Outcomes of enhanced prenatal services for Medicaid-eligible women in public and private settings.

OBJECTIVE: With changes in Medicaid, more low-income women are receiving prenatal care in private practice settings. The authors sought to determine whether private settings can provide the enhanced prenatal support services for low-income women that have been offered for decades in public settings. METHODS: The authors analyzed birth outcomes of Medicaid-eligible women receiving care from public and private providers certified to deliver enhanced prenatal care services, which included assessments of nutritional, psychosocial, and health educational risks and individualized counseling along with clinical care. Birth outcomes were compared by type of provider setting using multivariate logistic regression models to adjust for differences in risks and use of care. RESULTS: Among settings certified to deliver enhanced perinatal support services, private physicians'' offices had the best risk-adjusted birth outcomes and public health department clinics the worst, while public hospital clinics had outcomes no different from private physicians'' offices. Adjusted for prenatal care use, outcomes were still better for women seen in private physicians'' offices than for women seen in public health department clinics, community clinics, or private hospital clinics. CONCLUSIONS: The findings suggest that given a certification process, private providers can provide enhanced support services as effectively as providers in public practice settings.     

Rural Indian women's care-seeking behavior and choice of provider for gynecological symptoms

This study uses data from the India National Family and Health Survey-2 conducted in 1998-99 to investigate the level and correlates of care-seeking and choice of provider for gynecological symptoms among currently married women in rural India. Of the symptomatic women surveyed, 31 percent sought care, overwhelmingly from private providers (70 percent). Only 8 percent of women consulted frontline paramedical health workers. Care-seeking behavior and type of providers consulted varied significantly across different Indian states. Significant differentials in care-seeking by age, caste, religion, education, household wealth, and women's autonomy suggest the existence of multiple cultural, economic, and demand-side barriers to care-seeking. Although socially disadvantaged women were less likely than better-off women to consult private providers, the majority of even the poorest, uneducated, and lower-caste women consulted private providers. Geographical access to public health facilities had no significant association with choice of provider, whereas access to private providers had only a moderately significant association with that choice. The predominance of use of private services for self-perceived gynecological morbidity warrants the inclusion of private providers in the national reproductive health strategy to enhance its effectiveness.     

Public perceptions of private health care in socialist China

We present the findings of a United Nations Development Programme-World Health Organization study commissioned by China's Ministry of Health on use of public and private ambulatory care services in three Chinese provinces. We found much unmet medical need (16 percent), attributed mainly to the perceived high cost of care. Seventy-one percent had no health insurance (90 percent in rural and 51 percent in urban areas). For 33 percent, the last consultation was with a private practitioner. Widespread dissatisfaction with public providers (mainly high user fees and poor staff attitudes) is driving patients to seek cheaper but lower-quality care from poorly regulated private providers.     

Ecuador's silent health reform

Health sector reform was implemented in many Latin American countries in the 1980s and 1990s, leading to reduced public expenditure on health, limitations on public provision for disease control, and a minimum package of services, with concomitant growth of the private sector. At first sight, Ecuador appeared to follow a different pattern: no formal reform was implemented, despite many plans to reform the Ministry of Health and social health insurance. The authors conducted an in-depth review and analysis of published and gray literature on the Ecuadorian health sector from 1990 onward. They found that although neoliberal reform of the health sector was not openly implemented, many of its typical elements are present: severe reduction of public budgets, "universal" health insurance with limited coverage for targeted groups, and contracting out to private providers. The health sector remains segmented and fragmented, explaining the population's poor health status. The leftist Correa government has prepared an excellent long-term plan to unite services of the Ministry of Health and social security, but implementation is extremely slow. In conclusion, the health sector in Ecuador suffered a "silent" neoliberal reform. President Correa's progressive government intends to reverse this, increasing public budgets for health, but hesitates to introduce needed radical changes.     

