PUBLIC AND PRIVATE IMMUNISATION SERVICES: A COMPARISON OF COSTS

Cost inputs to infant immunisation programs were identified for both the public and private health systems, based on data from the fourteen local government areas which made up the Western Metropolitan Health Region in Sydney. New South Wales. The public health approach is shown to be significantly less costly than private immunisation services. The costs of the latter, however, are largely hidden within the national health bill, while the costs of the former are spread across all three levels of government. Total public sector costs of immunisation could be decreased, but only with increased input at the local government level. Thus, under present distribution and funding arrangements in NSW, covert fostering of the less cost efficient private immunisation services is likely to continue.     

Efficiency and quality in the public and private sectors in Senegal

It is often argued that the private sector is more efficient than the public sector in the production of health services, and that government reliance on private provision would help improve the efficiency and equity of public spending in health. A review of the literature, however, shows that there is little evidence to support these statements. A study of government and non-governmental facilities was undertaken in Senegal, taking into account case mix, input prices, and quality of care, to examine relative efficiency in the delivery of health services. The study revealed that private providers are highly heterogeneous, although they tend to offer better quality services. A specific and important group of providers--Catholic health posts--were shown to be significantly more efficient than public and other private facilities in the provision of curative and preventive ambulatory services at high levels of output. Policies to expand the role of the private sector need to take into account variations in types of providers, as well as evidence of both high and low quality among them. In terms of public sector efficiency, findings from the study affirm others that indicate drug policy reform to be one of the most important policy interventions that can simultaneously improve efficiency, quality and effectiveness of care. Relationships that this study identified between quality and efficiency suggest that strategies to improve quality can increase efficiency, raise demand for services, and thereby expand access.     

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

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

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.     

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific.     

Perception and provision of occupational health services in the UK

BACKGROUND: There is difficulty in defining occupational health services among stakeholders of the service. Concurrently, there are concerns about the state of occupational health provision in the UK. AIMS: To determine stakeholders' perception of the services that occupational health encompasses and the level as well as the rationale behind the provision of these services. METHODS: The research was undertaken as a postal questionnaire survey of the FTSE 350 companies and selected public sector organizations in the UK. This was followed up by telephone calls to a random selection of non-respondents to obtain non-respondent data. RESULTS: There is a difference in opinion among managers and occupational health professionals about the services provided by occupational health. Taking into account non-respondent data to partially adjust for overestimation biases, the level of provision of occupational health services among the FTSE 350 companies is 69% and in public sector organizations is 95%, giving an average provision of 72%. Sixteen per cent of respondents thought there was a trend towards outsourcing of services. The most frequently cited reason for provision of an occupational health service was that it was for the benefit of employees. CONCLUSIONS: There remains room for improvement in the level of occupational health services provision in large UK private sector organizations. By bridging the gap between the different stakeholders' perceptions of the remit and benefits of the service, a higher level of provision in the private sector similar to that of public sector organizations can be achieved.     

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)     

Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

A cautious approach to privatization in Papua New Guinea

Health services in Papua New Guinea have historically been providedpredominantly by the public sector, in close partnership withthe churches, which are largely subsidized by government andconsequently tend to be considered as part of the public healthsector. There is a small, but growing private health sectorabout which little is known and which until recently had developedwithout involvement by the government. Indeed, little interestwas shown by health officials, apart from the occasional animosityof hospital staff to in-patients of private doctors, until thelate 1980s when attention was brought to the high levels ofattrition of doctors from the public to the private sector.Budgetary constraints felt by the health sector in 1986, asa result of a change in governmental policy, emphasized theneed to improve the financial information available to enablepolicy makers to optimize the use of the limited resources andseek alternative financing sources. One alternative, which hassince been the suject of greater interest, has been the potentialfor sharing the responsibility for health care provision withthe private sector. This paper draws together what is knownabout the private health care sector in Papua New Guinea anddiscusses the implications of private sector growth for furtherhealth planning and policy formulation.     

