A new face for private providers in developing countries: what implications for public health?

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.     

Priority setting, public opinion and health care system in Spain]

OBJECTIVES: To examine the determinants of attitudes towards some "general criteria" guiding the financing, provision and satisfaction of the Spanish health system. First we examine the degree of acceptance of a publicly funded health system such as the use of an intergenerational equity criteria for health care rationing based on patient's age. Second, employing the same sample we analyse the determinants of citizen's satisfaction with the health system in order to identify the profile that defines attitudes of Spanish population to their health system. METHODOLOGY: We undertake a quantitative analysis of the public opinion survey Eurobarometer 49.1 (1998) for a subsample of the Spanish population. The Eurobarometer is a periodical public opinion survey representative of European Union (EU) citizens. Due to the categorical nature of individual responses to public opinion surveys, the model estimated is an ordered probit. The explanatory variables used refer to socio-economic status and political attitudes. RESULTS: There appears to be a consensus on the criteria that public sector should go a way forward from what the public envisages as "essential health care". 73.5% of the populations rejects a libertarian criteria that sustains that individuals are self responsible for funding non-essential health care. This attitude is especially supported by male with leftists political tendencies and high education achievement. The use of age-related criteria to ration health care (fair innings) is rejected by a 81.5% of the population. However, we find that self interest is the main criteria guiding this attitude since elderly and middle and high income individuals tend reject the use of this criteria more than other groups. Satisfaction with the Spanish health system is higher than other southern EU countries, as Italy and Greece but still far from the levels achieved by Scandinavian and northern EU countries. Political attitudes, age and socio-economic status are positively associated with a higher satisfaction.Conclusions: Health systems reforms that significantly reduce the collective funding of health systems would not be accepted by the majority of the population. As it happens in other EU countries, attitudes on the financing and provision of health care are influenced by political attitudes. Health reforms reducing the extent of health care funding would be rejected by the population. The use of and age-related criteria for health care rationing would be envisaged as discriminatory against the elderly. Health system satisfaction is in an intermediate position and its sensitive to demographic and socio-economic composition of the Spanish population, still far from the levels achieved by Scandinavian and northern EU countries. This results show a particular general criteria when evaluating health systems key elements, and may be expected to vary when applied to the concrete decision making scenario. Finally, it should be noted that quantitative analysis of general surveys is subject to large limitations. Thus, caution should be posed when interpreting these results, always should be seen as complementary of other studies using alternative methodologies (those using qualitative and experimental methodologies).     

A stated preference approach to assessing health care-quality improvements in Palestine: from theoretical validity to policy implications

User fees have been promoted as a potential complementary funding mechanism for health care in developing countries. In this paper, we appraise the use of contingent valuation (CV) as a tool to help develop user fees schemes that could be used to assist in allocating, and partially fund, health care. A random sample of 499 patients seeking care in primary health care centers, in Palestine, were asked to reveal their willingness to pay values for specified improvements in the quality of delivered medical care. Empirical analysis suggests that, in this context, CV can lead to internally consistent results and useful policy implications.     

Market strategies for publicly financed health care systems.

Most West European countries have health care systems financed by social insurance funds. In these pluralistic systems, decision-making processes are complex and involve many factors. The present paper focuses on the decision-making behavior of public authorities in health care. It is stressed that understanding the functioning of the political market is essential for explaining the development and performance of health care systems. This political market receives relatively little attention from economists. Specific mechanisms as they can be observed in this market are discussed, and the paper concludes with a plea for reducing the role of government in planning and price-setting in health care.     

Ethical dilemmas in current planning for polio eradication.

