Equity in access to zero-fees and low-cost Primary Health Care in Aotearoa New Zealand: Results from repeated waves of the New Zealand Health Survey, 1996-2016

Primary Health Care in Aotearoa New Zealand is mainly funded through capitation-based funding to general practices, supplemented by a user co-payment. Funding is designed in part to keep the costs of care low for key groups in the population who have higher health needs. We investigated changes in the socio-demographic determinants of no-cost and low-cost access to Primary Health Care using data from sequential waves of the New Zealand Health Survey (1996/97–2016/17). Fees paid were self-reported and inflated using CPI-adjustment to the value of the 2018NZD.Over the 20-year study period, there was an increase in the population accessing low-cost care. Access to low-cost care was particularly high for Pacific people, but also higher for Māori and Asian people compared to Other/New Zealand European ethnicities. Area-level deprivation was a stronger predictor of access to low-cost care for non-Māori than for Māori. Although Māori were more likely than non-Māori to access low-cost care at all levels of deprivation, this was less evident in more deprived compared to more affluent areas. Given ongoing reported inequity for Māori being less able to afford primary health care, we suggest that future policies to improve access should be fully aligned with the articles of Te Tiriti o Waitangi and should focus on equity.     

New Zealand health care: a background

New Zealand, its people and health care services are described, followed by a discussion of (i) the role of government and non-government agencies in the funding, provision and purchasing of health care and (ii) persistent problems in the health care system. The authors argue that recent New Zealand health care reforms represent a significant deviation from past policies. However, to have any prospect of being judged as successful, the reforms must address difficulties in the funding, purchasing and provision of health care that are not new but have been features of New Zealand health care over many years.     

How is Primary Health Care conceptualised in nursing in Australia? A review of the literature

Australia, in common with many other countries, is expanding the role of Primary Health Care (PHC) to manage the growing burden of chronic disease and prevent hospitalisation. Australia's First National Primary Health Care Strategy released in 2010 places general practice at the centre of care delivery, reflecting a constitutional division of labour in which the Commonwealth government's primary means of affecting care delivery in this sector is through rebates for services delivered from the universal healthcare system Medicare. A review of Australian nursing literature was undertaken for 2006–2011. This review explores three issues in relation to these changes: How PHC is conceptualised within Australian nursing literature; who is viewed as providing PHC; and barriers and enablers to the provision of comprehensive PHC. A review of the literature suggests that the terms ‘PHC’ and ‘primary care’ are used interchangeably and that PHC is now commonly associated with services provided by practice nurses. Four structural factors are identified for a shift away from comprehensive PHC, namely fiscal barriers, educational preparation for primary care practice, poor role definition and interprofessional relationships. The paper concludes that while moves towards increasing capacity in general practice have enhanced nursing roles, current policy and the nature of private business funding alongside some medical opposition limit opportunities for Australian nurses working in general practice.     

Household utilization and expenditure on private and public health services in Vietnam

The private provision of health services in Vietnam was legalized in 1989 as one of the country's means to mobilize resources and improve efficiency in the health system. Ten years after its legalization, the private sector has widely expanded its activities and become an important provider of health services for the Vietnamese people. However, little is known about its contribution to the overall objectives of the health system in Vietnam. This paper assesses the role of the private health care provider by examining utilization patterns and financial burden for households of private, as compared with public, services. We found that the private sector provided 60% of all outpatient contacts in Vietnam. There was no difference by education, sex or place of residence in the use of private ambulatory health care. Although there was evidence suggesting that rich people use private care more than the poor, this finding was not consistent across all income groups. The private sector served young children in particular. Also, people in households with several sick members at the same time relied more on private than public care, while those with severe illnesses tended to use less private care than public. The financial burden for households from private health care services was roughly a half of that imposed by the public providers. Expenditure on drugs accounted for a substantial percentage of household expenditure in general and health care expenditure in particular. These findings call for a prompt recognition of the private sector as a key player in Vietnam's health system. Health system policies should mobilize positive private sector contributions to health system goals where possible and reduce the negative effects of private provision development.     

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries’ approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country’s culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples’ self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.     

Preferences on Policy Options for Ensuring the Financial Sustainability of Health Care Services in the Future: Results of a Stakeholder Survey

Background

Universal access to health care in most western European countries has been a given for many decades; however, macroeconomic developments and increased pressure on health care budgets could mean the status quo cannot be maintained. As populations age, a declining proportion of economically active citizens are being required to support a larger burden of health and social care, while increasing availability of novel technologies for extending and improving life continues to push health care costs upwards. With health expenditure continuing to rise as a proportion of national income, concerns are raised about the current and future financial sustainability of Organisation for Economic Co-Operation and Development (OECD) health care systems. Against this backdrop, a discussion about options to fund health care in the future, including whether to raise additional health care finance (and the ways to do so), reallocate resources and/or ration services becomes very pertinent.

