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.     

The "unexpected" growth of the private health sector in Greece

The article analyses the situation which exists in the private health sector in Greece, it presents data on the growth of the private sector and discusses the reasons for this phenomenon in relation to privatisation trends in other European countries. The growth of private health care in Greece in the last 10 years is evident despite governmental attempts to minimise its role through the development of the National Health System in 1983 and the legislative restrictions on the private sector. Private health expenditure has increased, reaching 3.9% of the country's GNP (43% of the total expenditure in health) in 2000. The number of private hospitals and hospital beds has decreased (hospitals decreased from 468 in 1990 to 218 in 2000 and private beds decreased from 25,075 in 1980 to 15,806 in 2000) mainly because of the reduction in the number of small private hospitals. On the other hand, private doctors and private diagnostic centres have significantly increased. This situation is believed to be attributed mainly to the provision of inadequate and low quality public health services which have caused widespread dissatisfaction among the general public, and factors associated to improved standards of living, as well as the rapid growth of private insurance.     

Private expenditure and the role of private health insurance in Greece: status quo and future trends

The health care system in Greece is financed in almost equal proportions by public and private sources. Private expenditure, consists mostly of out-of-pocket and under-the-table payments. Such payments strongly suggest dissatisfaction with the public system, due to under financing during the last 25 years. This gap has been filled rapidly by the private sector. From this point of view, one might suggest that the flourishing development of private provision may lead in turn to a corresponding growth in private health insurance (PHI). This paper aims to examine the role of PHI in Greece, to identify the factors influencing its development, and to make some suggestions about future policies and trends. In the decade of 1985–1995 PHI show increasing activity, reflecting the intention of some citizens to seek health insurance solutions in the form of supplementary cover in order to ensure faster access, better quality of services, and increased consumer choice. The benefits include programs covering hospital expenses, cash benefits, outpatient care expenses, disability income insurance, as well as limited managed care programs. However, despite recent interest, PHI coverage remains low in Greece compared to other EU countries. Economic, social and cultural factors such as low average household income, high unemployment, obligatory and full coverage by social insurance, lead to reluctance to pay for second-tier insurance. Instead, there is a preference to pay a doctor or hospital directly even in the form of under-the-table payments (which are remarkably high in Greece), when the need arises. There are also factors endogenous to the PHI industry, related to market policies, low organisational capacity, cream skimming, and the absence of insurance products meeting consumer requirements, which explain the relatively low state of development of PHI in Greece.      

Les dépenses de soins remboursés durant la dernière année de vie,en 2008, en France

BackgroundTo measure the reimbursed health expenditures in the last year of life and the proportion it represents in total reimbursement costs in 2008, to analyse the structure of such expenditures and to identify costs by cause of death.MethodsData were obtained from the French national insurance information system (SNIIRAM). Data from the national hospital discharge database were linked to the outpatient reimbursement database for patients covered by the general health insurance scheme (n = 49 million persons). The cost of the last year of life was calculated for the exhaustive population (361,328 deaths in 2008). The supposed cause of death was mainly derived from the primary diagnosis of the last hospital stay during which the patient died.ResultsThe average reimbursed expenses during the last year of life were estimated at 22,000 € per person in 2008, with 12,500 € accounting for public hospital costs. Reimbursed health expenditures varied according to different medical causes of death: 52,300 € for HIV disease and about 40,000 € for tumors. A negative effect of age on the expenditure during the last year of life was observed. Health care spending increased with shorter time before death, the last month of life corresponding to 28% of reimbursed expenditures during the last year of life. Health care use in the last year of life represented 10.5% of the total health expenditures in 2008.ConclusionThis study found results similar to those observed in the past or in other countries. Our results show in particular that the weight of health expenditures during the last year of life on total health expenditures remains stable over the years.     

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.     

