Mixed Public-private Healthcare Research Articles

Assesing Health Services in Colombia: Development of a Conceptual Framework and Measurement tools based on primary data

Colombia has a mixed public-private health care system, and although official data indicate more than 95% of health coverage, research in this field has demonstrated the persistence of barriers to accessing health care services. This study aimed to analyze the conceptual framework of health services accessibility and develop measurement tools for its assessment using primary data and also to propose a method for ascertaining health services accessibility and availability using a territory-based approach. A mixed method study with concurrent design was carried out in four phases between 2014 and 2017. The starting points were a review of the literature and a documentary research that identified five conceptual frameworks for health services accessibility published between 1970 and 2013. It was found that the theoretical concept of health services availability has not been clear; the literature does not define it explicitly and does not differentiate it from the concept of health coverage. As a result, two measurement tools were developed: a Health Care Services Accessibility Household Survey and a Health Care Services Availability Questionnaire. These tools and the proposed method for ascertaining health services accessibility can be useful for government, institutions, and social and scientific organizations to monitor progress in guaranteeing the fundamental human right to health, declared in the Health Organic Law issued in 2015 in Colombia.

System Dynamic Modelling of Patient Flow and Transferral Problem in a Mixed Public-Private Healthcare System: A Case Study of Hong Kong SAR

The current healthcare system in Hong Kong is experiencing pressure due to constrained resources, with dramatic increases in inpatient services queue lengths, dissatisfaction with the working environment, unacceptable workforce arrangements and high turnover rate of hospital staff. To maintain the robustness of the healthcare system and a sustainable inpatients flow, the Food and Health Bureau launched a public-private partnership programme to utilise the resources of the public and private hospitals. This research investigates the potential for extension of the programme and further enhancing the sustainability of the long-term inpatient services under a mixed public-private healthcare policy via system dynamic modelling. The findings show that an increase of human resources in public hospitals does not substantially improve inpatient flow rate performance. Further, the results from the system dynamic approach provide insights into the expansion of the service areas of the programme and suggest increasing the number of referrals to private hospitals.

Health Care Utilization Inequality in a Mixed Public-Private Health Care System: An Insight from the National Survey in Iran

Background: Equitable health care utilization is a pillar of the Universal Health Coverage (UHC) and is also a concern to policymakers. Measuring and quantifying the inequalities are essential in assessing the progress toward achieving the UHC goals. Several studies have focused on overall measures of unfair inequality in health care utilization. The overall approaches to outpatient and inpatient services are not representative of the differences in health care usage in public and private sectors in a mixed healthcare system, like Iran. A few studies have assessed inequality measures for general practitioners (GPs), specialists (SPs), and hospital admission services in different sectors, separately. Objectives: This study aimed at measuring health care utilization inequalities in outpatient and inpatient health services in public and private sectors in Iran. Methods: In this study, national representative data derived from the utilization of health services survey (UHSS) in 2014 was used. The concentration curve (CC) and concentration index (CI) were applied to assess inequalities in health care utilization services, including the number of GP visits, SP visits, and admission in hospitals. We used ADePT software to produce a nonlinear estimation of CI for these count variables. The indirect standardization method was used to standardize the services for differences in needs by age and gender. The inequality in health care utilization was examined in both public and private sectors, separately. Results: Based on the results, public and private outpatient settings, except for the private GP visits, followed a pro-poor pattern. Inpatient admission in the public sector had a pro-poor model, but it showed a pro-rich pattern in the private sector. GP visits in the private sector changed in favor of the poorer people and SP visits in the public sector changed toward a pro-rich pattern after standardization for differences in needs. CI for family physician (FP) and GP visits in public and private sectors, and also SP visits in public and private sectors was -0.089, -0.086, -0.010, 0.025, and -0.018, respectively. CI for the inpatient admission in public and private sectors was -0.126 and 0.157, respectively. GP, SP and hospital services utilization showed a pro-poor pattern. Conclusions: The results of this study showed that most of the health care utilization followed a pro-poor model in the mixed health care system in Iran. SP visits in the public sector changed toward a pro-rich pattern after standardization for differences in needs. Although public outpatient services need more attention to maintain their pro-poor distribution, SP visits in the public sector should be more considered to follow a pro-poor pattern. Health policymakers are recommended to take measures to eliminate barriers to access this service. This may lead to reduce a gap between the poor and rich people in the utilization of the health care and moving toward the UHC.