Objective

This study elicits preferences among a group of key stakeholders (payers, providers, government, academia and health-related industry) on the issue of health care financial sustainability and the future funding of health care services, with a view to understanding the different degrees of acceptability between policy interventions and future funding options as well as their feasibility.

Study Design and Participants

We invited 842 individuals from academia, other research organisations (eg. think tanks), national health services, providers, health insurance organisations, government representatives and health-related industry and related advisory stakeholders to participate in an online survey collecting preferences on a variety of revenue-generating mechanisms and cost/demand reducing policies. Respondents represented the 28 EU member states as well as Norway, Iceland, Switzerland, Australia, Russian Federation, Canada and New Zealand.

Results

We received 494 responses to our survey from all stakeholder groups. Across all groups, the highest preference was for policies to modify lifestyle and implement more extensive screening within risk groups for high burden illnesses. There was a broad consensus not to reallocate resources from social security/education. Between stakeholders, there were differences of opinion between industry/advisory and a range of other groups, with industry being generally more in favour of market-based interventions and an increased role for the private sector in health care financing/delivery. Conversely, stakeholders from academia, government, national health services and insurance were relatively more in favour of more restrictive purchasing of new and expensive technologies, and (to varying extent) of higher income/corporate taxes. Taxes on cigarettes/alcohol were by far considered the most politically feasible option.

Conclusions

According to this study, policy options that are broadly acceptable across stakeholder groups with different inherent interests exist but are limited to lifestyle modification, screening interventions and excise taxes on harmful products. Representatives from the private sector tend to view solutions rooted in the private sector as both effective and politically feasible options, while stakeholders from academia and the public sector seem to place more emphasis on solutions that do not disproportionately impact certain population groups.     

Indigent health care plan for Tennessee

The author describes the development of an Indigent Health Care Program for the State of Tennessee from the campaign pledge of the Governor, through the development of an Indigent Care Cabinet Council, to the development and enactment of appropriate legislation required to implement this program. The program deals with availability of health care services, accessibility to health care services and funding mechanisms. The backbone of the program is the involvement of the local community and the coordinating and networking of the existing private, community and state health care providers.     

Decentralizing resource allocation: early experiences with district health boards in New Zealand

OBJECTIVES: In New Zealand in 2001, a system of purchasing health services by a centralized purchasing agency was replaced by 21 district health boards (DHBs) which are responsible for both providing health services directly and for purchasing services from non-government providers. This paper describes the processes associated with the allocation of health resources in the decentralized system and considers the extent to which four of the government's stated objectives are likely to be achieved. METHODS: Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis. RESULTS: The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decision-making has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts. CONCLUSIONS: Decentralized decision-making is starting to make some inroads towards achieving some of the government's objectives with respect to resource allocation and purchasing.     

Health information strategy for New Zealand

The health information strategy signposts the direction for health information services to meet national health information requirements for the 1990s and beyond. The Department of Health is involved in the essential business of funding and monitoring the health sector, providing policy advice and managing resources. The New Zealand Health Information Service will provide the data and analysis from both electronic and manual based systems to support the 'business' of health. Information systems must meet the needs of users. This requires consistency between the information strategy and the direction and goals of the organisation it is designed to service. The approach to health information is consistent with and supports the overall strategy and direction for the development of health services in New Zealand. The development and implementation of the New Zealand Health Information Strategy has been and continues to be an exciting and daunting challenge. All health professionals, managers and the public want high quality, relevant and timely information. The task now is to harness the information technology to support the health sector by providing the vital information.     

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.     

Perceptions and utilization of primary health care services in Iraq: findings from a national household survey

Background

After many years of sanctions and conflict, Iraq is rebuilding its health system, with a strong emphasis on the traditional hospital-based services. A network exists of public sector hospitals and clinics, as well as private clinics and a few private hospitals. Little data are available about the approximately 1400 Primary Health Care clinics (PHCCs) staffed with doctors. How do Iraqis utilize primary health care services? What are their preferences and perceptions of public primary health care clinics and private primary care services in general? How does household wealth affect choice of services?

