Reform strategies in Georgia and their impact on health care provision in rural areas: evidence from a household survey

The transition resulting from the break-up of the Soviet Union significantly affected the health care systems and population health status in the newly independent States. The available body of evidence suggests that contraction of public resources resulting from economic slowdown has led to the proliferation of out-of-pocket payments and private spending becoming a major source of finance to health service provision to the population. Emerging financial access barriers impede adequate utilization of health care services. Most transition countries embarked on reforming health systems and health care financing in order to tackle this problem. However, little evidence is available about the impact of these reforms on improved access and health outcomes. This paper aims to contribute to the assessment of the impact of health sector reforms in Georgia. It mainly focuses on changes in the patterns of health services utilization in rural areas of the country as a function of implemented changes in health care financing on a primary health care (PHC) level. Our findings are based on a household survey which was carried out during summer 2002. Conclusions derived from the findings could be of interest to policy makers in transitional countries. The paper argues that health financing reforms on the PHC level initiated by the Government of Georgia, aimed at decreasing financial access barriers for the population in the countryside, have rendered initial positive results and improved access to essential PHC services. However, to sustain and enhance this attainments the government should ensure equity, improve the targeting mechanisms for the poor and mobilize additional public and private funds for financing primary care in the country.     

The public sector and mental health parity: time for inclusion

BACKGROUND: In the United States, there is an uneasy division of responsibility for financing mental health care. For most illnesses, employer-sponsored health insurance and the large federal health insurance programs (Medicare, Medicaid) cover the costs of care. However, most employer-sponsored plans and Medicare provide only limited coverage for treatment of mental illness. A possible cause and result of this limited coverage in mental health is that states, and in some cases local (county) governments, finance a separate system of mental health care. This separate "public mental health system" provides a "safety net" of care for indigent individuals needing mental health care. However, there are potential negative consequences of maintaining separate systems. Continuity of treatment between systems may be impaired, and costs may be higher due to duplicate administrative costs. Maintaining a separate system managed by government may exacerbate the stigma associated with mental illness treatment. Most significantly, since eligibility for care may be linked to poverty status, and since having a serious mental illness may preclude regaining private coverage, maintaining a separate system may contribute to the poverty rate among persons with mental illnesses. AIMS OF THE PAPER: These potential problems have not been widely considered, perhaps because other problems and controversies in mental health care have captured our attention. In particular, controversies over deinstitutionalization in mental health have dominated the policy debate, especially when linked to related problems. These have included conflicts over authority and financial responsibility among federal, state and local governments, sensationalized media coverage of incidents involving people with mental illness, problems with siting community facilities, concern about mental illness among prisoners and the like. However, with the substantial reform of public mental health care in some states and localities, it is now possible to consider the implications of public and private integration. This paper considers such an approach. METHODS: This paper addresses the question of public and private integration, considering the state of Ohio as a case study. Ohio is a large state (population 11.2 million) and shares demographic, cultural and political characteristics with many other states. Ohio's successful experience implementing community mental health reform makes it a good candidate to use in evaluating issues in the potential integration of insurance-paid and public mental health care. RESULTS: The analysis indicates that the resources now used in Ohio's public system may be sufficient to support insurance financing of inpatient and ambulatory mental health treatment (the types of health care usually paid by insurance) while maintaining supportive services (e.g. housing, crisis care) as a residual safety net. DISCUSSION: At the current time, these resources are in state and local mental health budgets, and in the Medicaid program that finances health care for low income and disabled individuals. The analysis indicates that the aggregate level of resources expended on inpatient and ambulatory mental health treatment are substantially greater than expenditures for such care in an insurance plan for Ohio State employees. A substantial limitation of the analysis is that it is not possible to compare the need for care in a relatively healthy employed population versus a poor and disabled population. CONCLUSION: The paper concludes that there are substantial structural, economic and social problems associated with the "two-tiered" system of commercial/employer-paid insurance and public mental health care in the United States. Examining data from one state's public system, the paper further concludes that it might be feasible to finance a single system of acute and ambulatory mental health benefits, if public resources were redeployed and private contributions were continued. IMPLICATIONS FOR POLICY AND RESEARCH: Given the substantial problems associated with the two-tiered American approach to mental health care, further consideration and analyses of the feasibility of public and private integration are suggested. Given the complexity of this effort, much more sophisticated analysis is needed. However, given the possibility that sufficient resources may now be available to accomplish integration, further work is suggested.     