The impact of the introduction of user fees at a district hospital in Cambodia

Proponents of user fees in the health sector in poor countries cite a number of often interrelated rationales, relating inter alia to cost recovery, improved equity and greater efficiency. Opponents argue that dramatic and sustained decreases in service utilization follow the introduction of user fees, highlighting evidence that user fees reduce service utilization when they fail to result in improved quality of care and/or when services are priced higher than those charged by private health care providers. Utilization of public health services in Cambodia is low. Supply-side factors are significant determinants of such low public sector utilization, including low official salaries of service providers (forcing many to seek additional income in the private sector), and operations budgets which are erratic and often insufficient to cover running costs of service delivery outlets. The Cambodia Ministry of Health (MOH) encourages user fee schemes at operational district level. By allowing revenue to be retained at the health facility level, the MOH aims to improve health care delivery--and consequently service utilization--through increased salaries to health facility staff and increases in operations budgets. This case study of the introduction of user fees at a district referral hospital in Kirivong Operational District in Cambodia, using the findings from empirical research, examines the impact of user fees on health-careseeking behaviour, ability to pay and consultation prices at private practitioners. The research showed that consultation fees charged by private providers increased in tandem with price increases introduced at the referral hospital. It further demonstrates--for the first time that we are aware of from the available literature--that the introduction and subsequent increase in user fees created a 'medical poverty trap', which has significant health and livelihood impact (including untreated morbidity and long-term impoverishment). Addressing the medical poverty trap will require two interventions to be implemented immediately: regulation of the private sector, and reimbursing health facilities for services provided to patients who are exempted from paying user fees because of poverty. A third, longer-term initiative is also suggested: the establishment of a social health insurance mechanism.     

Quality of contraceptive services in Finland.

OBJECTIVE: To investigate whether the quality of contraceptive services in Finland varies by the type of care provider. DESIGN: A cross sectional questionnaire survey. PARTICIPANTS: A random sample of 3000 Finnish women aged 18-44 years (response rate 74%) in 1994. RESULTS: Almost all women (94%) had used contraception at some time and 75% were current users. Although self care was common (29% had obtained their latest method outside the health services), 83% had sometimes used the health services for contraception. For their last visit, 55% of women had chosen a health centre (a publicly administered and funded health service), and 33% a private unit. In the health centre, the care provider was usually a general practitioner or a public health nurse, whereas in private care the providers were gynaecologists. Women who used private care were more likely to be from higher social classes and urban areas. After adjustment for a women's background, the two groups were similar for most indicators of the quality of care, but access to care and woman's experiences of treatment were better with private care. CONCLUSIONS: In terms of availability and choices the current system of contraceptive services in Finland is adequate. It is not always an integral part of municipal primary health care, and many women prefer private care for gynaecological services; this may case problems of comprehensiveness and equality of care.     

Healthcare experiences of lesbian and bisexual women in Cape Town,South Africa

Understanding the health needs and experiences of South African lesbian and bisexual women is imperative for implementing effective and inclusive public health strategies. Such understanding, however, is limited due to the exclusion of these women from most existing research on healthcare access in the region. This paper bridges that gap by investigating the healthcare experiences of lesbian and bisexual women in Cape Town. Data were gathered from 22 interviews with self-identified lesbian and bisexual community members and university students in the Cape Town area. Interviews explored obstacles women face in accessing affirming services, different experiences with public and private healthcare, fear of stigma/discrimination, availability of relevant sexual health information and suggestions to improve existing programmes. Findings suggest that South African lesbians and bisexual women may have a range of both positive and negative experiences in public and private health services, that they use protective strategies when ‘coming out’ and that they find that sexual health information pertinent to them is largely unavailable. These discussions contribute to a more inclusive understanding of the experiences of lesbian and bisexual women accessing healthcare and other services and help to inform providers, thereby enabling them to deliver more meaningful care to lesbian, gay, bisexual and transgender persons in South Africa.     

Access to Specialty Health Care for Rural American Indians in Two States

ABSTRACT:  Context: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. Purpose: To examine specialty service access among rural Indian populations in two states. Methods: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). Findings: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. Conclusions: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.     