Methods

A 1256 household national survey was conducted in the catchment areas of randomly selected PHCCs in Iraq. A cluster of 10 households, beginning with a randomly selected start household, were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq's 18 governorates. A questionnaire was developed using key informants. Teams of interviewers, including both males and females, were recruited and provided a week of training which included field practice. Teams then gathered data from households in the service areas of randomly selected clinics.

Results

Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector. Private clinics are generally the most popular source of primary care, however the PHCCs are utilized more by poorer households. In spite of free services available at PHCCs many households expressed difficulty in affording health care, especially in the purchase of medications. There is no evidence of informal payments to secure health services in the public sector.

Conclusions

There is widespread satisfaction reported with primary health care services, and levels did not differ appreciably between public and private sectors. The public sector PHCCs are preferentially used by poorer populations where they are important providers. PHCC services are indeed free, with little evidence of informal payments to providers.     

Beyond the public-private debate: the mixed economy of health

Can or should private organisations provide public healthcare services? What is the scope for private finance in public healthcare services? This paper reviews some of the arguments for and against public or private ownership management and financing of public healthcare services. It concentrates on health services, where non-economic values and ethical questions are as important as the efficiency considerations, and on health purchasing or funding organisations. The paper describes the increasingly complex interrelationship and forms of competition between public and private providers, purchasers and financiers in the UK health sector. It argues that the simple private/public distinction never did describe well the many different forms of financing ownership and operation of health services in any country and is now a handicap to both scientific and lay policy debate about future options. It proposes a framework for describing the main forms of ownership and operations of health services and considers the future for health service purchasing and funding.     

The Australian Health Care Agreement 1998–2003: Implications and strategic directions for occupational therapists

Funding for public health services in Australia is provided to the States and Territories from the Commonwealth. Contractual obligations for how these monies are allocated are detailed in the Australian Health Care Agreement 1998 –2003, which has replaced the Medicare Agreement 1993–1998. Key issues identified in the new Agreement, which will impact on occupational therapy services, include arrangements for mental health services, palliative care initiatives, casemix, health system reform, and private health insurance. Particular implications stem from the proposed reforms to the health system. These include the quality agenda, outcome-based funding and evidence-based practice. Other themes identified include future opportunities for occupational therapists working in health services and the imperative to form collaborative partnerships with consumers and other health care providers. The Australian Health Care Agreement is analysed and suggestions given for strategic directions for occupational therapists to consider.     

Establishing a rural hospital cooperative: a case study.

Rural hospitals have traditionally been the providers of health services in rural areas. In recent years, however, rural hospitals have come under increasing economic and regulatory stress. Rural hospital cooperatives represent a new level of shared management that addresses mutual problems using a horizontal organizational model. In 1987, the Western New York Rural Health Care Cooperative was established by building on fragments of associations that had existed previously. Triggered by an opportunity for grant funding, a major regional cooperative evolved which has demonstrated effective responses to a variety of problems inherent in providing rural health care. Particularly successful programs have such features as a quality assurance plan that uses cooperative-wide peer review, nursing and allied health education, physician recruitment, and the active involvement of a university medical school. This paper is a case study of the development and success of the Western New York Rural Health Care Cooperative.     

Rural Health Care in Bolivia*

ABSTRACT: Eighty percent of Bolivians live in rural areas. However, because of a lack of resources and an urban / curative health sector orientation, rural primary health care services are woefully inadequate. Consequently, Bolivia has the worst health conditions of any of the Latin American countries. The broader factors which underlie Bolivia's poor health conditions, such as the low standard of living and impediments to socioeconomic development, are reviewed. Rural primary health programs are hampered by a lack of local support, overdependence on central and distant Ministry of Health supervisory staff, a lack of strong national political support for rural primary health care programs, the absence of public sector support for social programs, and a lack of appropriately trained health providers who are comfortable in the rural sociocultural mileu of community-oriented primary health care. The experience of Andean Rural Health Care is briefly described, and the potential contribution of private organizations working with local communities and with the Ministry of Health is addressed. The most viable option for improving rural primary health care in Bolivia is the census-based community-oriented approach.     