Survivorship Care, the Poor Cousin of Australian Cancer Services: Findings From a National Cross-Sectional Survey

Background: The significant role of survivorship care in improving the outcomes and experiences of cancer survivors is increasingly being recognised. In response to the changing health service landscape in Australia, this study aimed to map cancer services and identify important service gaps and factors associated with service provision. Methods: A mixed-method, prospective, cross-sectional survey was conducted throughout 2016. Government or privately-owned, hospital or community-based healthcare organisations with dedicated cancer services were identified. Each organisation was invited to nominate a staff member to answer a purpose specific online/paper questionnaire. Included was an open-ended question that asked about the most important unmet service needs and gaps in their region. Descriptive statistics, standardised rates, and single level and multilevel multinomial logistic regression were used to analyse the data that was augmented with a qualitative descriptive analysis. Findings: Of the 295 eligible organisations that were identified, 93·2% responded. After adjusting for remoteness, compared to government operated services, for-profit companies were significantly more likely to provide only one or two types of cancer services (e.g. radiotherapy) in a limited range of settings (e.g. day hospital with no in-patient or home care) (p<0·001) and less likely to provide comprehensive survivorship services (p<0·001). Survivorship services, either during or after treatment (e.g. allied health, psychosocial support) were most commonly identified by providers as the most pressing service gaps in major cities, rural and remote regions alike. This included the need for improved integration, outreach and affordability of these services. After adjusting for ownership and the respondent's role in the organisation, compared to major cities, remote regions of Australia were more likely to have service gaps that are dependent upon specialist oncology services (p=0.003). Interpretation: The findings from this survey provide intelligence for health service planning and policy in Australia along with insights for other countries with mixed public-private healthcare. Despite being a high-income country with well-established prevention, primary and secondary care, the challenge of providing equitable care across the continuum of cancer care persists. The low rate of service survivorship services in the for-profit sector suggests that current policies are failing to incentivise their provision. The results support calls for innovative service models and funding mechanisms that shift the focus from cancer to the survivor and deliver integrated and equitable cancer care across both the public and private health sectors. Funding: Western Sydney University in partnership with South West Sydney Local Health District and Oncology Massage Ltd. Declaration of Interests: Authors CS, JH, KT and SG are academic researchers at NICM Health Research Institute. The institute receives research grants and donations from foundations, universities, government agencies, individuals and industry. Sponsors and donors provide untied funding for work to advance the vision and mission of the institute. The project that is the subject of this article was not undertaken as part of a contractual relationship with any donor or sponsor. Author GD is Director of Cancer Services for the South Western Sydney Local Health District and Director of Liverpool Cancer Centre in Australia. Author JH is a general practitioner with a clinical interest in evidence-based integrative medicine. Author SG works as an acupuncturist at the Chris O’Brien Lifehouse cancer treatment center in Camperdown, Australia. Author JU is an academic researcher at the Translational Research Institute that receives research grants from foundations, universities, government agencies, and industry. The institute and JU have no competing interests to declare. Ethics: Approval was obtained from Western Sydney University Human Research Ethic Committee (HREC) (H11389) and the Joint University of Wollongong and Illawarra Shoalhaven Local Health District Health and Medical HREC (HREC/16/WGONG/178).

Financial hardship associated with colorectal cancer survivorship: The role of asset depletion and debt accumulation.