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.     

Private health expenditure in the Greek health care system: Where truth ends and the myth begins

Greece today has the most “privatized” health care system among EU countries. Given the country's universal coverage by a public system this may be called “the Greek paradox”. The Objective of this paper is to analyze private health payments by provider and type of service in order to bring to light the reasons for and the nature of the extraordinary private expenditure in Greece. Methods: We used a randomized countrywide sample of 1616 households. Regression analysis was used to determine the extent to which social and economic household characteristics influence the frequency of use of certain health services and the size of household payments for such services. In all statistical analyses we used the p < 0.05 level of significance. Results: Out of the total private household health expenditure (€6141 million), 66% is for outpatient services, with the largest share for dental services, absorbing 31.1% (€1912 million or 1.5% of GDP) of the total out-of-pocket health expenditure. Rural dwellers seek private outpatient care more often, because of the understaffed public primary facilities. The hospital sector absorbs less than 15% (or €884 million) of household private health expenditure. A significant part (20%) of hospital care financed privately concerns informal payments within public hospitals, an amount almost equal with formal payments in the form of cost sharing. Admissions to private hospitals are only 16% of total admissions. Our results indicate that this is a result of the political emphasis in public hospitals and of the considerably high cost of private hospital care. Conclusions: The rise in private health expenditure and the development of the private sector during the last 20 years in Greece is associated with public under financing. The gap was filled by the private sector through increased investment, mostly in upgraded amenities and new technology. Today, the complementary nature of private care in Greece is no longer disputed, but is a matter of serious concern, as it undermines the constitutionally guaranteed free access and equitable distribution of health resources.     

Dimensions of health system reform

During recent years there has been a growth of worldwide interest in health system reform. Countries at all levels of economic development are engaged in a creative search for better ways of organizing and financing health care, while promoting the goals of equity, effectiveness, and efficiency. Together with economic, political, and ideological reasons, this search has been fueled by the need to find answers to the complexities posed by the epidemiologic transition, whereby many nations are facing the simultaneous burdens of old, unresolved problems and new, emerging challenges. In order to better understand reform attempts, it is necessary to develop a clear conception of the object of reform: the health system. This paper presents the health system as a set of relationships among five major groups of actors: the health care providers, the population, the state as a collective mediator, the organizations that generate resources, and the other sectors that produce services with health effects. The relationships among providers, population, and the state form the basis for a typology of health care modalities. The type and number of modalities present in a country make it possible to characterize its health system. In the last part, the paper proposes that health system reform operates at four policy levels: systemic, which deals with the institutional arrangements for regulation, financing, and delivery of services; programmatic, which specifies the priorities of the system, by defining a universal package of health care interventions; organizational, which is concerned with the actual production of services by focusing on issues of quality assurance and technical efficiency; and instrumental, which generates the institutional intelligence for improving system performance through information, research, technological innovation, and human resource development. The dimensions of reform offer a repertoire of policy options, which need to be enriched by cross-national comparison of experiences and rigorous social experimentation. Maybe then reform will be a more systematic effort, and nations will be better able to learn from each other.     

Transnational capital and confessional politics: the paradox of the health care system in Lebanon.

For the past two decades there has been a debate over the implementation of structural adjustment policies in the health sector of developing countries, much of it focusing on the political and economic relevance of the reform process for public health provision. However, very few studies have been able to assess the relevance of the private sector, which has had a central role in the restructuring of health services worldwide. Lebanon provides just such a case, with a predominantly private provider and the role of the state relegated to financing, with few controls over supply. This situation has ensured the systematic destruction of what remained of public provision in the 1970s. The country is now faced with one of the most expensive health services in the world, and one in which much of the population continues to live under conditions of considerable economic deprivation. The unique situation of Lebanon is maintained by its politics of confessionalism, with sociopolitical relations dominated by primordial ties of family, tribe, and kin, which does not seem to be an obstacle to the process of globalization. The authors suggest that this context reinforces the gross inequalities in access to health care; they explore the complex relationship between state, finance capital, and confessional politics in the context of health sector reform, in particular the financing of health care.     