Intensification of polio eradication efforts worldwide raises concerns about costs and benefits for poor countries. A major argument for global funding is the high benefit-cost ratio of eradication; however, financial benefits are greatest for rich countries. By contrast, the greatest costs are borne by poor countries; the Pan American Health Organization has estimated that host countries bore 80% of costs for polio eradication in the Americas. The 1988 World Health Assembly resolution setting up the Polio Eradication Initiative carried the proviso that programs should strengthen health infrastructures. Drastic cuts in donor funding for health make this commitment even more important. Two international evaluations have reported both positive and negative effects of polio and Expanded Programme on Immunization programs on the functioning and sustainability of primary health care. Negative effects were greatest in poor countries with many other diseases of public health importance. If poor countries are expected to divert funds from their own urgent priorities, donors should make solid commitments to long-term support for sustainable health development.     

Advocacy and opportunity--planning for child mental health in Sri Lanka

Planning for mental health can be seen as low priority by policymakers and planners in developing countries. The article describesexperiences which led to the implementation of a child mentalhealth programme within primary care in Sri Lanka. It highlightsaspects of the planning process which may be relevant for theintroduction of any new programme proposals within country situationswhere multiple demands are made on available resources, andservice expansion is restricted due to scant funding and limitedprofessional resources.     

Priority setting of public spending in developing countries: do not try to do everything for everybody

BACKGROUND: Public spending on health care in many developing countries falls short to provide a comprehensive set of essential health services, which indicates the need to target and prioritize resources. However, governments often attempt to provide free services to the whole population, and often spend resources on low-impact services. This results in an inequitable and inefficient use of resources. METHODS: This paper presents a rational approach to targeting and prioritization of public spending, with an application to Ghana. First, interventions were tested against the economic justification for public funding, to define to whom spending should be targeted. Second, resulting interventions were prioritized on the basis of medical and non-medical criteria. RESULTS: The step-wise approach led to a rank ordering of interventions with a specification whether public spending should be targeted at the whole population or the poor only. Disease control priorities are prevention of mother-to-child HIV/AIDS transmission and oral rehydration therapy to treat diarrhea in childhood, and public funding of these interventions is warranted for the whole population. Case-management of pneumonia in childhood is also a priority but public funding should be targeted at the poor only. Low priorities for public funding are certain interventions to control blood pressure, tobacco and alcohol abuse, be it for the whole population or the poor only. CONCLUSION: Governments should not try to provide everything for everybody. This may help health systems to move towards a more equitable and efficient use of resources.     

Health care insurance for Africa

Long-term substantial development aid has not prevented many African countries from being caught in a vicious circle in health care: the demand for care is high, but the overburdened public supply of low quality care is not aligned with this demand. The majority of Africans therefore pay for health care in cash, an expensive and least solidarity-based option. This article describes an innovative approach whereby supply and demand of health care can be better aligned, health care can be seen as a value chain and health insurance serves as the overarching mechanism. Providing premium subsidies for patients who seek health care through private, collective African health insurance schemes stimulates the demand side. The supply of care improves by investing in medical knowledge, administrative systems and health care infrastructure. This initiative comes from the Health Insurance Fund, a unique collaboration of public and private sectors. In 2006 the Fund received Euro 100 million from the Dutch Ministry of Foreign Affairs to implement insurance programmes in Africa. PharmAccess Foundation is the Fund's implementing partner and presents its first experiences in Africa.     

Is decentralisation the real solution? A three country study

Decentralisation in the health care sector has been perceived in these last years as a means to revamp the performance of health care systems. Many European countries have undergone this process of delegating funding and/or management responsibilities to sub-layers of government. However, there has also been a recentralisation of health care systems in Nordic states, which typically had a highly decentralised model of service provision and funding. Three country cases will be analysed (Italy, Spain and Norway) and light will be shed on some possible difficulties that Italy and Spain might experience, given their present health decentralised structure. Moreover, there will be an analysis of the reasons that led to recentralisation of health care in Norway. The scope is to make people aware that decentralisation per se is not always successful. The three country cases highlight possible drawbacks that can arise from decentralisation.     