To estimate the prevalence of financial objective stress and subjective strain among colorectal cancer survivors and assess associated financial coping factors in Ireland, which has a mixed public-private health care system. Colorectal cancer survivors were identified from the National Cancer Registry, and a sample of 496 respondents were included in the analysis. A postal survey collected information on survivor demographics, socio-economic background, medical characteristics, cancer-related financial hardship, debt accumulation, and asset depletion. Cancer-related financial objective stress and subjective strain were used as dependent variables in logistic regression analysis. Approximately 2 in 5 survivors experienced objective stress (40.9%) or subjective strain (39.4%). Depletion of savings (49.1%) was the most prevalent form of financial coping strategy. Factors significantly associated with increased objective stress were having a stoma (OR=2.1; 95% CI, 1.1-3.9), using savings (OR=9.4; 95% CI, 4.9-18.0), formally borrowing money (OR=3.1; 95% CI, 1.0-9.6), and loans from family members/friends (OR=3.8; 95% CI, 1.9-7.8). Not working (excluding retirees) (OR=0.44; 95% CI, 0.20-0.96) was associated with decreased objective stress. Significant predictors of subjective strain included having dependents, a stoma, using savings (OR=5.3; 95% CI, 2.9-9.5), and loans from family members/friends (OR=2.0; 95% CI, 1.1-3.9) but excluded borrowing money. Cancer-related financial objective stress and subjective strain are common in colorectal cancer survivors, even where all citizens are entitled to publicly funded care, but the financial coping strategies significantly associated with these 2 measures differed. These findings will help inform targeted measures across disparate health care systems and survivor groups to alleviate financial hardship.

Financial Impact of Colorectal Cancer and Its Consequences: Associations Between Cancer-Related Financial Stress and Strain and Health-Related Quality of Life.

The financial impact and consequences of cancer on the lives of survivors remain poorly understood. This is especially true for colorectal cancer. We investigated objective cancer-related financial stress, subjective cancer-related financial strain, and their association with health-related quality of life in colorectal cancer survivors. This was a cross-sectional postal survey. The study was conducted in Ireland, which has a mixed public-private healthcare system. Colorectal cancer survivors, diagnosed 6 to 37 months prior, were identified from the population-based National Cancer Registry. Cancer-related financial stress was assessed as impact of cancer on household ability to make ends meet and cancer-related financial strain by feelings about household financial situation since cancer diagnosis. Health-related quality of life was based on European Organisation for Research and Treatment of Cancer QLQ-C30 global health status. Logistic regression was used to identify associations between financial stress and strain and low health-related quality of life (lowest quartile, score ≤50). A total of 493 survivors participated. Overall, 41% reported cancer-related financial stress and 39% cancer-related financial strain; 32% reported both financial stress and financial strain. After adjustment for sociodemographic and clinical variables, the odds of low health-related quality of life were significantly higher in those who reported cancer-related financial stress postdiagnosis compared with those who reported no change in financial stress postcancer (OR = 2.54 (95% CI, 1.62-3.99)). The odds of low health-related quality of life were also significantly higher in those with worse financial strain postdiagnosis (OR =1.73 (95% CI, 1.09-2.72)). The OR for those with both cancer-related financial stress and financial strain was 2.59 (95% CI, 1.59-4.22). Survey responders were younger, on average, than nonresponders. Responders and nonresponders may have differed in cancer-related financial stress and strain or health-related quality of life. Four in 10 colorectal cancer survivors reported an adverse financial impact of cancer. Cancer-related financial stress and strain were significantly associated with low health-related quality of life. To inform support strategies, additional research is needed to better understand how both objective and subjective financial distress influence survivors' health-related quality of life. See Video Abstract http://links.lww.com/DCR/A447.

