Beyond the public-private debate: the mixed economy of health

Can or should private organisations provide public healthcare services? What is the scope for private finance in public healthcare services? This paper reviews some of the arguments for and against public or private ownership management and financing of public healthcare services. It concentrates on health services, where non-economic values and ethical questions are as important as the efficiency considerations, and on health purchasing or funding organisations. The paper describes the increasingly complex interrelationship and forms of competition between public and private providers, purchasers and financiers in the UK health sector. It argues that the simple private/public distinction never did describe well the many different forms of financing ownership and operation of health services in any country and is now a handicap to both scientific and lay policy debate about future options. It proposes a framework for describing the main forms of ownership and operations of health services and considers the future for health service purchasing and funding.     

'Where is the public health sector?' Public and private sector healthcare provision in Madhya Pradesh, India

OBJECTIVE: This paper aims to empirically demonstrate the size and composition of the private health care sector in one of India's largest provinces, Madhya Pradesh. METHODOLOGY: It is based on a field survey of all health care providers in Madhya Pradesh (60.4 million in 52,117 villages and 394 towns). Seventy-five percent of the population is rural and 37% live below poverty line. This survey was done as part of the development of a health management information system. FINDINGS: The distribution of health care providers in the province with regard to sector of work (public/private), rural-urban location, qualification, commercial orientation and institutional set-up are described. Of the 24,807 qualified doctors mapped in the survey, 18,757 (75.6%) work in the private sector. Fifteen thousand one hundred forty-two (80%) of these private physicians work in urban areas. The 72.1% (67793) of all qualified paramedical staff work in the private sector, mostly in rural areas. CONCLUSION: The paper empirically demonstrates the dominant heterogeneous private health sector and the overall the disparity in healthcare provision in rural and urban areas. It argues for a new role for the public health sector, one of constructive oversight over the entire health sector (public and private) balanced with direct provision of services where necessary. It emphasizes the need to build strong public private partnerships to ensure equitable access to healthcare for all.     

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.     

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.     

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.     

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。     

Outpatient care utilization in urban Kerala, India

CONTEXT: Kerala is characterized by a high density of public and private health infrastructure. While less inequality in access has been reported in this Indian state, few studies have looked at problems found within cities. Escalation of costs of private services and reduced public investments could generate some inequalities in access for the poor. OBJECTIVE: To assess factors associated with utilization and source of outpatient care in urban Kerala, and to discuss policy implications with regards to access to care. METHODS: A multilevel analysis of individual and urban characteristics associated with utilization and source of outpatient care was conducted using data from a 1995-96 survey by the National Sample Survey Organisation on health care in urban Kerala. RESULTS: There is a high level of utilization (83.6%) of allopathic medical services. Controlling for illness severity and age, utilization thereof was lower for the very poor (OR 0.13 [0.03; 0.49]), inhabitants of medium towns (OR 0.20 [0.05; 0.70]), and inhabitants of cities with a lower proportion of permanent material (pucca) houses (0.21 [0.06; 0.72]). Among all users, 77% resorted to a private source of care. Utilization of a private provider was less likely for the very poor (OR 0.13 [0.03; 0.51]) and individuals from casual worker households (OR 0.54 [0.30; 0.97]), while it was more likely for inhabitants of cities from both low public bed density districts (OR 4.08 [1.05; 15.95]) and high private bed density districts (OR 5.83 [2.34; 14.53]). Problems of quality and accessibility of the public sector were invoked to justify utilization of private clinics. A marked heterogeneity in utilization of outpatient care was found between cities of various sizes and characteristics. CONCLUSION: This study confirms high utilization of private outpatient care in Kerala and suggests problems of access for the poorest. Even in a context of high public availability and considering the health transition factor, relying on the development of the private sector to respond to increasing health care needs could create inequalities in access. Investing in the public urban primary care system and ensuring access to quality health care for the poorest is warranted.     

Health services financing in Greece: a role for private health insurance

Private health insurance can play a significant role in the financing and delivery of health services in relatively undeveloped health systems which suffer from limited public expenditures, resource shortages, and quality of care problems. Research results, however, indicate that private health insurance in Greece has not yet assumed that role. The rapid increase of private health insurance was the result of underfinancing by the public sector and restrictive policies for the private sector. The private sector, however, largely financed by private health insurance, found alternative investment and profit opportunities, which, unfortunately, did not improve health system microeconomic efficiency. In this paper we propose that a way of cooperation could exist between the public sector and private health insurance, which would improve public health services provision and the overall technical, allocative and dynamic efficiency of the health system.     

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.     