Coping with health care expenses among poor households: evidence from a rural commune in Vietnam

With the 1980s "Doi Moi" economic reforms, Vietnam transitioned from state-funded health care to a privatized user fee system. Out-of-pocket payments became a major source of funding for treatments received at both public and private health facilities. We studied coping strategies used by residents of Dai Dong, a rural commune of Hanoi, for paying health care costs, assessing the effects of such costs on economic and health stability. We developed a 2008 survey of 706 households (166 poor, 184 near-poor, 356 non-poor; 100% response rate). Outcome measures were reported episodes of illness; inpatient, outpatient, and self-treatments; out-of-pocket expenditures; and funding sources for health care costs. Households of all income levels borrowed to pay for inpatient treatments; loans are also more heavily used by the poor and near-poor than the non-poor for outpatient treatments. Compared to low cost treatments, the use of loans is intensified for extremely high cost health treatments for all poverty levels, but especially for the poor and near-poor. The likelihood of reducing food consumption to pay for extremely high cost treatment versus low cost treatments increased most for the poor in both inpatient and outpatient contexts. Decreased funding and increased costs in health care rendered Dai Dong's population vulnerable to the consequences of detrimental coping strategies such as debt and food reduction. Future reforms should focus on obviating these funding measures among at-risk populations.     

What can developing economies learn from health system reforms of developed countries?

This paper outlines some general lessons developing nations can draw from the health system reform experiences of developed nations. Using the experiences of developed countries, developing countries should be better able to anticipate socio-economic changes and choose an optimal path for their health systems development to accompany those changes. Most developed countries have adopted rather common objectives and principles in their health systems because of market failure in health care; developing countries may start adopting those principles because they do not have market conditions in the first place. It is suggested that developing countries strengthen what is probably the most fundamental initial systemic asset they have: public finance. They should do so by attracting democratically, possibly through earmarked taxes, resources otherwise channelled through the private sector, competing with public finance for limited real resources. This effort can be promoted by giving consumers, mainly of high income groups and in urban areas, more say (through institutions performing the OMCC function) in the nature of care these groups have access to under auspices of public finance. Where feasible, private insurance as a major source of finance should be seen as a transitional phenomenon, giving way to the emergence of OMCC institutions which require similar financial and managerial market infrastructure. Private and competitive provision of care may be unrealistic in many developing areas because of both scarcity of real resources, mainly manpower, and health needs. The challenge of government is, as resources grow, to divest itself from the provision of care and stay involved in activities and facilities that are of 'public nature'--under specific circumstances--that foster private competitive provision. In general, the government should play an enabling role also by investing in health promotions and management skills for health systems.     

Does general practitioner gatekeeping curb health care expenditure?

OBJECTIVES: It is generally assumed that health care systems in which specialist and hospital care is only accessible after referral by a general practitioner (GP) have lower total health care costs. In this study, the following questions were addressed: do health care systems with GPs acting as gatekeepers to specialized care have lower health care expenditure than those with directly accessible specialist care? Does health care expenditure increase more rapidly in countries without a referral system than in those with the GP acting as a gatekeeper? METHODS: Multiple regression analyses on total and ambulatory health care expenditure in 18 OECD countries. RESULTS: Analyses showed only one statistically significant effect (P < 0.05) in countries with gatekeeping GPs: ambulatory care expenditure has increased more slowly than in non-gatekeeping systems. No significant effects of gatekeeping were found on the level of ambulatory care costs, or on the level or growth of total health care expenditure. As in earlier studies, the most important factor influencing aggregate health care costs and their growth is gross national product (GNP), followed by the share of public funding. Relationships that exist at a micro level (such as lower costs with a gatekeeping primary care doctor) did not show up in aggregate data at a macro level. CONCLUSIONS: Gatekeeping systems appear to be better able to contain ambulatory care expenditure. More research is necessary to understand micro level mechanisms and to distinguish the effects of gatekeeping from other structural aspects of health care systems.     