The privatization of health care in three Latin American social security systems

Most Latin American social security institutes are direct providers of medical care services to their beneficiaries. As many of the institutes have developed serious financial problems over the course of the last decade and a half, they have come under increasing attack for (a) exacerbating inequalities in access to and use of health care, (b) further heightening the geographic overconcentration of services, (c) focusing a disproportionate amount of resources on high technology, curative care to the near total exclusion of primary health care, and (d) being administratively top heavy and, more generally, inefficient. In the past few years, many Latin American countries have begun searching for methods to ameliorate these problems. This paper analyzes three recent efforts, all of which involve some degree of privatization: (1) El Salvador's partial privatization of specialty physician outpatient consultations, (2) Peru's minor surgery and its decentralized ambulatory care programme, and (3) Nicaragua's "administrative services only' approach wherein social security beneficiaries choose to join a certified public or private provider organization for one year, and, on behalf of the individual, social security pays the organization a fixed, annual, per capita fee to provide all health care for the enrollee. The paper also identifies political and technical considerations, as well as health care market characteristics that have shaped these efforts and that condition their likelihood of success, including: the size, composition, level of capacity utilization, degree of organization and geographic distribution of private sector resources; relative prices in the private vis-a-vis the public sector; and the size and nature of the private health insurance market. Other Latin American countries would do well to examine these factors and characteristics before embarking on efforts to reform their own social security health care delivery systems.     

Analysis of reproductive health expenditures in Mexico, 2003]

OBJECTIVES: To estimate reproductive health expenditures in Mexico during 2003; analyze how costs were distributed across the main programs, funding entities, and providers of health goods and services; and evaluate the relationship between reproductive health expenditures and economic indicators in different states, using health accounts methods. METHODS: We estimated reproductive health expenditures between January and December 2003, at the national and state level. We used health accounts methods adjusted for the particular characteristics of Mexico on the basis of information from public and private sources. Expenditures were calculated for the four main reproductive health programs (maternal-perinatal health, family planning, cervical and uterine cancer, and breast cancer) according to different funding entities, goods and services providers, and functions of health care, in both the public and private sector. We estimated public expenditures by state per beneficiary, and analyzed how these costs were related with pubic health care expenditures and annual per capita gross domestic product (GDP) for each state. RESULTS: The reproductive health expenditures in Mexico during the year 2003 were US$ 2.912 6 billion, a figure that represented 0.5% of the national GDP in 2003 and slightly more than 8% of the total health care expenditures. Costs were higher for public entities (53.5%) than for private entities (46.5%). The maternal-perinatal health program accounted for the highest costs, mainly from deliveries and complications; direct payments from households accounted for nearly 50% of the total figure. Costs for family planning were accrued mainly in the public sector, and represented 5.9% of the total expenditure. Of the total spending on reproductive health, 7.9% was devoted to cervical and uterine cancer and breast cancer programs. Mean public expenditures on reproductive health per beneficiary were US$ 680.03, and differences between states were associated with differences in public health expenditures (r=0.80; P<0.001) and per capita GDP (r=0.75; P<0.0001). CONCLUSIONS: The health accounts method allowed us to estimate reproductive health expenditures in Mexico in 2003. Enhancing reproductive health actions and programs by basing expenditure assignments on evidence and focusing on least-favored populations is an ethical, human rights, and developmental imperative.     

Public and private imperatives of Greek health policies

Health care in Greece has historically developed into a multi-tier system, a mosaic of public and private providers of services covering the members of occupational social insurance organizations. In 1983 PASOK's socialist government established a unified National Health System. The aim was to arrest the growth of the private sector and promote the public sector to a dominant position. The socialist legislation has recently been reviewed by a conservative government that aims at a competitive mixed market of public and private providers. The growth of private health care, however, is not solely a matter of political support but also of new opportunities for profitable investments that arise from a shrinking public sector under economic and fiscal constraints.     

The consequences of health service privatisation for equality and equity in health care in South Africa

The trend towards the privatisation of health services in South Africa reflects a growing use of private sources of finance and the growing proportion of privately owned fee-for-service providers and facilities. Fee-for-service methods of reimbursement aggravate the geographical maldistribution of personnel and facilities, and the competition for scarce personnel resources aggravates the difference in the quality of the public and private services. Thus the growth in demand for these types of providers may be expected to increase inequality of access in these two respects. The potential expansion of medical scheme coverage is shown to be limited to well under 50% of the population, leaving the majority of the population without access to private sector health care. Even for members of the medical schemes, benefits are linked to income, thus clashing with the principle of equal care for equal need. The public funds needed to overcome financial obstacles to access to private providers could be more efficiently deployed by financing publicly owned and controlled health services directly. Taxation also offers the most equitable method of financing health services. Finally, attention is drawn to the dilemma resulting from the strengthening of the private health sector; while in the short term this can offer better care to more people on a racially non-discriminatory basis, in the long term, health care for the population as a whole may become more unequal and for those dependent on the public sector it may even deteriorate.     