高端医疗服务发展的国际经验与启示

高端医疗服务业是健康服务业发展的关键领域,但由于公立医院特需服务不断扩张、社会办医政策存"玻璃门"等原因,我国高端医疗服务业的发展尚处于初期阶段。事实上,高端医疗服务业在部分国家(特别是发达国家)已经初具规模,并在发展基础、运营模式、保障体系等方面积累了比较丰富的经验。本研究介绍了英国、美国、德国、新加坡、澳大利亚和印度发展高端医疗服务业的经验:建立国家安全网医院起兜底作用,实行分层定价和差异化补贴政策,借助商业健康保险,运用公私合作模式,优先发展若干领域。并结合我国实际情况,提出我国发展高端医疗服务业的启示:在确保基本医疗服务的前提下,实行有差别的支付政策;推广商业健康保险,拓展公私合作,确定发展高端医疗的优先领域。     

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.     

Health technology assessment in Portugal

The Portuguese healthcare system is often portrayed as a National Health Service (NHS) model, characterized by universal coverage, comprehensive benefits, nearly free services, national tax financing, and public ownership or control of the factors of production. However, in reality the system fails to accomplish these features in a complete way. There coexist a number of occupation-related health insurance schemes that were originally intended to be integrated into the NHS. In addition, in key areas the NHS does not provide the wide range of services it promises. The public sector has a predominant role in the provision of hospital stays and general practitioner consultations, but the private sector provides a major portion of specialist consultations, dental consultations, and diagnostic services. Major problems in the system led to health reforms in the 1990s. New reform proposals include some specific steps concerning health technology, including standards for medical equipment based on quality, geographic distribution, sustainability, and cost-effectiveness. A new National Plan of Health Equipment was completed in 1998, aimed at improving the distribution of equipment. Despite reforms, healthcare expenditures continue to rise. There is general agreement that gains in efficiency could be made. This situation is beginning to encourage interest in health technology assessment (HTA) in Portugal, although these activities are not yet very developed. Recently, legislation requiring presentation of economic evaluations for new pharmaceutical products was enacted. Present plans also call for the creation in the future of a national agency for HTA.     

The Australian health policy changes of 1999 and 2000

This article evaluates three measures introduced by the Australian Federal Government in 1999 and 2000 that were designed to encourage private health insurance and relieve financial pressure on the public healthcare sector. These policy changes were (i) a 30% premium rebate, (ii) health insurers offering lifetime enrolment on existing terms and the future relaxation of premium regulation by permitting premiums to increase with age, and (iii) a mandate for insurers to offer complementary coverage for bridging the gap between actual hospital billings and benefits paid. These measures were first evaluated in terms of expected benefits and costs at the individual level. In terms of the first criteria, the policy changes as a whole may have been efficiency-increasing. The Australian Government mandate to launch gap policies may well have created a spillover moral hazard effect to the extent that full insurance coverage encouraged policy holders to also use more public hospital services, thus undermining the government's stated objective to relieve public hospitals from demand pressure. Without this spillover moral hazard effect, there might have been a reduction in waiting times in the public sector. Secondly, the measures were evaluated in terms of additional benchmarks of the cost to the public purse, access and equity, and dynamic efficiency. Although public policy changes were found to be largely justifiable on the first set of criteria, they do not appear to be justifiable based on the second set. Uncertainties and doubts remain about the effect of the policy changes in terms of overall cost, access and equity, and dynamic efficiency. This is a common experience in countries that have considered shifts of their healthcare systems between the private and public sectors.     

Public expenditure and healthcare utilization: the case of reproductive health care in India

An important reason for public intervention in health in developing countries is to address the issue of accessibility. However, numerous studies have found inconclusive evidence of the effect of public expenditure on health outcomes. Here, I revisit the debate by examining the effect of public expenditure on the use of health services, which is an important link between expenditure and outcomes. I use data from two recent waves of the National Family Health Survey of India to study the role of public expenditure on the use of healthcare services during pregnancy and childbirth. India has high state-level variations in the use of prenatal care and delivery by skilled personnel as well as levels of public expenditure. I exploit the variation in public expenditure to identify its effect on the use of healthcare services, controlling for other confounding factors. The results show a significant effect of public expenditure at the state level on the use of both prenatal and delivery care at the individual level. Also, there is no evidence of public expenditure crowding out private expenditure. Further, there is strong evidence that public expenditure reaches the desired targets. The results highlight the positive implications of raising public expenditure for healthcare use of pregnancy and childbirth services in the Indian context.     

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.     