The impact of changes in private health expenditure on New Zealand households

The proportion of New Zealand's total health expenditure financed by the public sector has fallen from 87% in 1983/84 to 77% in 1997/98 in real per capita terms. In the paper, we firstly describe changes in private health expenditure in New Zealand and compare these changes with trends in private and public health expenditure in a number of OECD countries. Secondly, we find that in New Zealand, there have been increases in both out-of-pocket payments and membership of private health insurance funds over the period from 1983/84 to 1997/98. We analyze the relationship between out-of-pocket expenditure, insurance expenditure, and household income across income deciles and across time. We find that out-of-pocket payments are regressive but the regressivity did decline in 1993/94 in response to a government initiative to improve the targeting of government subsidies towards lower income households.     

Bundled payments for chronic diseases increased health care expenditure in the Netherlands,especially for multimorbid patients.

Bundled payments aim to stimulate the integration of healthcare services and ultimately reduce healthcare expenditure growth through improved quality of care. The Netherlands introduced bundled payments for chronic diseases in 2010 by reimbursing providers annually for a bundle of primary care services related to COPD, Diabetes, or Vascular Risk Management. We aimed to assess the long-term effects of these bundled payments on healthcare expenditure. We used health insurance claims data from 2008 to 2015 to compare the healthcare expenditure between everyone who was included in bundled payments and a control group. We performed a difference-in-difference analysis in combination with propensity score matching and found that bundled payments consistently increased health care expenditure over seven years. The average half-year increase was €233 (95%CI: 204-262) for DM2, €609 (95%CI: 533-686) for COPD, and €231 (95%CI: 208-254) for VRM, representing 13%, 52%, and 20% of 2008 half-year cost. The increase was higher for those with multimorbidity compared to those without multimorbidity. This suggests that the expectations of the bundled payments are yet to be fulfilled.     

Informal payments in the Greek health sector amid the financial crisis: old habits die last...

Background

Under-the-table informal payments are commonplace as reimbursements for health care services in Greece. As the country faces a severe financial crisis, the need to investigate the extent of such payments, their incidence and their impact on household income is pressing.

Methods

A survey of 2,741 persons from across the country was conducted between December 2011 and February 2012. The sample was defined via a multistage selection process using a quota for municipality of residence, sex and age. The maximum error margin was 2.41 % with a confidence interval of 95 %.

Results

The survey reports under-the-table payments for approximately 32.4 % of public hospital admissions. Private clinics, which display the bulk of out-of-pocket payments, naturally display the lowest under-the-table payments. The highest percentage of under-the-table payments in the private sector appears at visits to private practitioners and dentists (36 %). Informal payments are most frequently made upon request, prior to service provision, to facilitate access to care and to reduce waiting times, and at a much lower percentage, to post-service provision, and out of gratitude.

Conclusions

This survey reveals that, due to severe financial pressure, there is a growing unwillingness of citizens to pay informally and an increasing demand for these payments as a prerequisite for access to services or to redeem services provided. This “hidden” financial burden of at least 27 % impacts negatively on the living conditions of households and is not reported as purchasing ability or cost of living.

     

Modelling the affordability and distributional implications of future health care financing options in South Africa

South Africa is considering introducing a universal health care system. A key concern for policy-makers and the general public is whether or not this reform is affordable. Modelling the resource and revenue generation requirements of alternative reform options is critical to inform decision-making. This paper considers three reform scenarios: universal coverage funded by increased allocations to health from general tax and additional dedicated taxes; an alternative reform option of extending private health insurance coverage to all formal sector workers and their dependents with the remainder using tax-funded services; and maintaining the status quo. Each scenario was modelled over a 15-year period using a spreadsheet model. Statistical analyses were also undertaken to evaluate the impact of options on the distribution of health care financing burden and benefits from using health services across socio-economic groups. Universal coverage would result in total health care spending levels equivalent to 8.6% of gross domestic product (GDP), which is comparable to current spending levels. It is lower than the status quo option (9.5% of GDP) and far lower than the option of expanding private insurance cover (over 13% of GDP). However, public funding of health services would have to increase substantially. Despite this, universal coverage would result in the most progressive financing system if the additional public funding requirements are generated through a surcharge on taxable income (but not if VAT is increased). The extended private insurance scheme option would be the least progressive and would impose a very high payment burden; total health care payments on average would be 10.7% of household consumption expenditure compared with the universal coverage (6.7%) and status quo (7.5%) options. The least pro-rich distribution of service benefits would be achieved under universal coverage. Universal coverage is affordable and would promote health system equity, but needs careful design to ensure its long-term sustainability.     