The Canterbury pathway to integrated care, warts and all

Introduction: In 2008, Canterbury was delivering traditional hospital-centric care, with a weak primary-secondary interface. This did not meet the needs of the population, was financially unsustainable, and was adversely affecting patient care. Practice change implemented: Multiple integrated care system changes were designed, implemented, embedded and monitored using HealthPathways: consensus clinical guidance for general practice teams and hospital clinicians. Aim and theory of change: HealthPathways provides online information to consistently assess and manage medical conditions, as well as how to request local health services. It aims to improve the quality and range of services and care in the community, reduce unwarranted variation, and minimise patient waiting times. Targeted population and stakeholders: The Canterbury District Health Board (CDHB) funds and provides the majority of health care for 540,000 people. HealthPathways has involved hundreds of local clinicians in its development. Timeline: The first pathways were produced in 2008. The Christchurch earthquakes of 2010-11 heightened the need for efficient, integrated use of health care resources. There are now approximately 620 clinical condition pathways, and 220 request pages, which document referral options, criteria and wait times. Highlights: By investing in primary and community services, and managing care at the interface between hospital and community services, Canterbury has decreased acute medical bed days by 7% by managing acute conditions in the community, increasing elective efficiency and managing follow-ups. For example, an integrated falls prevention programme and pathway has saved 32,008 fractured neck of femur bed days (figures will be presented). Sustainability: HealthPathways is now highly regarded, with eighty per cent of Canterbury general practice teams using HealthPathways more than 6 times a week as a manual in consultation with patients. There are approximately 1,500,000 annual page views (1). Transferability: HealthPathways has been implemented across 30 health districts in New Zealand, Australia and the United Kingdom, covering a total population base of over 22 million. Pathways have particular potential for Ireland, which has similar population levels, mixed public-private health care and general practice consultation fees to New Zealand. Conclusions: HealthPathways is both the enabler and end product of health system change. It was recognised by the King’s Fund as ‘one of Canterbury’s most innovative and most effective changes’ (2). Discussions: The Canterbury health system continues to address problem areas, quake-damaged and dated facilities, and unmet need measured at 4.3% (in publication). Nonetheless, by first documenting business as usual, pathways identify service gaps and enable new integrated care models to be developed. The results of these will be discussed. Lessons learned: Build relationships: getting clinicians who might not normally interact into the same room allays suspicion and ‘patch protection’, and helps foster new ways of working. Pathways don’t have to be perfect from their inception. Pathways are an iterative process of constant change and improvement. A robust and secure electronic-referral system alongside pathways is key to communication at the interface.

Drug Policy in Bulgaria

Bulgaria has a mixed public-private health care financing system. Health care is financed mainly from compulsory health insurance contributions and out-of-pocket payments. Out-of-pocket payments constitute a large share of the total health care expenditure (44.14% in 2014). The share of drugs expenditure for outpatient treatment was 42.3% of the total health care expenditure in 2014, covered mainly by private payments (78.6% of the total pharmaceutical expenditure). The drug policy is run by the Ministry of Health (MoH), the National Council on Prices and Reimbursement of Medicinal Products, and the Health Technology Assessment Commission. The MoH defines diseases for which the National Health Insurance Fund (NHIF) pays for medicines. The National Council on Prices and Reimbursement of Medicinal Products maintains a positive drug list (PDL) and sets drug prices. Health technology assessment was introduced in 2015 for medicinal products belonging to a new international nonproprietary name group. The PDL defines prescription medicines that are paid for by the NHIF, the MoH, and the health care establishments; exact patient co-payments and reimbursement levels; as well as the ceiling prices for drugs not covered by the NHIF, including over-the-counter medicines. The reimbursement level can be 100%, 75%, or up to 50%. The PDL is revised monthly in all cases except for price increase. Physicians are not assigned with pharmaceutical budgets, there is a brand prescribing practice, and the substitution of prescribed medicines by pharmacists is prohibited. Policies toward cost containment and effectiveness increase include introduction of a reference pricing system, obligation to the NHIF to conduct mandatory centralized bargaining of discounts for medicinal products included in the PDL, public tendering for medicines for hospital treatment, reduction of markup margins of wholesalers and retailers, patient co-payment, and the introduction of health technology assessment. Although most of the policies have been introduced since 2011, there is still weak evidence for improvement regarding cost containment and effectiveness.