Spending and financing in health care: situation and trends]

Being knowledgeable about national health expenditures and sources of financing is essential for decision-making. This awareness also makes it possible to evaluate the equity of allocation and the efficiency of utilization of these resources. Changes in financing have been a substantial component of health sector reform in the Americas. The goal has shifted from merely one of financial sustainability to simultaneously seeking equitable access to quality services. In this article the Pan American Health Organization (PAHO) presents a proposal for analyzing and designing a policy on health financing. The aim of the policy is to identify the mix of financing mechanisms most likely to simultaneously produce financial sustainability, equity, access, and efficiency. The PAHO proposal combines traditional mechanisms for generating resources (public funds from taxes, as well as private health insurance, national health insurance, and user fees) with complementary subsidy mechanisms for vulnerable groups. Health financing strategies ought to explicitly consider the financing both of care for individuals and of health interventions for the general public good, for which public financing is the most equitable and efficient approach.     

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.     

Private payers of health care in Brazil: characteristics, costs and coverage

The private sector is the predominant provider of health care in Brazil, particularly for inpatient services, and financing is a mix of public (through a prospective reimbursement system) and private. Roughly a quarter of the population has private insurance coverage, reflecting rapid growth in the past decade fuelled by the crisis in the public reimbursement system and the perceived deterioration of publicly provided care. Four major forms of insurance exist: (1) prepaid group practice; (2) medical cooperatives, physician owned and operated preferred provider organizations; (3) company health plans where employers ensure employee access to services under various types of arrangements from direct provision to purchasing of private services; and (4) health indemnity insurance. Each type of plan includes a wide variety of subplans from basic individual/family coverage to comprehensive executive coverage. The paper discusses the characteristics, costs and utilization patterns of all types of privately financed care, as well as the major problems associated with private financing: the limited package of benefits and low payout ceilings, inadequate consumer information and virtually no regulation.     

Users of home‐care services in a Nordic welfare state under marketisation: the rich,the poor and the sick

Stricter access to public services, outsourcing of municipal services and increasing allocation of public funding for the purchase of private services have resulted in a marketisation wave in Finland. In this context of a Nordic welfare state undergoing marketisation, this paper aims to examine the use of Finnish care services among older people and find out who are using these new kinds of private services. How wide is their use and do the users of private care services differ from those who are using public services? How usual is it to mix both public and private care services? The questionnaire survey data set used here was gathered in 2010 among the population aged 75 and over in the cities of Jyväskylä and Tampere (N = 1436). The methods of analysis used include cross‐tabulation, chi‐square tests and multinomial logistic regression. The findings showed that among those respondents who used care services (n = 681), 50% used only public services, 24% utilised solely private services and the remaining 26% used both kinds of services. Users of solely private services had significantly higher income and education as well as better health than those using public services only. The users of public services had the lowest education and income levels and usually lived in rented housing. The third group, those mixing both public and private services, reported poorer health than others. The results increase concerns about the development towards a two‐tier service system, jeopardising universalistic Nordic principles, and also suggest that older people with the highest needs do not receive adequate services without complementing their public provisions with private services.     

Paying for and receiving benefits from health services in South Africa: is the health system equitable?