Linezolid versus vancomycin cost in the treatment of staphylococcal pneumonia

ObjectiveStaphylococcus aureus is involved in around 20% of nosocomial pneumonia cases. Vancomycin used to be the reference antibiotic in this indication, but new molecules have been commercialized, such as linezolid. Previous studies comparing vancomycin and linezolid were based on models. Comparing their real costs from a hospital perspective was needed.MethodsWe performed a bicentric retrospective analysis with a cost-minimization analysis. The hospital antibiotic acquisition costs were used, as well as the laboratory test and administration costs from the health insurance cost scale. The cost of each hospital stay was evaluated using the national cost scale per diagnosis related group (DRG), and was then weighted by the stay duration.ResultsFifty-eight patients were included. All bacteria identified in pulmonary samples were S. aureus. The cost of nursing care per stay with linezolid was €234.10 (SD = 91.50) vs. €381.70 (SD = 184.70) with vancomycin (P = 0.0029). The cost of laboratory tests for linezolid was €172.30 (SD = 128.90) per stay vs. €330.70 (SD = 198.40) for vancomycin (P = 0.0005). The acquisition cost of linezolid per stay was not different from vancomycin based on the price of the generic drug (€54.92 [SD = 20.54] vs. €40.30 [SD = 22.70]). After weighting by the duration of stay observed, the mean cost per hospital stay was €47,411.50 for linezolid and €57,694.0 for vancomycin (NSD).ConclusionThese results, in favor of linezolid, support other former pharmacoeconomic study based on models. The mean cost per hospitalization stay was not statistically different between the two study groups, but a trend in favor of linezolid is emerging.     

El gasto sanitario en España, 2002-2008: ¿empieza el rescate presupuestario de la atención primaria?

ObjectiveTo determine the distribution of the public health spending (PHS) among health sectors from 2002 to 2008, and the eventual regional inequalities related to the regional income level and the ageing population.DesignA longitudinal and retrospective study.SettingSpain.ParticipantsThe 17 Autonomous Communities.MethodsThe relationship between health expenditure and income and ageing population in the regions, their growth and participation in PHS was analysed.ResultsPrimary Care (PC) expenditure has increased 25% more than the PHS; hospital spending has grown 18% more than the PC and hospital staff spending has grown 5% more than the PC staff. Hospital participation in PHS is twice (10%) that of PC participation (5%). Hospital expenditure variables were positively correlated with income but barely, or negatively, with ageing population. PC expenditure variables were positively correlated with ageing but negative with income. The richest regions spend less on drugs (r = 0.56, p = 0.02), more on hospitals (r = 0.52, p = 0.03) but not more on PC (r = 0.07). Regions with more ageing populations spend more on PC (r = 0.39, P = .12) and drugs (r = 0.63, P < .01) but just more on hospitals (r = 0.15). The income level barely correlates with ageing population (r = 0.15).ConclusionsBetween 2002 and 2008 the differences detected during the previous years in the budget growth between hospitals and PC were reduced. The growth of spending on hospitals is higher than on PC, but this is higher than PHS. The centralising of care in hospitals is notable in the richest regions.     

Changes in Equity in Out-of-pocket Payments during the Period of Health Care Reforms: Evidence from Hungary

Background

At the beginning of 2007, health care reforms were implemented in Hungary in order to decrease public expenditure on health care. Reforms involved the increase of co-payments for pharmaceuticals and the introduction of co-payments for health care services.

Objective

The objective of this paper is to examine the progressivity of household expenditure on health care during the reform period, separately for expenditures on pharmaceuticals and medical devices, as well as for formal and informal patient payments for health care services.