Addressing the Needs of an Aging Population in the Health System: The Australian Case

Although smaller as a proportion of total population than Western Europe or Japan, almost 15% of Australia's population is aged 65 years and over and expected to increase to nearly 22.5% by 2050. Health policy makers in Australia have tried multiple approaches to address the growing health care needs of an aging population and the related burden of noncommunicable conditions (NCDs). We assess how these interventions—in primary care, hospital services and private health insurance—have influenced outcomes and draw inferences from their successes and some of their main difficulties. Among the key lessons from the Australian experience, also relevant for the Asia Pacific region, are the challenge of aligning financial incentives in a mixed public-private health care and financing system and the difficulty of reforming a medically-centered primary care model to one that integrates care across a range of dimensions, including the services of allied health professionals and long-term care services. The clearest specific policy lessons for the region include the suggestions that public subsidy of private health insurance is unlikely to be an efficient approach to reducing the health-related cost burdens of aging populations, and that countries should build alternatives to fee-for-service payment mechanisms into their plans for achieving Universal Health Coverage. Australians might look to the experience of other countries in the region for additional models of coordination between national government and sub-national divisions and for approaches to reducing the disadvantages faced by minority groups in the health system.

Pre-diagnosis employment status and financial circumstances predict cancer-related financial stress and strain among breast and prostate cancer survivors.

Cancer may have a significant financial impact on patients, but the characteristics that predispose patients to cancer-related financial hardship are poorly understood. We investigated factors associated with cancer-related financial stress and strain in breast and prostate cancer survivors in Ireland, which has a complex mixed public-private healthcare system. Postal questionnaires were distributed to 1373 people diagnosed with cancer 3-24 months previously identified from the National Cancer Registry Ireland. Outcomes were cancer-related financial stress (impact of cancer diagnosis on household ability to make ends meet) and financial strain (concerns about household financial situation since cancer diagnosis). Modified Poisson regression was used to estimate relative risks (RR) for factors associated with cancer-related financial stress and strain. Seven hundred forty survivors participated (response rate = 54 %). Of the respondents, 48 % reported cancer-related financial stress and 32 % cancer-related financial strain. Compared to those employed at diagnosis, risk of cancer-related financial stress was significantly lower in those not working (RR = 0.71, 95 % CI 0.58-0.86) or retired (RR = 0.48, 95 % CI 0.34-0.68). It was significantly higher in those who had dependents; experienced financial stress pre-diagnosis; had a mortgage/personal loans; had higher direct medical out-of-pocket costs; and had increased household bills post-diagnosis. For cancer-related financial strain, significant associations were found with dependents, pre-diagnosis employment status and pre-diagnosis financial stress; risk was lower in those with higher direct medical out-of-pocket costs. Cancer-related financial stress and strain are common. Pre-diagnosis employment status and financial circumstances are important predictors of post-diagnosis financial wellbeing. These findings could inform development of tools to identify patients/survivors most in need of financial advice and support.

When Health Systems Are Barriers to Health Care: Challenges Faced by Uninsured Mexican Kidney Patients

BackgroundChronic Kidney Disease disproportionately affects the poor in Low and Middle Income Countries (LMICs). Mexico exemplifies the difficulties faced in supporting Renal Replacement Therapy (RRT) and providing equitable patient care, despite recent attempts at health reform. The objective of this study is to document the challenges faced by uninsured, poor Mexican families when attempting to access RRT.MethodsThe article takes an ethnographic approach, using interviewing and observation to generate detailed accounts of the problems that accompany attempts to secure care. The study, based in the state of Jalisco, comprised interviews with patients, their caregivers, health and social care professionals, among others. Observations were carried out in both clinical and social settings.ResultsIn the absence of organised health information and stable pathways to renal care, patients and their families work extraordinarily hard and at great expense to secure care in a mixed public-private healthcare system. As part of this work, they must navigate challenging health and social care environments, negotiate treatments and costs, resource and finance healthcare and manage a wide range of formal and informal health information.ConclusionsExamining commonalities across pathways to adequate healthcare reveals major failings in the Mexican system. These systemic problems serve to reproduce and deepen health inequalities. A system, in which the costs of renal care are disproportionately borne by those who can least afford them, faces major difficulties around the sustainability and resourcing of RRTs. Attempts to increase access to renal therapies, therefore, need to take into account the complex social and economic demands this places on those who need access most. This paper further shows that ethnographic studies of the concrete ways in which healthcare is accessed in practice provide important insights into the plight of CKD patients and so constitute an important source of evidence in that effort.