The interdependence of mental health service systems: the effects of VA mental health funding on veterans' use of state mental health inpatient facilities

BACKGROUND: There are relatively few published data on how the financial structures of different health systems affect each other. With increasing financial restrictions in both public and private healthcare systems, it is important to understand how changes in one system (e.g. VA mental healthcare) affect utilization of other systems (e.g. state hospitals). AIMS OF THE STUDY: This study utilizes data from state hospitals in eight states to examine the relationship of VA per capita mental health funding and state per capita mental health expenditures to veterans' use of state hospitals, adjusting for other determinants of utilization. METHODS: This study utilized a large database that included records from all male inpatient admissions to state hospitals between 1984 and 1989 in eight states (n = 152541). Funding levels for state hospitals and VA mental health systems were examined as alternative enabling factors for veterans' use of state hospital care. Logistic regression models were adjusted for other determinants of utilization such as socio-economic status, diagnosis, travel distances to VA and non-VA facilities and the proportion of veterans in the population. RESULTS: The single strongest predictor of whether a state hospital patient would be a veteran was the level of VA mental healthcare funding (OR = 0.81 per $10 of funding per veteran in the population, p = 0.0001), with higher VA funding associated with less use of state hospitals by veterans. Higher per capita state funding, reciprocally, increased veterans' use of state hospitals. We also calculated elasticities for state hospital use with respect to VA mental healthcare funding and with respect to state hospital per capita funding. A 50% increase in VA per capita mental health spending was associated with a 30% decrease in veterans' use of state hospitals (elasticity of -0.6). Conversely, a 50% increase in state hospital per capita funding was associated with only an 11% increase in veterans' use of state hospitals (elasticity of 0.06). IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These data indicate that per capita funding for state hospitals and VA mental health systems exerts a significant influence on service use, apparently mediated by the effect on supply of mental health services. Veterans are likely to substitute state hospital care for VA care when funding restrictions limit the availability of VA mental health services. However, due to the relative sizes of the two systems, VA funding has a larger effect than state hospital funding upon state hospital use by veterans. IMPLICATIONS FOR HEALTH POLICIES: These data indicate that changes in the organizational and/or financial structure of any given healthcare system have the potential to affect surrounding systems, possibly quite substantially. Policy makers should take this into account when making decisions, instead of approaching systems as independent, as has been traditional. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed in two areas. First, these results should be replicated in other systems of care using more recent data. Second, these results are difficult to generalize to individual behavior. Future research should examine the extent and individual determinants of cross-system use.     

An Ethical Analysis of International Health Priority-Setting

Health care systems throughout the developed world face ‘crises’ of quality, financing and sustainability. These pressures have led governments to look for more efficient and equitable ways to allocate public resources. Prioritisation of health care services for public funding has been one of the strategies used by decision makers to reconcile growing health care demands with limited resources. Priority setting at the macro level has yet to demonstrate real successes. This paper describes international approaches to explicit prioritisation at the macro-governmental level in the six experiences most published in the English literature; analyzes the ways in which values, principles and other normative concepts were presented in these international priority setting experiences; and identifies key elements of a more robust framework for ethical analysis which could promote meaningful and effective health priority setting.     

Contextual factors affecting health information system strengthening

At the turn of the century, several major efforts were initiated to combat HIV/AIDS and other major epidemics affecting low- and middle-income countries (LMICs). They were accompanied by initiatives to enable recipient countries to collect and use data to guide their public health programmes. These health information systems (HIS) typify systems in that they have multiple interacting components, and they are embedded within larger systems. Components of a larger system act as the context for all lower-level systems. Their effects can be pervasive, and thus be taken for granted or regarded as unchangeable. We identify four contextual factors that affect efforts to strengthen HIS: hierarchical roles, aid funding, corruption, and competing priorities. We provide examples of each as experienced by those working to strengthen HIS in LMICs. Each of these contextual factors can seriously diminish the effectiveness of HIS strengthening efforts and their long-term sustainability. We propose research questions about each that would enable those engaged in HIS strengthening to work effectively and sustainably.     