Methods

We use data on household expenditure from the Household Budget Survey carried out by the Central Statistical Office of Hungary. We present household expenditure as a percentage of household income across different income quintiles and calculate Kakwani indexes as a measure of progressivity for a four years period (2005–2008): before, during and after the implementation of the health care reforms.

Results

We find that out-of-pocket payments on health care are highly regressive in Hungary with a Kakwani index of ?0.22. In particular, households from the lowest income quintile spend an about three times larger share of their income on out-of-pocket payments (6–7?%) compared to households in the highest income quintile (2?%). Expenditures on pharmaceuticals and medical devices are the most regressive types of expenditure (Kakwani index ?0.23/-0.24), and at the same time they represent a major part of the total household expenditure on health care (78–85?%). Informal payments are also regressive while expenditures on formal payments for services are the most proportional to income. We find that expenditures on formal payments became regressive after the introduction of user fees (Kakwani index ?0.1). At the same time, we observe that expenditures on informal payments became less regressive during the reform period (Kakwani index increases from ?0.20/-0.18 to ?0.12.)

Conclusions

More attention should be paid on the protection of low-income social groups when increasing or introducing co-payments especially for pharmaceuticals but also for services. Also, it is important to eliminate the practice of informal payments in order to improve equity in health care financing.

     

Private health expenditure in Ireland: Assessing the affordability of private financing of health care

This paper investigates the affordability of private health expenditure among Irish households and the services contributing towards financial hardship. We use data from the Irish Household Budget Survey, a representative survey of household spending in Ireland, covering 2009-10 and 2015-16. Private health expenditure comprises out-of-pocket payments for health and social care services and private health insurance (PHI) premiums. The poverty threshold is 60% of median total equivalised consumption and households with consumption below this level were defined as poor. Households were classified as having unaffordable health expenditure if: 1) they were poor and reported any spending; 2) they were pushed below poverty threshold by health spending; or 3) their spending on health exceeded 40% of capacity to pay. Despite signs of economic recovery, the incidence of unaffordable private health spending increased over the years—from 15% in 2009-10 to 18.8% in 2015-16. People on low incomes were disproportionately affected. The largest component of unaffordable spending for poorer households is PHI and not user charges, which have actually fallen as a cause of hardship. Our findings indicate that reliance on private health expenditure as a funding mechanism undermines the fundamental goals of equity and appropriate access within the health care system.     

Public/private financing in the Greek health care system: implications for equity

The 1983 health reforms in Greece were indirectly aimed at increasing equity in financing through expansion of the role of the public sector and restriction of the private sector. However, the rigid application of certain measures, the failure to change health care financing mechanisms, as well as growing dissatisfaction with publicly provided services actually increased the private share of health care financing relative to that of the public share. The greatest portion of this increase involved out-of-pocket payments, which constitute the most regressive form of financing, and hence resulted in reduced equity. The growing share of private insurance financing, though as yet quite small, has also contributed to reducing equity. Within public funding, while a small shift has occurred in favor of tax financing, it is questionable whether this has contributed to increased equity in view of widespread tax evasion. On balance, it is most unlikely that the 1983 health care reforms have led to increased equity; it is rather more likely that the system in operation today is more inequitable from the point of view of financing than the highly inequitable system that was in place in the early 1980s.     

Lack of private health insurance is associated with higher mortality from cancer and other chronic diseases,poor diet quality,and inflammatory biomarkers in the United States

