PFP. PNFP and PFP
hospitals show
a lower risk of in-hospital mortality for all
diagnoses, myocardial infarction and stroke in comparison with public
hospitals.
Discussion: The question about which type of
hospital ownership performs better in Chile remains open. Policy
decisions regarding
health service provision requires more evidence
explaining differences by ownership. Better controls for health risk and
hospital
characteristics are suggested to address these
differences in hospital performance. |
Can mobile phone messages to drug sellers improve treatment of childhood diarrhoea?—A randomized controlled trial in Ghana
Willa Friedman, Benjamin Woodman, and Minki Chatterji Oral rehydration solution (ORS) and zinc are the recommended treatment
in developing countries for the management of uncomplicated
diarrhoea in children under five (World Health Organization and UNICEF 2004).
However, drug sellers often recommend costly and unnecessary treatments
instead. This article reports findings from an
experiment to encourage licensed chemical sellers
(LCS) in Ghana to recommend ORS and zinc for the management of childhood
diarrhoea. The intervention consisted of mobile
phone text messages (Short Message Service or SMS) sent to a randomly
assigned
group of LCS who had been trained on the diarrhoea
management protocols recommended by the World Health Organization (WHO).
The SMS campaign comprised informational messages
and interactive quizzes sent over an 8-week period. The study measured
the
impact of the SMS messages on both reported and
actual practices. Analysis of data from both face-to-face interviews and
mystery
client visits shows that the SMS intervention
improved providers’ self-reported practices but not their actual
practices.
The study also finds that actual practices deviate
substantially from reported practices. |
Regulating the for-profit private health sector: lessons from East and Southern Africa
Jane E Doherty International evidence shows that, if poorly regulated, the private
health sector may lead to distortions in the type, quantity,
distribution, quality and price of health services,
as well as anti-competitive behaviour. This article provides an
overview
of legislation governing the for-profit private
health sector in East and Southern Africa. It identifies major
implementation
problems and suggests strategies Ministries of
Health could adopt to regulate the private sector more effectively and
in line
with key public health objectives. This qualitative
study was based on a document review of existing legislation in the
region,
and seven semi-structured interviews with
individuals selected purposively on the basis of their experience in
policymaking
and legislation. Legislation was categorized
according to its objectives and the level at which it operates. A
thematic content
analysis was conducted on interview transcripts.
Most legislation focuses on controlling the entry of health
professionals
and organizations into the market. Most countries
have not developed adequate legislation around behaviour following
entry.
Generally the type and quality of services provided
by private practitioners and facilities are not well-regulated or
monitored.
Even where there is specific health insurance
regulation, provisions seldom address open enrolment, community rating
and comprehensive
benefit packages (except in South Africa). There is
minimal control of prices. Several countries are updating and improving
legislation although, in most cases, this is
without the benefit of an overarching policy on the private sector, or
reference
to wider public health objectives. Policymakers in
the East and Southern African region need to embark on a programme of
action
to strengthen regulatory frameworks and instruments
in relation to private health care provision and insurance. They should
not underestimate the power of the private health
sector to undermine efforts for increased regulation. Consequently they
should conduct careful stakeholder analyses and
build alliances to help drive through reform. Full Text (HTML)
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