Regulation of the private health sector in India

The expansion of the private sector in India has forced the passages of a number of regulations to promote quality of care and protect consumers. This has expanded the role of government in developing and enforcing regulations in three areas of the health sector: drugs, medical practice, and health facilities. These regulations have been promulgated by both national and state governments. Three particular Acts are examined: the Consumer Protection Act, Medical Councils, and the Nursing Home Act. These Acts have provided basic guidelines for regulation of certain aspects of the health sector, but have also created new challenges, as consumers have become more involved in monitoring health service delivery. The challenge for the future will be to ensure the quality and efficiency of health services in both the public and private sectors through these regulatory mechanisms while seeking to promote national health objectives.     

Characteristics of private medical practice in India: a provider perspective.

Supply factors, depicted by input market conditions and government regulations, and demand factors, depicted by financing mechanisms and utilization patterns, are likely to determine the shape and character of private medical practice. The interaction of this complex set of factors will have considerable implications for the cost access and quality of services offered by this sector. Understanding these characteristics from a provider perspective is imperative to influence the behaviour of providers in this sector. This paper describes some of the important characteristics of private medical practice using a case study of an urban district in India, Ahmedabad, and analyzes their implications. Using survey data of 130 private doctors in the allopathic system, the paper describes broad characteristics of private medical practice using parameters such as growth of private practice, patient load and referrals within the sector, payment methods and determinants, patient concerns, and risks associated with private practice. The paper presents views on the prevalence of various undesirable practices in the private medical sector. It also discusses the awareness of providers about selected important regulations. The findings suggest that growing capital intensity due to cost of location, medical equipment and technology, and financial sources of capital investments are some unfavourable environmental factors experienced by private providers. The findings also indicate a high prevalence of various undesirable practices and low awareness of the objectives of important legislation among practicing doctors. Lack of awareness of important and relevant legislation raises serious questions about the implementation of these laws. The paper identifies the strong need for instituting and implementing an effective continuing medical education programme for practicing doctors, and linking it with their registration and continuation of their license to practice. The paper also suggests that cost of health care, access and quality problems will worsen with the growth of the private sector. The public policy response to check some of the undesirable consequences of this growth is critical and should focus on strengthening the existing institutional mechanisms to protect patients, developing and implementing an appropriate regulatory framework and strengthening the public health care delivery system. The study also discusses various other policy implications arising.     

Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India

The private medical sector is an important and rapidly growing source of health care in India. Private medical providers (PMP) are a diverse group, known to be poorly regulated by government policies and variable in the quality of services provided. Studies of their practices have documented inappropriate prescribing as well as violation of ethical guidelines on patient care. However, despite the critique that inequitable services characterise the private medical sector, PMPs remain important and preferred providers of primary care. This paper argues that their greater involvement in the public health framework is imperative to addressing the goal of health equity. Through a review of two research studies conducted in Pune, India, to examine the role of PMPs in tuberculosis (TB) and HIV/AIDS care, the themes of equity and access arising in private sector delivery of care for TB and HIV/AIDS are explored and the future policy directions for involving PMPs in public health programmes are highlighted. The paper concludes that public-private partnerships can enhance continuity of care for patients with TB and HIV/AIDS and argues that interventions to involve PMPs must be supported by appropriate research, along with political commitment and leadership from both public and private sectors.     

Managing uncertainty around HIV/AIDS in an urban setting: private medical providers and their patients in Pune, India

Changing epidemiological patterns and the advent of new rapid diagnostic technologies and therapies have created considerable uncertainty for providers working in HIV. In India, the demand for HIV care is increasingly being met by private practitioners (PPs), yet little is known about how they deal with the challenges of managing HIV patients. To explore HIV management practices in the private medical sector, a survey was conducted with 215PPs in Pune, India, followed by in-depth interviews focusing on the social context of practice among a sub-set of 27PPs. Drawing primarily on interview data, this paper illustrates a number of uncertainties that underlie the reported actions of providers in a competitive medical market. PPs perceive HIV as a 'new' and challenging disease for which they lack adequate knowledge and skills. Combined with the perceived high cost and complexity of antiretroviral treatment, preconceptions about HIV patients' social, financial and mental capacity lead to highly individualistic management practices. While these fall short of clinical 'best practice' guidelines, they reflect adaptive responses to the wider uncertainties surrounding HIV care in urban India. By highlighting contextual issues in PPs' management of HIV patients, the paper suggests the need to explicitly acknowledge the social, moral and economic bases of uncertainty beyond the clinical setting.     