ObjectiveThe lack of health insurance reduces access to care and often results in poorer health outcomes. The present study simultaneously assessed the effects of health insurance on cancer and chronic disease mortality, as well as the inter-relationships with diet, obesity, smoking, and inflammatory biomarkers. We hypothesized that public/no insurance versus private insurance would result in increased cancer/chronic disease mortality due to the increased prevalence of inflammation-related lifestyle factors in the underinsured population.MethodsData from the Third National Health and Nutrition Examination Survey participants (NHANES III;1988–1994) were prospectively examined to assess the effects of public/no insurance versus private insurance and inflammation-related lifestyle factors on mortality risk from cancer, all causes, cardiovascular disease (CVD) and diabetes. Cox proportional hazards regression was performed to assess these relationships.ResultsMultivariate regression analyses revealed substantially greater risks of mortality ranging from 35% to 245% for public/no insurance versus private insurance for cancer (HR = 1.35; 95% CI = 1.09,1.66), all causes (HR = 1.54; 95% CI = 1.39,1.70), CVD (HR = 1.62; 95% CI = 1.38,1.90) and diabetes (HR = 2.45; 95% CI = 1.45,4.14). Elevated CRP, smoking, reduced diet quality and higher BMI were more prevalent in those with public insurance, and were also associated with increased risks of cancer/chronic disease mortality.DiscussionInsurance status was strongly associated with cancer/chronic disease mortality after adjusting for lifestyle factors. The results suggest that inadequate health insurance coverage results in a substantially greater need for preventive strategies that focus on tobacco control, obesity, and improved dietary quality. These efforts should be incorporated into comprehensive insurance coverage programs for all Americans.     

Economic burden of anal cancer management in France

BackgroundThe incidence of anal cancer has increased over the last 25 years. No organized screening exists for the precursors of anal cancer (anal intraepithelial neoplasia and carcinoma in situ) and diagnosis is often delayed. Treatment for precursor lesions is of limited success, while cancer management is traumatic for the patient. Like cancers of the cervix, most cases of anal cancer are associated with infection with human papillomavirus (HPV). With increases in the incidence of anal cancer, and in light of the availability of prevention strategies such as screening and HPV vaccination, it is important, from a public health perspective, to assess the economic burden of anal cancer in France.MethodsWe performed a retrospective analysis based on data extracted from a French hospital database – the Programme de médicalisation des systèmes d’information (PMSI) – to assess the number and management of patients hospitalized for anal cancer in 2006. Data on radiotherapy sessions performed in private hospitals were obtained from the Statistiques annuelles des établissements de santé (SAE) database. Costs of hospitalization, from the healthcare-payer perspective, were obtained from official diagnosis-related group tariffs for public and private hospitals. Ambulatory and indirect costs were estimated using information obtained from the literature.ResultsIn 2006, 3,711 patients with anal cancer were treated in hospitals in France. Of these, the majority were women (69%). The annual cost of hospital treatment for anal cancer was estimated at €20,326,868. The overall estimated cost (including hospitalization, outpatient and daily allowances costs) to the healthcare payer was €38,249,981.ConclusionThis study, the first to investigate the economic burden of anal cancer in France, shows that the management costs of anal cancer are high and comparable to cervical cancer management costs (€44 million). Further research is required to determine the cost of management of precursor lesions, which is mostly performed in an outpatient setting. Prophylactic HPV vaccination could significantly reduce the burden of this disease.     

EU Country Specific Recommendations for health systems in the European Semester process: Trends,discourse and predictors

In the framework of “Europe 2020”, European Union Member States are subject to a new system of economic monitoring and governance known as the European Semester. This paper seeks to analyse the way in which national health systems are being influenced by EU institutions through the European Semester. A content analysis of the Country Specific Recommendations (CSRs) for the years 2011, 2012, 2013 and 2014 was carried out. This confirmed an increasing trend for health systems to feature in CSRs which tend to be framed in the discourse on sustainability of public finances rather than that of social inclusion with a predominant focus on the policy objective of sustainability. The likelihood of obtaining a health CSRs was tested against a series of financial health system performance indicators and general government finance indicators. The odds ratio of obtaining a health CSR increased slightly with the increase in level of general Government debt, with an OR 1.02 (CI: 1.01, 1.03; p = 0.007) and decreased with an increased public health expenditure/total health expenditure ratio, with an OR 0.89 (CI: 0.84, 0.96; p = 0.001). The European Semester process is a relatively new process that is influencing health systems in the European Union. The effect of this process on health systems merits further attention. Health stakeholders should seek to engage more closely with this process which if steered appropriately could also present opportunities for health system reform.     