Understanding women's provider choice for induced abortion in Turkey

In Turkey, women gained free access to induced abortion from public facilities through the legalization of abortion in 1983. However, due to unmet need and abortion stigma, women use predominantly private services. The political discourse on anti-abortion in the past decade has triggered a diminishing trend in public provision. This runs against both the 1983 Law and the healthcare reforms initiated in 2003, which aimed at universal access to health services. This study investigates the socioeconomic characteristics of women affecting the utilization of public services for induced abortion. Using “Turkey Demographic and Health Survey 2013”, the results of Probit models indicate that women who were young, unmarried, wealthier and whose abortion decisions were made by themselves or their spouses were less likely to choose the public services for induced abortion. Regional differences in the utilization of public sector were also observed. Findings indicate a need to ensure and widen women's access to abortion nationwide; both at the hospital and outpatient level. Health education programs including family planning should give special emphasis to young, single and socioeconomically disadvantaged women who are more prone to apply for unsafe abortion when access to public and/or private sector is limited. A transparent referral system should be designed to timely direct women to abortion services.     

Primary Healthcare Services Among a Migrant Indigenous Population Living in an Eastern Indian City

This paper reports the accessibility and utilization of the healthcare services among a migrant indigenous community inhabiting slums of an eastern Indian city. It is based on data collected through semi-structured interviews conducted with heads of the households. The results indicated that the services of health personnel by visiting households are rare and the service provision was very poor. For curative services, the people heavily depend on private practitioners, including unqualified practitioners, by spending large proportions of their earnings. Due to migration, this community becomes more vulnerable to low utilization of healthcare services. This study warrants evolving a system of healthcare to cater the needs of vulnerable migrant groups in urban areas of India.     

Innovative health service delivery models in low and middle income countries - what can we learn from the private sector?

Background  

The poor in low and middle income countries have limited access to health services due to limited purchasing power, residence in underserved areas, and inadequate health literacy. This produces significant gaps in health care delivery among a population that has a disproportionately large burden of disease. They frequently use the private health sector, due to perceived or actual gaps in public services. A subset of private health organizations, some called social enterprises, have developed novel approaches to increase the availability, affordability and quality of health care services to the poor through innovative health service delivery models. This study aims to characterize these models and identify areas of innovation that have led to effective provision of care for the poor.     

Public policy and private sector provision of health services

Public sector policies often try to extend access and redirect public resources, depending on private sector actions. These strategies focus on reducing demand, improving efficiency, and generating increased revenues in the public sector. In order to provide incentives for efficiency, acquire capital, and redirect limited public resources to public priorities, there must be an expanded role for the private market in the provision of health services. This presents opportunities to improve the focus of resources on high-priority health activities in the public sector and to make more effective and efficient use of the resources of the private sector. The authors discuss the form that such policies may take. However, while the overall set of options available to policy makers can be identified, what is an effective strategy in one country may be neither appropriate nor feasible in another. The challenge to policy research is not to identify what works, but rather to understand the conditions that make a policy effective in some settings but not in others. The objective is not to prescribe the actions to take but to understand the factors that create the current experience in a specific setting.     

Unequable spatial accessibility to hospitals in developing megacities: New evidence from Beijing

The increasing inequality in spatial accessibility to hospitals in developing countries has been attracting attention from researchers and politicians. The situation seems to be worse in growing megacities where more than 10 million people live and rapid urban sprawl has caused serious problems with the supply of health and public transport services. The recent global COVID-19 pandemic calls for particular attention to be afforded to the matter of equal access to basic medical facilities and services for people across different neighborhoods. Although some studies have already been undertaken into the subject of health-focused inequality in the cities of developing countries, the spatial inequity in hospital accessibility has rarely been discussed to date. In this paper, I aim to provide new evidence by considering Beijing as a case study. With the results of my analysis, I show that low-income neighborhoods have experienced lower levels of accessibility not only to high-tier hospitals (secondary and tertiary hospitals) but also to primary healthcare services (primary hospital and neighborhood clinics). The rate at which high-income neighborhoods access secondary and tertiary hospitals is approximately 4 times and 1.5 times as high as that of low-income neighborhoods. Low-income face nearly twice the travel time of those from high-income neighborhoods to reach the nearest primary hospital or neighborhood clinics. Suburban neighborhoods have less access to medical services than neighborhoods that are located in the central urban areas. It seems that the rapid urban sprawl has been worsening spatial inequality in the context of access to medical services in the growing megacity of Beijing. Equal access to healthcare services should be prioritized in future policy discussions, especially in relation to the urban growth management of megacities in developing countries in order to ensure that fair and inclusive urbanization processes are undertaken. Equal access to healthcare services would also be widely beneficial in the context of managing the COVID-19 pandemic.