Market share of the for-profit and not-for-profit sector from health insurance expenditures

AIM: The aim of the study is to analyze the market share of for-profit private and not-for-profit sector from the expenditures on medical services of the Hungarian National Health Insurance Fund (NHIF), to show its changes in the last years and to show on which field they can be found. DATA AND METHODS: The data derives from the financial database of the National Health Insurance Fund (NHIF) covering the period 1995-2002. The analysis includes the medical provisions (primary care, health visitors, dental care, out- and inpatient care, home care, kidney dialysis, CT-MRI). RESULTS: In 1995 only 6.91% (12.5 billions Ft) of total expenditure for medical services went to for-profit private providers. By 2002 the market share of private providers increased to 15.95% (78.5 billions Ft). During the same period we realized a dynamic increase in the market share of non-profit sector: from 1.04% in 1995 to 2.58% in 2002. The role of private providers is dominant in the case of general practitioners, dental care, transportation, kidney dialysis, CT/MRI and home care (home nursing). CONCLUSIONS: The financial data of the NHIF showed the dynamic increase of market share of for-profit private providers and non-profit sector in many field of health care, although they role in the two most important fields (out- and inpatient care) is still negligible.     

Uniform documentation of measures in cases of MRSA - an important step towards improving the quality of treatment

The basis for the management and documentation of multiresistant organisms (MRO) in medical facilities in Germany are the Infection Protection Act (IPA) and the recommendations given by the Commission for Hospital Hygiene and Infection Prevention at the Robert Koch Institute (KRINKO).With the Infection Protection Amendment Act an accounting capability for the treatment of patients with MRO will be established in the outpatient care sector. At the same time an electronic documentation is required. In order to comply with the law demanding that the transfer of data concerning the carrier status of a patient should be done without any delays or errors and with minimal effort. Therefore, the documentation should be done according to standards across all sectors and institutions.The documentation of services by multiple providers is to plan with all stakeholders in order to meet the requirements for a proper and professional documentation.The sheet developed in the framework of the HICARE project allows documenting the decolonisation process across sector and service providers. Additionally, it is approved by the MDK MV for documenting the additional efforts to claim the OPS 8-987.     

The private/public mix in health care in India

Private hospitals and private medical practitioners play a significantpart in delivering health care services in India. As the demandfor health care has increased, institutions in this sector haveexpanded widely in both urban and rural areas. The relationshipbetween patient and private practitioner considerably influencesthe perceived and actual needs about health care. This relationshipis expected to play an important role in the control of diseasepatterns and management. However, the developments in this sectorhave prompted concern about the efficiency of resources, equityand access to facilities, and the availability of financingmechanisms to support private health care. Also, the efficiencywith which the resources are used in this sector has directbearing on the cost and quality of services. The existence ofthese health care institutions therefore has profound implicationsfor the present character of the Indian health care system,and its future course. The objectives of the present study are to review the role ofthe private health care sector in India and the policy concernsit engenders. The discussion suggests that policy makers inIndia should take serious note of the growing influence of theprivate sector in providing health care in India. Policy interventionsin health should not ignore their existence and this sectorshould be explicitly involved in the health management process.It is argued that regulatory and supportive policy interventionsare inevitable to promote this sector's viable and appropriatedevelopment.     

Comparative quality of private and public health services in rural Vietnam

BACKGROUND: Private health care services were officially recognized in Vietnam in 1989, and for the last 15 years have competed with the public health system in providing primary curative care and pharmaceutical sales to rural populations. However, the quality of these private and public health care services has not been evaluated and compared. METHODS: A community-based survey was conducted in 30 of the 160 communes in Hung Yen, which were selected by probability proportional to population size (PPS) sampling. All commune health centres (CHCs) and private health care providers in the selected communes were surveyed on human resources, services provided, availability of medical equipment and pharmaceuticals, knowledge and clinical performance for acute and chronic problems. Patient satisfaction and cost of care associated with recent illness were measured using a random household survey covering 30 households from each of the selected communes. RESULTS: There were 11.5 private providers per 10,000 population, compared with 6.7 public providers per 10,000. A quarter of private providers were employees of the public health sector. Less than 20% of the private providers had registered their practice with the government system. Eleven per cent (26/234) had no professional qualifications. Fifty-eight per cent (135/234) provided treatment as well as selling medications. Public sector infrastructure was superior to that of the private providers. The quality of services provided by public providers was poor but significantly better than that of private providers. Patient satisfaction and costs of care were similar between the two groups. CONCLUSIONS: Private providers are successfully competing with the public health centre system in rural areas but not because they provide cheaper or better services. The quality of private health care services is not controlled and is significantly poorer than public services. Current practice in both systems falls below the national standard, especially for the management of chronic health problems. The low quality of health care services at a community level may help explain the previously observed phenomena of high levels of self-medicating, low utilization of commune health centres and over-utilization of tertiary health care facilities.     