The public and private sectors in health: economic issues

Major changes in the public/private mix of health services are occurring in many countries. These changes may be analysed by examining the financing and provision of services and subsidization of the purchase of the factors of production. The public sector and not-for-profit and for-profit elements of the private sector must be viewed as separate entities in such analyses due to their differing objectives, motives and form of operation. The issues to be dealt with by countries in finding the public/private mix which is appropriate for their health system and achieves their objectives include efficiency, quality, regulation, equity and consumer choice and satisfaction. The recommendations for action for countries include: promoting collaboration between private and public sectors; testing different public/private mix models; identifying appropriate expansion paths for private sector services; improving information for policy and planning decisions; enhancing management capacity; and, reviewing programme and project support. International agencies also have a role in this process by supporting countries through the provision of technical assistance, financial aid, promoting policy reviews, and facilitating the sharing of information and experiences among countries concerning these public/private mix issues.     

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.     

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

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

Public health care under pressure in sub-Saharan Africa

Taking as point of departure the need for a strong public health care sector in developing countries the article firstly outlines how in sub-Saharan Africa enhanced scarcity has characterized the content and quality of health care in the public sector. This has eroded the trust among the public in the government as provider of health care and guardian of public health. Secondly, it describes how workers in the public health domain have dealt with the implications of scarcity by etching out a "puvate" zone in health care provision and how these informal activities need to be interpreted as "muddling through". It also points out what are reactions of clients to a decline in public health care provision. Thirdly, it discusses the changing relation between the state as provider of health care and private sector health care provision at a time of emerging public-private partnerships. The article emphasizes the need for strong health services at basic health centre level. It is at that level that the state has to address problems of scarcity and regain public trust. It also is at that level where major long-term health policies like the imminent large-scale delivery of antiretrovirals (3by5) have to be accomplished.     

Private initiatives and policy options: recent health system experience in India

In the recent past the impact of structural adjustment in the Indian health care sector has been felt in the reduction in central grants to States for public health and disease control programmes. This falling share of central grants has had a more pronounced impact on the poorer states, which have found it more difficult to raise local resources to compensate for this loss of revenue. With the continued pace of reforms, the likelihood of increasing State expenditure on the health care sector is limited in the future. As a result, a number of notable trends are appearing in the Indian health care sector. These include an increasing investment by non-resident Indians (NRIs) in the hospital industry, leading to a spurt in corporatization in the States of their original domicile and an increasing participation by multinational companies in diagnostics aiming to capture the potential of the Indian health insurance market. The policy responses to these private initiatives are reflected in measures comprising strategies to attract private sector participation and management inputs into primary health care centres (PHCs), privatization or semi-privatization of public health facilities such as non-clinical services in public hospitals, innovating ways to finance public health facilities through non-budgetary measures, and tax incentives by the State governments to encourage private sector investment in the health sector. Bearing in mind the vital importance of such market forces and policy responses in shaping the future health care scenario in India, this paper examines in detail both of these aspects and their implications for the Indian health care sector. The analysis indicates that despite the promising newly emerging atmosphere, there are limits to market forces; appropriate refinement in the role of government should be attempted to avoid undesirable consequences of rising costs, increasing inequity and consumer exploitation. This may require opening the health insurance market to multinational companies, the proper channelling of tax incentives to set up medical institutions in backward areas, and reinforcing appropriate regulatory mechanisms.     

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.     

Private choices,public costs: Evaluating cost-shifting between private and public health sectors in New Zealand

New Zealand’s dual public-private health system allows individuals to purchase health services from the private sector rather than relying solely upon publicly-funded services. However, financial boundaries between the public and private sectors are not well defined and patients receiving privately-funded care may subsequently seek follow-up care within the public health system, in effect shifting costs to the public sector. This study evaluates this phenomenon, examining whether cost-shifting between the private and public hospital systems is a significant issue in New Zealand.We used inpatient discharge data from 2013/14 to identify private events with a subsequent admission to a public hospital within seven days of discharge. We examined the frequency of subsequent public admissions, the demographic and clinical characteristics of the patients and estimated the direct costs of inpatient care incurred by the public health system.Approximately 2% of private inpatient events had a subsequent admission to a public hospital. Overall, the costs to the public system amounted to NZ$11.5 million, with a median cost of NZ$2800. At least a third of subsequent admissions were related to complications of a medical procedure.Although only a small proportion of private events had a subsequent public admission, the public health system incurred significant costs, highlighting the need for greater understanding and discussion around the interface between the public and private health systems.     

Mental health services system research: the National Institute of Mental Health program.