There is a global challenge for health systems to ensure equity in both the delivery and financing of health care. However, many African countries still do not have equitable health systems. Traditionally, equity in the delivery and the financing of health care are assessed separately, in what may be termed 'partial' analyses. The current debate on countries moving toward universal health systems, however, requires a holistic understanding of equity in both the delivery and the financing of health care. The number of studies combining these aspects to date is limited, especially in Africa. An assessment of overall health system equity involves assessing health care financing in relation to the principles of contributing to financing according to ability to pay and benefiting from health services according to need for care. Currently South Africa is considering major health systems restructuring toward a universal system. This paper examines together, for both the public and the private sectors, equity in the delivery and financing of health care in South Africa. Using nationally representative datasets and standard methodologies for assessing progressivity in health care financing and benefit incidence, this paper reports an overall progressive financing system but a pro-rich distribution of health care benefits. The progressive financing system is driven mainly by progressive private medical schemes that cover a small portion of the population, mainly the rich. The distribution of health care benefits is not only pro-rich, but also not in line with the need for health care; richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. The importance of the findings for the design of a universal health system is discussed.     

南非公立医院改革的主要做法与特点

相对于私立医院占有五分之三的卫生支出为20%的人群提供服务,南非公立医院约使用五分之二的卫生支出,为南非80%的人群提供医疗卫生服务,但面临着资源不足和人力短缺的问题。为此,南非政府着重建立公平导向的卫生管理体制,加大政府财政投入,重点保障基层公立医院发展,探索公私合作,在优先保障弱势人群基本医疗服务的同时,动员可利用的所有医疗资源,着力保障居民公平地获得基本医疗卫生服务。改革的主要特点是建立以基本医疗卫生保健为基础的医疗管理体制,以更公平的方式分配医疗资源,建立公私合作机制,动员民营机构力量,优先保障居民对基本医疗卫生服务的可及性和公平性。这些经验对于同属于发展中国家的中国有良好启示。     

卫生立法的国际经验对我国的启示

本文通过分析典型国家卫生立法的现状和发展的共同点,结合我国政治、社会和经济环境,对我国《基本卫生法》立法提出政策建议。多数工业化国家都有一个相同的价值观,即政府确保公民不受地域和经济能力的限制享有卫生服务。各国卫生立法都经历了与政治发展同步的数次改革。几乎每一个以公共筹资体系为主的国家,都同时存在商业医疗保险和私人医疗服务,但医疗卫生服务体系很少以市场为主导。所有国家都在向建立整合的协同医疗服务体系方向努力,并已建立了与经济发展和国民收入相适应的、长期稳定的卫生筹资模式。作为卫生领域的根本法,《基本卫生法》应以更宏观的视角对卫生和健康问题的基本定位、基本价值和基本框架进行定位,突出"无论公民的性别、年龄、宗教、社会地位和经济状况,政府都有责任确保其获得基本医疗卫生服务和基本药物"的核心价值观。     

Incoherent policies on universal coverage of health insurance and promotion of international trade in health services in Thailand

The Thai government has implemented universal coverage of health insurance since October 2001. Universal access to antiretroviral (ARV) drugs has also been included since October 2003. These two policies have greatly increased the demand for health services and human resources for health, particularly among public health care providers. After the 1997 economic crisis, private health care providers, with the support of the government, embarked on new marketing strategies targeted at attracting foreign patients. Consequently, increasing numbers of foreign patients are visiting Thailand to seek medical care. In addition, the economic recovery since 2001 has greatly increased the demand for private health services among the Thai population. The increasing demand and much higher financial incentives from urban private providers have attracted health personnel, particularly medical doctors, from rural public health care facilities. Responding to this increasing demand and internal brain drain, in mid-2004 the Thai government approved the increased production of medical doctors by 10,678 in the following 15 years. Many additional financial incentives have also been applied. However, the immediate shortage of human resources needs to be addressed competently and urgently. Equity in health care access under this situation of competing demands from dual track policies is a challenge to policy makers and analysts. This paper summarizes the situation and trends as well as the responses by the Thai government. Both supply and demand side responses are described, and some solutions to restore equity in health care access are proposed.     