Behaviour of the private sector in the health market of Bombay

In Bombay, the private sector plays a major role in providingmedical care to all strata of society and these services arewell utilized by everyone. Of late there have been criticismsabout the quality of private medical care and there is a needfor a proper policy on the development and regulation of privatesector health services. This paper contributes to this by unravellingthe inadequacies in the medical infrastructure and manpower,and highlighting the unethical medical practice rampant in privatepractice. The paper also assesses the existing regulatory mechanismsand their inability to control the quality of private sectormedical care. After exposing the behaviour of the private sector,the paper suggests a holistic policy approach to increase andstrengthen the public sector health services in poor areas,to develop norms to maintain quality in medical infrastructureand manpower, and to discipline unethical professional behaviour.     

Health Resources in a 200,000 Urban Indian Population Argues the Need for a Policy on Private Sector Health Services

Background:

There are limited primary data on the number of urban health care providers in private practice in developing countries like India. These data are needed to construct and test models that measure the efficacy of public stewardship of private sector health services.

Objective:

This study reports the number and characteristics of health resources in a 200 000 urban population in Pune.

Materials and Methods:

Data on health providers were collected by walking through the 15.46 sq km study area. Enumerated data were compared with existing data sources. Mapping was carried out using a Global Positioning System device. Metrics and characteristics of health resources were analyzed using ArcGIS 10.0 and Statistical Package for the Social Sciences, Version 16.0 software.

Results:

Private sector health facilities constituted the majority (424/426, 99.5%) of health care services. Official data sources were only 39% complete. Doctor to population ratios were 2.8 and 0.03 per 1000 persons respectively in the private and public sector, and the nurse to doctor ratio was 0.24 and 0.71, respectively. There was an uneven distribution of private sector health services across the area (2-118 clinics per square kilometre). Bed strength was forty-fold higher in the private sector.

Conclusions:

Mandatory registration of private sector health services needs to be implemented which will provide an opportunity for public health planners to utilize these health resources to achieve urban health goals.     

Spatial pattern of private health care provision in Ujjain, India: a provider survey processed and analysed with a Geographical Information System

In developing countries like India, official information on private health care providers is scanty. This is an obstacle for effective health care planning and policy development. In this paper, we present a project aimed to enumerate, characterise and digitally map all private providers (PPs) using Geographical Information System (GIS) in a rural district in India. A team of surveyors carried out a census of private providers in the district. This data was combined with official data on geophysical characteristics and infrastructure, demographic situation and location of settlements and public health care providers. This study highlights the need to consider PPs in health policy making in India. The survey identified about 2000 additional PPs over and above those listed with the health authorities. About half practised modern medicine (Allopathy) while the rest practised other types of formal medical systems (Ayurveda or Homeopathy) or informal therapeutic systems. Individuals with no formal health care training constituted the majority of PPs. Formally trained doctors were highly concentrated in urban areas while trained non-doctors and untrained PPs dominated in the rural areas. The study shows how GIS can be used to create an improved basis for health services research. In the future, the digitised map will be used as a sampling frame and point of reference for studies on quality and utilisation of PPs in Ujjain district. However, the utility for health care planning is less clear. GIS has limitations in countries like India due to lack of valid routine data to enter into GIS as well as to competing demand for health care resources.     

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.     

Income-based disparities in health care utilisation under universal health coverage in Brazil, 2002–2003

Since Brazil's adoption of universal health care in 1988, the country's health care system has consisted of a mix of private providers and free public providers. We test whether income-based disparities in medical visits and medications remain in Brazil despite universal coverage using a nationally representative sample of over 48,000 households. Additional income is associated with less public sector utilisation and more private sector utilisation, both using simple correlations and regressions controlling for household characteristics and local area fixed effects. Importantly, the increase in private care use is greater than the drop in public care use. Also, income and unmet medical needs are negatively associated. These results suggest that access limitations remain for low-income households despite the availability of free public care.     

Private health care in Nigeria: walking the tightrope.

The persistently low quality and inadequacy of health services provided in public facilities has made the private sector an unavoidable choice for consumers of health care in Nigeria. Ineffective state regulation, however, has meant little control over the clinical activities of private sector providers while the price of medical services has, in recent years, grown faster than the average rate of inflation. Reforms that are targeted at reorganizing the private sector, with a view to enhancing efficiency in the supply of services, are urgently required if costs are to be contained and consumers assured of good value for money.     

The impact of the Community Care Act: views from the independent sector

The 1990 NHS and Community Care Act introduced changes that had significant implications for independent service providers. The legislation was intended to decrease unnecessary institutionalization, increase the demand for non-statutory community care services, and improve collaboration between the private and public service sectors. Preliminary evidence on the impact of the Act suggests that the principal changes related to private service provision have not been translated into practice, but the data are confined to studies from the local authorities' perspective or that of carers. In this paper, the views of independent service providers in an urban area of Scotland were examined through interviews with 24 administrators of nursing homes or residential care facilities. The study investigated their perceptions of the impact of the law on institutionalization, diversification into community care, and partnerships between the public and private spheres. The findings show that facilities have experienced a range of problems since the law came into effect, including higher vacancy rates, more disabled residents, delays in admissions, cash flow problems and reductions in private pay patients. Those owned by public limited companies were more able to buffer themselves from the adverse effects. A large proportion of the facilities had diversified into community based long-term care, but these were perceived as a minor sideline. Finally, the legislation did not result in links forged between independent service providers and the social service departments of local authorities who are charged with assessing, coordinating and purchasing long-term care.     