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.     

Health Differences Among Lumbee Indians Using Public and Private Sources of Care

CONTEXT: Of 2.4 million American Indians, approximately 60% are eligible to receive Indian Health Service (IHS) benefits, leaving many to seek care elsewhere. It is unknown if their quality of care, health behaviors, and health status vary by source of care, as demonstrated for other populations. PURPOSE: The purpose of this study was to determine whether preventive services, health behaviors, and number of health conditions vary as a function of having non-IHS public versus private physicians as sources of usual care. METHODS: 1,177 Lumbee Indians, who are ineligible to receive IHS services, completed a telephone interview that included information on receipt of preventive measures, tobacco use, physical activity, breast self-examination, and medical conditions. Frequencies, chi-squares, t tests, odds ratios, and confidence intervals were used to compare variables by source of care. FINDINGS: 939 respondents (80%) had a private and 210 (18%) a public health clinic physician as their usual source of care; 28 (2%) reported having neither. Logistic regression analyses, restricted to the 1,149 participants who reported either a private or public source of care, revealed no differences in receipt of preventive services or health status by usual source of care. Smokeless tobacco use was less common among persons using private than public providers. CONCLUSIONS: Lumbees whose usual source of care was a public clinic physician did not differ in receipt of preventive services or in health status compared to their counterparts who received care from a private physician. More targeted research into health similarities and differences arising from access to public and private sources of care is warranted.     

Health services reforms in revolutionary Nicaragua.

Before the Nicaraguan revolution of 1979, access to health services was largely limited to the affluent sectors of the urban population and the minority of workers with social security coverage. Repeated attempts at reform by organized medicine were ineffective. Since the revolution, a tremendous expansion in health services has occurred. The national health system receives approximately one-third of its funds from the social security system. Steadily increasing equity in access is a result of the promotion of primary care, health campaigns involving up to 10 per cent of the general population as volunteers, the use of paramedical aides, and foreign assistance. Private practice nevertheless remains strong. In the coming years, several complex issues must be examined, including: a balance in the number of nurses and doctors trained, the role of private practice, and the relationship of the Ministry of Health to the social security system. Further progress in health reforms may be delayed by the defensive war which Nicaragua is fighting on its northern and southern borders. Despite emergent health problems in the war zones, most of the innovative aspects of the health system remain intact as of this writing.     

Private sector, human resources and health franchising in Africa

In much of the developing world, private health care providers and pharmacies are the most important sources of medicine and medical care and yet these providers are frequently not considered in planning for public health. This paper presents the available evidence, by socioeconomic status, on which strata of society benefit from publicly provided care and which strata use private health care. Using data from The World Bank's Health Nutrition and Population Poverty Thematic Reports on 22 countries in Africa, an assessment was made of the use of public and private health services, by asset quintile groups, for treatment of diarrhoea and acute respiratory infections, proxies for publicly subsidized services. The evidence and theory on using franchise networks to supplement government programmes in the delivery of public health services was assessed. Examples from health franchises in Africa and Asia are provided to illustrate the potential for franchise systems to leverage private providers and so increase delivery-point availability for public-benefit services. We argue that based on the established demand for private medical services in Africa, these providers should be included in future planning on human resources for public health. Having explored the range of systems that have been tested for working with private providers, from contracting to vouchers to behavioural change and provider education, we conclude that franchising has the greatest potential for integration into large-scale programmes in Africa to address critical illnesses of public health importance.     