The importance of public sector health care in an underserved population

California's employed Latinos are less likely to have private health insurance than most other segments of the US population and face a variety of other barriers to obtaining health care. To better understand the availability and adequacy of health services for these individuals, researchers analyzed data from a telephone survey of 1,000 randomly-selected, employed adults. Among all survey respondents, a significant percentage obtained their health care from sources fully or partially dependent on government financing. Among the uninsured (30.7 percent of the sample), a majority of those who had a regular source of care received services from publicly-supported providers. Dissatisfaction with care was infrequent (less than 5 percent of the total sample) and apparently no greater among those receiving care from public sources than among those served by private doctors. These findings underscore the importance of the public sector in providing health care for the underserved, the high quality of the services provided (or partially supported) by the public sector, and the seriousness of the consequences for the disadvantaged should public support for their healthcare diminish.     

Regulation versus practice--the impact of accessibility on the use of specialist health care in Norway

In Norway specialized health services are provided both by public hospitals and by privately practicing specialists who have a contract with the public sector. A patient's co-payment is the same irrespective of the type of provider he visits. The ambition of equity in the allocation of medical care is high among all political parties. The instruments for auditing whether these goals are fulfilled are not equally ambitious. The objective of the present study is to explore whether laws and regulations that govern the allocation of specialist health care resources in fact are fulfilled. Panel data from the Survey of Living Conditions are merged with data on capacity and spatial access to primary and specialist care. We find that accessibility and socio-economic variables play a considerable role in determining both the probability of at least one visit and the number of visits to a private specialist. A person with a higher university degree living in a municipality with the highest value of the geographical accessibility index has a 46%-points higher probability of at least one visit to a private specialist compared with a person with junior high living in a municipality with the lowest value of the accessibility index. With regard to visits to a hospital outpatient department these variables are not found to have significant effects.We conclude that public ambitions and regulations are fulfilled for specialist services provided by public hospitals. With regard to the provision of services provided by publicly financed private specialists we find a discrepancy between public goals and surveyed practice.     

政治体制对政府医疗卫生支出及健康产出的影响综述

大多数发展中国家的政府医疗卫生支出及健康产出长期处于较低水平,与发达国家有较大差距。这种差距并不能仅仅由经济因素解释,政府主导了卫生资源的分配,因此分析理性政府在公共资源分配中的激励问责机制尤为重要。本文分析了政治体制对政府提供医疗卫生服务的激励问责机制,综述了近年来有关政治体制影响政府医疗卫生支出及健康产出的实证研究。大量研究结果表明与非民主政治体制相比,民主政治体制在增加政府医疗卫生支出、提高健康产出方面有显著的积极作用。     

Health services reform in Poland: issues in recent developments

After ten years of debate and discussion, the political situation within Poland finally allows the possibility to implement basic reforms in the health care system. Parallel development of the political and technical aspects of the reform has now lead to a final proposal for fundamental reforms in health system responsibility, financing and management. This article describes the current conceptual developments and the political and social context for these final reform proposals at the time of their submission to the government. The primary changes suggested are aimed at increasing the awareness of local, regional and national administrations, health care professionals and the general public that health care has a cost, and that resources must be used carefully if they are to cover health needs. In addition, 'health care' as a term must be extended to include factors and activities besides direct medical services. Such factors as air and water quality, diet, smoking and alcohol consumptions are examples of matters which will also be included in the focus of health system planners. A key element of the organisational reforms is decentralisation of responsibility for health care planning and administration within the framework of nationally set standards and priorities. Based on local decisions, the current basic organisation unit of health care delivery, the ZOZ or integrated health care units, will be redefined and either decomposed into their component services or receive newly defined responsibilities more adapted to the local realities of available manpower and medical facilities. In addition, the development of a private health care sector complementing and even competing with the public services sector will be actively encouraged.     

The political process and the private health sector's role in Vietnam

Vietnam has experienced a period of economic and political transition from a command economy to one of market socialism. This transition has precipitated a shift in the policies concerning the private sector, as well as increased demand for services from the private health sector. The private sector has evolved, though more rapidly in the Ho Chi Minh City area, with the passing of laws and regulations concerning private practice. The policy maker's concern is to maintain the equity gains realized under the public health system while using the private sector growth to make improvements in the system's efficiency. The political process enabling expansion of the private health sector has been slow, and will continue to be measured as it seeks to create a national health system with a rational integration of the public and private sectors.