Catastrophic and poverty impacts of health payments: results from national household surveys in Thailand

OBJECTIVE: To estimate the incidence and describe the profile of catastrophic expenditures and impoverishment due to household out-of-pocket payments, comparing the periods before and after the introduction of universal health care coverage (UC). METHODS: Secondary data analyses of socioeconomic surveys on nationally representative households pre-UC in 2000 (n = 24,747) and post-UC in 2002 (n = 34,785) and 2004 (n = 34,843). FINDINGS: Households using inpatient care experienced catastrophic expenditures most often (31.0% in 2000, compared with 15.1% and 14.6% in 2002 and 2004, respectively). During the two post-UC periods, the incidence of catastrophic expenditures for inpatient services at private hospitals was 32.1% for 2002 and 27.8% for 2004. For those using inpatient care at district hospitals, the corresponding catastrophic expenditures figures were 6.5% and 7.3% in 2002 and 2004, respectively. The catastrophic expenditures incidence for outpatient services from private hospitals moved from 27.9% to 28.5% between 2002 and 2004. In 2000, before universal coverage was introduced, the percentages of Thai households who used private hospitals and faced catastrophic expenditures were 35.8% for inpatient care and 36.0% for outpatient care. Impoverishment increased for poor households because of payments for inpatient services by 84.0% in 2002, by 71.5% in 2004 and by 95.6% in 2000. The relative increase in out-of-pocket impoverishment was found in 98.8% to 100% of those who were poor following payments made to private hospitals, regardless of type of care. CONCLUSION: Households using inpatient services, especially at private hospitals, were more likely to face catastrophic expenditures and impoverishment from out-of-pocket payments. Use of services not covered by the UC benefit package and bypassing the designated providers (prohibited under the capitation contract model without proper referrals) are major causes of catastrophic expenditures and impoverishment.     

Private medicine and the privatisation of health care in South Africa

Health services in the Republic of South Africa (RSA) are provided by a mixture of public and private providers and institutions. Estimates of total health-related expenditure for 1985 range between 5.3% and 5.9% of gross national product (GNP), divided on approximately a 55:45 basis between public and private sectors. Basic preventive and curative services are provided by a hospital- and clinic-based public system. The public system does not adequately serve the rural areas and African tribal bantustans, and racial discrimination and/or segregation are obvious in its organisation and funding. The public sector's strength is the provision of state-subsidised care to many citizens who are unable to afford private medicine. The vast majority of hospitals are operated on a non-profit basis by government, industries, and voluntary agencies. Excluding hospitals that receive state subsidies, private investor-owned hospitals control about 10% of all hospital beds in the RSA. One-third of these investor-owned beds are held by state-dependent contractors providing long-term care. Two-thirds are wholly independent. Growth has been rapid in the independent hospital sector, and major corporations have entered the market. In 1985, over 85% of the white population was privately insured by a variety of prepayment programmes, including those organised through parastatal corporations and government departments. Despite major enrollment growth in the preceding decade, only 8% of blacks held private insurance by 1985; their coverage also tended to be less comprehensive. Faced with deficit financing, a sluggish economy, complaints from its white constituency about taxation levels, and pressure from private sector interest groups, the Nationalist government has endorsed the concept of privatisation of health care. Exponents of privatisation claim that it will permit differentiation by income to supplant discrimination by race. However, the direct links between disposable income and race, the rapidly rising costs of private insurance, and the still-limited extent of private coverage among the black majority, indicate that privatisation is likely to co-opt a comparatively small proportion of the total black population. It may exacerbate the urban-rural imbalance in health status and health services, promote growth of hospital-intensive curative services rather than needed expansion of community-centred preventive and primary care, and create financial barriers to access for low-income patients.(ABSTRACT TRUNCATED AT 400 WORDS)