Government subsidies for dental care in Australia

OBJECTIVES: To evaluate the impact of recent changes in public subsidies for oral health care in Australia, and to propose more effective and equitable uses of Commonwealth Government subsidies. METHODS: Review of literature and Australian Research Centre for Population Oral Health information. RESULTS: Commonwealth subsidies for oral health care services in Australia have been moved from public dental services to private dental health insurance. This has resulted in a redistribution of funds from people on low incomes with poor oral health, to people on middle to high incomes with relatively better oral health. CONCLUSIONS: Public funding for dental care in Australia favours the financially and orally better off at the expense of disadvantaged and orally unhealthy Australians. Current approaches to public funding for oral health services in Australia are unlikely to result in a substantial improvement in oral health. IMPLICATIONS: Maximum gains in oral health are likely to be achieved by a reorientation of Commonwealth subsidies towards preventive and basic treatment services. This reorientation needs to occur within a primary health care framework. Whereas the Commonwealth plays a national leadership role in the provision of general health services, this is not apparent in relation to oral health. This lack of leadership leaves many vulnerable Australians without basic preventive services and at high risk of losing teeth that might otherwise have been preserved. Channelling the funding now used to subsidise private dental services for the well off and dentally healthy to community-wide and targeted preventive services for vulnerable and low-income Australians would have a larger impact on oral health and represent a more equitable use of these funds.     

National Public Health Institutes: contributing to the public good

Donor and government funding for public health programs in low-resource countries - to increase immunizations or treat HIV/AIDS, for example - has risen dramatically. Rising less rapidly is the funding for public health functions that are not direct services or linked to programs for high-priority diseases and conditions. In many countries, these functions are housed in National Public Health Institutes (NPHIs). NPHIs are science-based agencies, usually within national governments, that include in their missions such public goods as assessing and monitoring the population's health and responding to outbreaks. Through a survey, we collected information from and about members of a new international organization for NPHIs. The responses illustrate the roles of NPHIs as purveyors of public goods. Data collected in the future on NPHI structures, practices, and challenges will be helpful to countries that are creating or restructuring NPHIs. The new knowledge will also help advocates for increasing budgetary support for the public goods functions of NPHIs.     

Paying for and receiving benefits from health services in South Africa: is the health system equitable?

There is a global challenge for health systems to ensure equity in both the delivery and financing of health care. However, many African countries still do not have equitable health systems. Traditionally, equity in the delivery and the financing of health care are assessed separately, in what may be termed 'partial' analyses. The current debate on countries moving toward universal health systems, however, requires a holistic understanding of equity in both the delivery and the financing of health care. The number of studies combining these aspects to date is limited, especially in Africa. An assessment of overall health system equity involves assessing health care financing in relation to the principles of contributing to financing according to ability to pay and benefiting from health services according to need for care. Currently South Africa is considering major health systems restructuring toward a universal system. This paper examines together, for both the public and the private sectors, equity in the delivery and financing of health care in South Africa. Using nationally representative datasets and standard methodologies for assessing progressivity in health care financing and benefit incidence, this paper reports an overall progressive financing system but a pro-rich distribution of health care benefits. The progressive financing system is driven mainly by progressive private medical schemes that cover a small portion of the population, mainly the rich. The distribution of health care benefits is not only pro-rich, but also not in line with the need for health care; richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. The importance of the findings for the design of a universal health system is discussed.     

The inequity of informal payments for health care: the case of Hungary

As in most countries of Central and Eastern Europe, informal payments have been a characteristic feature of the Hungarian health care system both during and since the demise of Soviet type socialist rule. Although informal payments continue to be so characteristic in the region, little empirical evidence exists on their scope or working. As far as equity is concerned, it has sometimes been suggested that physicians play a 'Robin Hood' role and subsidise the poor at the expense of the rich. With the aid of an interview survey of a representative sample of the Hungarian population, we examine the distribution of the burden of informal payments across income groups. Results indicate that informal payments are a highly regressive way of funding health care, with Kakwani progressivity indices of -0.38, -0.39, -0.35 and -0.36 for GP, outpatient specialist, hospital, and total care, respectively. The finding that people with lower income pay proportionally more for public health care through informal payments underlines the emptiness of the 'Robin Hood' claims and the need for reform.