Mixed Public-private Healthcare System Research Articles

Commercial determinants of human rights: for-profit health care and housing.

Commercial determinants of human rights: for-profit health care and housing.

Inequity in psychiatric healthcare use in Australia

BackgroundDespite recent substantial mental healthcare reforms to increase the supply of healthcare, mental health inequality in Australia is rising. Understanding of the level of inequity (unmet need gap) in psychiatric service use in Australia’s mixed public–private health care system is lacking.ObjectiveTo present a novel method to measure inequity in the delivery of psychiatric care.MethodsData came from wave 9 (year 2009, n = 11,563) and wave 17 (year 2017, n = 16,194) of the Household, Income and Labour Dynamics in Australia (HILDA) survey. Multiple logistic regression was employed to estimate the psychiatric care utilisation compared to its need and the Gini index was used to estimate the standardised distribution of utilisation to measure the extent of inequity.ResultsThe results show the inequity indices (need-standardised Gini) in psychiatric care utilisation were significant and found to be 0.066 and 0.096 in 2009 and 2017, respectively, for all individuals. In 2009, the inequity indices were found to be 0.051 and 0.078 for males and females, respectively, and 0.045 and 0.068 for rural and urban residents, respectively. In 2017, the indices were calculated to be 0.081 and 0.109 for males and females, respectively, and 0.086 and 0.097 for rural and urban residents, respectively.ConclusionsThis study showed a marked increase in unmet needs in psychiatric care utilisation since 2009. There is a greater need to develop policies to improve equity in psychiatric care utilisation in Australia.

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.

Rotavirus vaccines contribute towards universal health coverage in a mixed public-private healthcare system.

To evaluate rotavirus vaccination in Malaysia from the household's perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes. The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model. We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles. We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

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.

Pakistan: health is an opportunity to be seized

Pakistan: health is an opportunity to be seized

Learning from disasters to save lives every day in Pakistan

Pakistan faces a challenging array of complex humanitarian crises. Political instability, conflict, entrenched poverty, and natural disasters are all too common and devastating. Threats to public health, particularly after large-scale disasters such as the earthquake in 2005 and flooding in 2010, have been well publicised. 1 Bhutta ZA Bhutta SZ The unfolding human tragedy in Pakistan: fighting alone. Lancet. 2010; 376: 664-665 Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 2 Warraich H Zaidi AKM Patel K Floods in Pakistan: a public health crisis. Bull World Health Organ. 2011; 89: 236-237 Crossref PubMed Scopus (42) Google Scholar However, there is a striking lack of evidence for a direct negative effect of disasters on major health indicators in Pakistan. Post-disaster disease epidemics have been successfully averted and health service indicators have even improved. 3 Ahmad N Annual report 2010. National Disaster Management Authority, Islamabad2010 Google Scholar , 4 Carraro L Estimating the impact of large natural disasters on the Millennium Development Goals—the case of Pakistan. Oxford Policy Management, Oxford2005http://www.opml.co.uk/sites/opml/files/Natural_disasters_and_MDGs_-_Pakistan_case.pdf Google Scholar Although it might seem intuitive that ongoing instability and frequent natural disasters negatively affect health outcomes, this is not necessarily the case. Nepal, for example, with far fewer resources per person than Pakistan, has achieved improved health indicators in the face of humanitarian disasters and unstable governance. 5 Pradhan YV Upreti SR Naresh KC et al. Newborn survival in Nepal: a decade of change and future implications. Health Policy Plan. 2012; 27: iii57-iii71 Crossref PubMed Scopus (62) Google Scholar Medical education and research in PakistanThe construction of health facilities, establishment of medical schools, and recruitment of health workers in the public sector have been important aspects of a popular political agenda in Pakistan, especially for elected governments. According to official reports, the number of medical graduates has increased from 500 in 1947 to 171 450 in 2012 and the number of medical colleges has increased from two to 88, respectively. The total budget of the Pakistan Medical Research Council (PMRC) has increased 2·5 times between the fiscal years 2007–08 and 2011–12; and the number of health research publications has increased 7·5 times between 2001 and 2011 (figure). Full-Text PDF Open AccessPhilanthropic funding for health in PakistanAlthough increasing use of technology continues to escalate health-care costs, Pakistan's experience shows how in a low-income country that allocates little public funding for the health sector,1 more privileged individuals are assisting those who are less privileged. Sadly, similar to public funding, private donations mainly support curative efforts with little spent on preventive care. Health professionals, particularly physicians, have an important role in persuading philanthropists to redress this imbalance. Full-Text PDF Non-communicable diseases and injuries in Pakistan: strategic prioritiesNon-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders, and injuries have become the major causes of morbidity and mortality in Pakistan. Tobacco use and hypertension are the leading attributable risk factors for deaths due to cardiovascular diseases, cancers, and respiratory diseases. Pakistan has the sixth highest number of people in the world with diabetes; every fourth adult is overweight or obese; cigarettes are cheap; antismoking and road safety laws are poorly enforced; and a mixed public–private health-care system provides suboptimum care. Full-Text PDF Health reform in Pakistan: a call to actionPakistan's enormous macroeconomic, internal, and human security challenges coexist alongside the opportunity created by a huge desire for change. With democracy taking root and a new constitutionally ushered era in state governance, The Lancet Series about Pakistan and health focuses on health as a nation-building and social-welfare agenda at a time of unprecedented social upheaval and economic hardships in the country. We call for a unified vision for the goal of universal and equitable health access. Full-Text PDF

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...

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 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 and private specialists are found to be substitute sources of medical care. In contrast, a naive model finds they are complements.

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.

Iron and anemia

Non-communicable diseases, including cardiovascular diseases, cancers, respiratory diseases, diabetes, and mental disorders, and injuries have become the major causes of morbidity and mortality in Pakistan. Tobacco use and hypertension are the leading attributable risk factors for deaths due to cardiovascular diseases, cancers, and respiratory diseases. Pakistan has the sixth highest number of people in the world with diabetes; every fourth adult is overweight or obese; cigarettes are cheap; antismoking and road safety laws are poorly enforced; and a mixed public–private health-care system provides suboptimum care. Furthermore, almost three decades of exposure to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation have contributed to a high prevalence of mental health disorders. Projection models based on the Global Burden of Disease 2010 data suggest that there will be about 3·87 million premature deaths by 2025 from cardiovascular diseases, cancers, and chronic respiratory diseases in people aged 30–69 years in Pakistan, with serious economic consequences. Modelling of risk factor reductions also indicate that Pakistan could achieve at least a 20% reduction in the number of these deaths by 2025 by targeting of the major risk factors. We call for policy and legislative changes, and health-system interventions to target readily preventable non-communicable diseases in Pakistan.