The 2019 introduction of the new National Healthcare System in Cyprus

In 2019, Cyprus launched its new National Healthcare System (NHS) as one of the major structural reforms required by the bail-out agreement with the International Monetary Fund, the European Commission and the European Central Bank (known as the Troika) which averted Cyprus bankruptcy in 2011. This paper presents the key features of the new NHS: A National Health Insurance Fund operated by the Health Insurance Organisation pays for services provided by a mix of public and private providers. A prerequisite for the establishment of this new quasi-market was the transfer of public hospitals from the Ministry of Health to the new State Health Services Organisation, thus establishing a purchaser-provider and regulator split. The first implementation phase started in June 2019 and introduced coverage of outpatient healthcare services for the entire population, providing access – with relatively small user charges – to family physicians, outpatient specialists, pharmaceuticals and laboratories. The second implementation phase began in June 2020 with the inclusion of hospital care, followed by the inclusion of specialty pharmaceuticals in September and was completed in December 2020. The reform is a vital achievement as it is a major step towards the goal of universal health coverage, reducing the excessive reliance on out-of-pocket payment and glaring inequities in access to care.     

Preferences for home delivery in Ethiopia: Provider perspectives

More than half of the maternal deaths worldwide occur in sub-Saharan Africa, most commonly during childbirth or the immediate post-partum period. Although delivery in health care facilities can avert maternal deaths, many women in sub-Saharan Africa continue to deliver at home. Factors influencing mothers' decisions to use facility-based delivery services in rural, low-income settings are not well understood. Health care professionals who provide delivery services in these areas may have unique insights about factors specific to such settings. Accordingly, we conducted a qualitative study of health care professionals in rural Ethiopia to determine key factors influencing facility delivery, using in-depth interviews and the constant comparative method of data analysis. Results suggest multiple influences on women's decisions to deliver at home, including inadequate resources in facilities; unappealing aspects of delivery in facility settings; and known barriers to accessing services such as distance, transportation and cost. Our findings suggest that local health care providers offer valuable insight into why many rural Ethiopian women deliver their babies at home, despite major efforts to promote facility-based delivery. Their perspectives underscore the importance of a patient-centred approach to delivery services, which is often lacking in low-resource settings but may be fundamental to encouraging facility-based deliveries.     

Addressing barriers to perinatal care: a case study of the Access to Maternity Care Committee in Washington State

Access to obstetrical services has deteriorated in recent years, as large numbers of physicians have discontinued or restricted obstetrical practice. In Washington State, one response to this access crisis has been the establishment of the Access to Maternity Care Committee (AMCC), an ad hoc group composed primarily of private sector obstetrical providers and representatives of State government responsible for the delivery of health care to women and children. The major objectives of the AMCC is to improve access to obstetrical services for socially vulnerable women, both rural inhabitants and the medically indigent. The committee has been successful in serving as a forum in which to resolve many of the administrative problems that have arisen between private sector obstetrical providers and the State's Medicaid Program, the major source of payment for the one-third of pregnant women who are medically indigent. Building upon the trust that the committee members developed in working together, the AMCC served as a major force in persuading the State legislature to expand substantially its investment in perinatal care by increasing Medicaid eligibility, raising provider reimbursement, and improving social service for pregnant women. Such ad hoc coalitions between the private and public sector may be quite effective in addressing obstetrical access problems in other States.     

Socioeconomic inequalities in health care utilisation in Norway: the population-based HUNT3 survey

ABSTRACT: BACKGROUND: In this study we investigated the distribution of self-reported health care utilisation by education and household income in a county population in Norway, in a universal public health care system based on ideals of equal access for all according to need, and not according to wealth. METHODS: The study included 24,147 women and 20,608 men aged 20 years and above in the third Nord-Trondelag Health Survey (HUNT 3) of 2006--2008. Income-related horizontal inequity was estimated through concentration indexes, and inequity by both education and income was estimated as risk ratios through conventional regression. RESULTS: We found no overall pro-rich or pro-educated socioeconomic gradient in needs-adjusted utilisation of general practitioner or inpatient care. However, we found overall pro-rich and pro-educated inequity in utilisation of both private medical specialists and hospital outpatient care. For these services there were large differences in levels of inequity between younger and older men and women. CONCLUSION: In contrast with recent studies from Norway, we found pro-rich and pro-educated social inequalities in utilisation of hospital outpatient services and not only private medical specialists. Utilisation of general practitioner and inpatient services, which have low access threshold or are free of charge, we found to be equitable.