There is a critical need for research to examine the changing mental health services system, to evaluate major innovations in the provision of mental health treatment, and to remove existing barriers to comprehensive and cost-effective care. To achieve these aims, collaboration is needed among government agencies, mental health services programs, academic institutions, and the private sector. The National Institute of Mental Health supports research and research training on the mental health services system primarily through the Division of Biometry and Applied Sciences. This article focuses on the division's three priority research areas of the mental health services system: the provision of mental health care in the primary care sector, the organization and delivery of care for the chronically mentally ill, and financing and reimbursement of care. The various mechanisms of research support are also highlighted.     

A systematic review of different models of home and community care services for older persons

Background

The Government of the Republic of Kenya is in the process of implementing health care reforms. However, poor knowledge about costs of health care services is perceived as a major obstacle towards evidence-based, effective and efficient health care reforms. Against this background, the Ministry of Health of Kenya in cooperation with its development partners conducted a comprehensive costing exercise and subsequently developed the Kenya Health Sector Costing Model in order to fill this data gap.

Methods

Based on standard methodology of costing of health care services in developing countries, standard questionnaires and analyses were employed in 207 health care facilities representing different trustees (e.g. Government, Faith Based/Nongovernmental, private-for-profit organisations), levels of care and regions (urban, rural). In addition, a total of 1369 patients were randomly selected and asked about their demand-sided costs. A standard step-down costing methodology was applied to calculate the costs per service unit and per diagnosis of the financial year 2006/2007.

Results

The total costs of essential health care services in Kenya were calculated as 690 million Euros or 18.65 Euro per capita. 54% were incurred by public sector facilities, 17% by Faith Based and other Nongovernmental facilities and 23% in the private sector. Some 6% of the total cost is due to the overall administration provided directly by the Ministry and its decentralised organs. Around 37% of this cost is absorbed by salaries and 22% by drugs and medical supplies. Generally, costs of lower levels of care are lower than of higher levels, but health centres are an exemption. They have higher costs per service unit than district hospitals.

Conclusions

The results of this study signify that the costs of health care services are quite high compared with the Kenyan domestic product, but a major share are fixed costs so that an increasing coverage does not necessarily increase the health care costs proportionally. Instead, productivity will rise in particular in under-utilized private health care institutions. The results of this study also show that private-for-profit health care facilities are not only the luxurious providers catering exclusively for the rich but also play an important role in the service provision for the poorer population. The study findings also demonstrated a high degree of cost variability across private providers, suggesting differences in quality and efficiencies.     

Health care utilisation in India

India has a plurality of health care systems as well as different systems of medicine. The government and local administrations provide public health care in hospitals and clinics. Public health care in rural areas is concentrated on prevention and promotion services to the detriment of curative services. The rural primary health centers are woefully underutilized because they fail to provide their clients with the desired amount of attention and medication and because they have inconvenient locations and long waiting times. Public hospitals provide 60% of all hospitalizations, while the private sector provides 75% of all routine care. The private sector is composed of an equal number of qualified doctors and unqualified practitioners, with a greater ratio of unqualified to qualified existing in less developed states. In rural areas, qualified doctors are clustered in areas where government services are available. With a population barely able to meet its nutritional needs, India needs universalization of health care provision to assure equity in health care access and availability instead of a large number of doctors who are profiting from the sicknesses of the poor.     

Private health care provision in developing countries: a preliminary analysis of levels and composition

While the importance of the private sector in providing health services in developing countries is now widely acknowledged, the paucity of data on numbers and types of providers has prevented systematic cross-country comparisons. Using available published and unpublished sources, we have assembled data on the number of public and private health care providers for approximately 40 countries. This paper presents some results of the analysis of this database, looking particularly at the determinants of the size and structure of the private health sector. We consider two different types of dependent variable: the absolute number of private providers (measured here as physicians and hospital beds), and the public-private composition of provision. We examine the relationship between these variables and income and other socioeconomic characteristics, at the national level. We find that while income level is related to the absolute size of the private sector, the public-private mix does not seem to be related to income. After controlling for income, certain socioeconomic characteristics, such as education, population density, and health status are associated with the size of the private sector, though no causal relationship is posited. Further analysis will require more complete data about the size of the private sector, including the extent of dual practice by government-employed physicians. A richer story of the determinants of private sector growth would incorporate more information about the institutional structure of health systems, including provider payment mechanisms, the level and quality of public services, the regulatory structure, and labour and capital market characteristics. Finally, a normative analysis of the size and growth of the private sector will require a better understanding of its impact on key social welfare outcomes.