Vouchers for primary healthcare services in an ageing world? The perspectives of elderly voucher recipients in Hong Kong

Considering the ageing population in economically advanced regions across the world, measures are necessary to enhance the health of the older population as well as contain public healthcare spending. Hong Kong implements the Elderly Health Care Voucher Scheme (EHCVS), providing older people aged 65 or above an annual subsidy of visiting private healthcare service providers for chronic disease prevention and management. The services also aim at reallocating demand from the public to private sector as well as improve quality of services. This qualitative study explored the experiences of EHCVS recipients (n = 55, aged 61–94) with eight focus group interviews in Hong Kong in the year 2016. Convenience sampling was used. Research questions were: (1) Why do older people choose not to use EHCVS for preventive as well as disease management services among older people in Hong Kong? (2) What are the barriers to reallocating demand from the public to private sector? (3) In what ways did EHCVS improve the quality of primary care services for older people? Using a deductive and inductive approach, eight qualitative themes were identified. Findings suggested that the non‐targeted services and inadequate knowledge on EHCVS deterred older people from using the vouchers for disease management and prevention. The relatively expensive private services, lack of trust in the private sector, low public clinic fees and good services quality of the public sector, together with inadequate private practitioners in the healthcare market were barriers that hinder demand reallocation. Nevertheless, the quality of primary care services had been improved after the implementation of EHCVS with shortened wait times and opportunities to discuss health‐related issues with private practitioners. Findings were discussed with practice, policy and research implications.     

Offloading social care responsibilities: recent experiences of local voluntary organisations in a remote urban centre in British Columbia, Canada

Services offered by voluntary organisations are an integral but often overlooked component of health and social care. Of late, there has been a renewed interest in voluntary welfare provision as a viable alternative to state and market. Recent developments in welfare provision in Canada appear to have brought greater social care roles for the voluntary sector at the same time as new and arguably more restrictive funding and accountability mechanisms are being imposed by different arms of the state. To explore these issues more closely, the present paper examines the impressions and experiences of voluntary and formal sector providers of services for senior citizens and people with disabilities in a remote urban centre (population less than 100 000) in the interior of British Columbia, Canada. Two important operational pressures provide the context of the analysis: (1) reform of provincial government funding and regulation of voluntary services; and (2) the restructuring of welfare provision, especially in the areas of health care and social services. The authors found evidence of an escalating incursion of the state into local voluntary sector affairs that needs to be understood in the context of long-standing institutional links between government and 'professional' voluntary welfare provision in British Columbia. The results point to three important directions in contemporary local voluntary provision: (1) an emerging ethos of accountability, efficiency and competition in voluntary provision; (2) increasing pressure to centralise volunteer services; and consequently, (3) the potential erosion of flexibility and personalisation that are seen to characterise the voluntary sector.     

Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia

Background  

One strategic approach available to policy makers to improve the availability of reproductive and child health care supplies and services as well as the sustainability of programs is to expand the role of the private sector in providing these services. However, critics of this approach argue that increased reliance on the private sector will not serve the needs of the poor, and could lead to increases in socio-economic disparities in the use of health care services. The purpose of this study is to investigate whether the expansion of the role of private providers in the provision of modern contraceptive supplies is associated with increased horizontal inequity in modern contraceptive use.     

我国基层卫生机构服务功能分析

基层卫生机构功能决定着基本卫生服务的供给。本文利用国家第四次卫生服务总调查以及专题调查资料,对城乡基层卫生机构服务开展情况进行了分析。根据经济社会发展水平、基层卫生机构服务能力和城乡居民需要解决的主要健康问题,本研究将基本卫生服务项目按照优先程度分为三个等级。约三分之一的城乡基层卫生机构尚不能提供最应优先开展的基本卫生服务;农村基层卫生机构服务能力与城市基层卫生机构相比更为薄弱,特别是村级卫生机构基本卫生服务能力需要加强;乡镇卫生院和社区卫生服务中心开展最优先项目的比例均不足70%;村卫生室和社区服务站开展最优先项目比例分别为62%和77%。影响基层卫生机构功能的主要因素为人员数量不足、人员能力不够、缺乏运转资金等。需要以基层卫生机构功能建设为核心,创新我国基本医疗卫生保健体系。     

Evaluation of immunization knowledge, practices, and service-delivery in the private sector in Cambodia

A study of private-sector immunization services was undertaken to assess scope of practice and quality of care and to identify opportunities for the development of models of collaboration between the public and the private health sector. A questionnaire survey was conducted with health providers at 127 private facilities; clinical practices were directly observed; and a policy forum was held for government representatives, private healthcare providers, and international partners. In terms of prevalence of private-sector provision of immunization services, 93% of the private inpatient clinics surveyed provided immunization services. The private sector demonstrated a lack of quality of care and management in terms of health workers' knowledge of immunization schedules, waste and vaccine management practices, and exchange of health information with the public sector. Policy and operational guidelines are required for private-sector immunization practices that address critical subject areas, such as setting of standards, capacity-building, public-sector monitoring, and exchange of health information between the public and the private sector. Such public/private collaborations will keep pace with the trends towards the development of private-sector provision of health services in developing countries.