The multidimensional nature of the financial and economic burden of a cancer diagnosis on patients and their families: qualitative findings from a country with a mixed public–private healthcare system

Although awareness is increasing that cancer can have an adverse financial and economic impact for patients, the overall burden remains poorly understood. To elucidate these issues, we used qualitative methods to explore the financial impact of a cancer diagnosis in Ireland, which has a mixed public-private healthcare system and where sick leave and sick pay are at employers' discretion. Face-to-face semi-structured interviews were conducted with hospital-based oncology social workers (OSWs; 21 OSWs from 11 hospitals) and patients (20 from eight hospitals; 11 breast, 5 prostate and 4 lung cancer). Participants were asked about the (1) extra expenses incurred, (2) cancer's impact on work and income, and (3) accessing financial assistance/social welfare benefits. The two interview sets were analysed separately using thematic analysis. Broad themes that emerged included the wide range of additional cancer-related medical and non-medical expenses incurred by all patients, including those with medical cards (which entitle the bearer to receive health services free of charge) and those with private health insurance; the major impact of cancer and its treatment on work and patient/household income (all patients who were working at diagnosis experienced a drop in income); and difficulties in accessing medical cards and benefits. This study reveals the complex, multidimensional nature of the financial and economic burden cancer imposes on patients and the whole family unit. Changes in income post-cancer exacerbate the effects of cancer-related out-of-pocket expenses. These findings have implications for healthcare professionals, service providers and policy makers.

O5-4.2 From NCD research to policy and program: experience in Pakistan

Non-communicable diseases (NCD) have become the leading cause of morbidity and mortality in the population in Pakistan, leading to an estimated loss of US $3.5 billion annually just from productive...

Is Health Care a Right or a Commodity? Implementing Mental Health Reform in a Recession

Is Health Care a Right or a Commodity? Implementing Mental Health Reform in a Recession

Assessment of health care needs and utilization in a mixed public-private system: the case of the Athens area

BackgroundGiven the public-private mix of the Greek health system, the purpose of this study was to assess whether variations in the utilisation of health services, both primary and inpatient care, were associated with underlying health care needs and/or various socio-economic factors.MethodsData was obtained from a representative sample (N = 1426) residing in the broader Athens area (response rate 70.6%). Perceived health-related quality of life (HRQOL), as measured by the physical and mental summary component scores of the SF-36 Health Survey, was used as a proxy of health care need. Health care utilization was measured by a) last-month visits to public sector physicians, b) last-month visits to private sector physicians, c) last-year visits to hospital emergency departments and d) last-year hospital admissions. Statistical analysis involved the implementation of logistic regression models.ResultsHealth care need was the factor most strongly associated with all measures of health care utilization, except for visits to public physicians. Women, elderly, less wealthy and individuals of lower physical health status visited physicians contracted to their insurance fund (public sector). Women, well educated and those once again of lower physical health status were more likely to visit private providers. Visits to hospital emergency departments and hospital admissions were related to need and no socio-economic factor was related to the use of those types of care.ConclusionThis study has demonstrated a positive relationship between health care need and utilisation of health services within a mixed public-private health care system. Concurrently, interesting differences are evident in the utilization of various types of services. The results have potential implications in health policy-making and particularly in the proper allocation of scarce health resources.

Are Primary Care Physicians, Public and Private Sector Specialists Substitutes or Complements? Evidence from a Simultaneous Equations Model for Count Data

In this paper, we examine the relationships between health care visits to general practitioners, public sector specialists and private sector specialists using data from Italy, which has a mixed public-private health care system. We develop a simultaneous equations model that allows for the discreteness of measures of utilization and estimate this model using maximum simulated likelihood. Once common unobserved heterogeneity is properly accounted for, general practitioners, public specialists and private specialists are found to be substitute sources of medical care. In contrast, a naive model finds they are complements.

A look at catastrophic medical expenses and the poor.

A look at catastrophic medical expenses and the poor.