Private and public health care in rural areas of Uganda

Background  

In many low and middle income countries, the private sector is increasingly becoming an important source of health care, filling gaps where no or little public health care is available. However, knowledge on the private sector providers is limited The objective of this study was to determine the type and number of different types of health care providers, and the quality, cost and utilization of care delivered by those providers in rural Uganda.     

Factors influencing private health providers' technical quality of care for acute respiratory infections among under-five children in rural West Bengal,India

In many developing countries, private health practitioners provide a significant portion of curative care for diseases which are of public health importance. Currently, health sector reform efforts in these countries are fostering increased participation of private providers in the delivery of health services, including those of public health importance. Guaranteeing good technical quality of care is critical to the process. However, little is known about private providers' technical quality of care (disease management practices) and the factors influencing these services. The purpose of this study was to contribute information on this topic.The study was conducted among private providers in rural West Bengal, India and focused on providers' disease management practices for acute respiratory infections (ARI) among under-five children. World Health Organization (WHO) guidelines for ARI case management were used as the expected standard of care. Observations of patient-provider encounters and interviews with the providers and mothers were the main sources of data.The study found that private health providers in rural West Bengal have inadequate technical quality of care. The problem was related both to low levels of performance (limited potential) and inconsistency in performance (within-provider variation). Limited potential for good technical quality for ARI among the providers was related to lack of knowledge (technical incompetence). One of the important factors influencing within-provider variation was patient load. Since rural private providers operate on a fee-for-service payment system, there are incentives related to seeing many patients. The study concluded that to bring about sustainable improvements in private providers' ARI disease management practices, training programs and interventions that improved compliance were necessary.     

Growth of private medical education in India

BACKGROUND: Medical education has grown in India in nearly 6 decades since independence, but no quantitative assessment of this growth exists. DISCUSSION: We examine the growth of medical education institutions in India, especially in the private sector, and their geographical distribution during the period 1950-2004. We show that the rapid growth in the number of medical colleges in India since 1950 has been driven largely by developments in the private sector. The private sector, currently accounting for over 45% of medical colleges in India, grew by 900% between 1970 and 2004, with the bulk of this growth occurring in the richer states. We assess the reasons for these trends and the ensuing equity implications. CONCLUSION: The growth of the private medical education sector over the last 6 decades is the most dominant feature of the Indian medical education landscape.     

Mason Tenders agrees to pay $1 million to end ADA litigation

The Mason Tenders District Council Welfare Fund has agreed to pay $1 million to construction workers who have been denied medical coverage for AIDS-related care. The decision establishes self-insured health care benefits programs as covered entities under the Americans with Disabilities Act (ADA). The settlement ends a three-year battle which began in 1992 between Mason Tenders and fourteen HIV-positive construction workers who were refused medical coverage. The first suit was filed by Terrence P. Donaghey, Jr., a construction worker who lost coverage for his HIV-related care in July 1991. At that time, the union fund decided to exclude care for HIV on the grounds that it was too expensive. The Equal Employment Opportunity Commission (EEOC) filed an ADA lawsuit that challenged disability-based distinctions in health insurance. The U.S. Attorney's Office filed a complaint against the union under the Racketeer Influenced and Corrupt Organizations (RICO) statute to end organized crime associated with the union. In late 1994, the government announced a consent decree, settling its racketeering suit against the union. Under the terms of the settlement, Donaghey was awarded $16,000 in damages. In the EEOC case, damages for plan members ranged as high as $50,000.     

Accountability and the accounting regime in the public sector. Some messages from the NHS

In the UK, the government is keen to introduce private sector procedures into the public sector. The latest stage of this process has been to suggest the adoption of accruals accounting by those parts of the public sector where it is not already operated. This approach to accounting was introduced into the NHS as part of the reforms which implemented a quasi-market to match the demands of purchasers of health care with its providers. Outlines the assumptions which underlie accruals accounting and considers whether the environment created for NHS Trusts is sufficiently like that of the private sector to justify its use. Shows that the initial ideas of the extent to which Trusts could mimic private sector organizations have not been fulfilled in practice, and concludes that it is not possible to justify the use of accruals accounting in the public sector simply on the grounds that as it is the technique used in the private sector it must be superior to the available alternatives.