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PubMed1988

Regional and welfare perspectives on the public-private hospital dichotomy in New Zealand.

Concern with the social welfare implications of dual (public and private) hospital systems has grown over the last decade as national commitments to welfare state ideals have wavered in the continuing atmosphere of fiscal conservatism that has permeated through western democracies. New Zealand provides an excellent example of a health care system in which private hospitals have survived (and recently flourished) alongside those provided by the state. Following a brief survey of the evolution of the New Zealand hospital system, variations in the 'mix' of public and private hospitals are described at the (regional) Hospital Board District level. It is noted that competition for patients and funding between the public and private sectors occurs almost exclusively in the larger, urban hospital districts, and is invariably to the detriment of public hospitals. Districts with a substantial private hospital presence are found to have fewer resources in the public sector (relative to their population) than those which have few or no private hospitals. The welfare implications of this situation are explored. It is proposed that the maintenance of a dual hospital system in New Zealand has provided, in some parts of the country at least, a 'choice' for those able to afford private hospital charges or insurance coverage, but at the expense of those dependent solely upon a (shrinking) public sector.

Economics, Hospital↗
PubMed2004

Financing and planning of public and private not-for-profit hospitals in the European Union.

While much has been written about health care financing in Europe in recent years, discussion has almost entirely focused on revenue. In contrast, there has been remarkably little written on financing of capital investment in European health care systems. Yet major changes are underway in several countries, in particular involving new forms of public-private partnerships (PPP). At the same time, there is growing recognition of the way in which the inherited structure of the health care delivery system constrains the system's ability to adapt to changing circumstances. This paper reports the results of a survey undertaken among key informants in the member states of the European Union to begin to ascertain existing practices and future plans in relation to hospital planning and financing amongst public and private not-for-profit hospitals. The locus of hospital planning decisions reflect the constitutional framework of the country involved, and thus the emphasis on national or local plans. There has been an expansion of private sector involvement, with four basic models identified: private loans direct to the hospital; private loans to a regional health body; a PPP where the private sector's role is to build, design and operate the non-clinical functions of the hospital; and, finally, a PPP, where the private sector's involvement also includes management of the clinical functions of the hospital. It is too early to say whether these approaches will be more successful than the models they are replacing.

Capital Financing↗
PubMed1975

Private specificities of H-2K and H-2D loci as possible selective targets for effector lymphocytes in cell-mediated immunity.

Receptors of effector T lymphocytes of congeneic strains of mice do not recognize public H-2 specificities and react to private H-2 specificities only. This has been established with the use of three tests: direct cytotoxicity assay of immune lymphocytes upon target cells, specific absorption of the lymphocytes on the target cells, and rejection of skin grafts at an accelerated fashion. Immunization with two private H-2 specificities in the system C57BL/10ScSn leads to B10.D2 induces formation of two corresponding populations of effector lymphocytes in unequal proportion: a greater part of them is directed against the private specificity H-2.33 (Kb), while the smaller part is towards H-2.2 (Db) private specificity. These two populations of effector lymphocytes do not overlap, as demonstrated by experiments on their cross-absorption on B10.D2 (R107), B10.D2 (R101), B10.A(2R), and B10.A(5R) target cells, as well as on mixtures of R107 and R101 targets. Following removal of lymphocytes reacting with one of the private H-2 specificities, lymphocytes specific to the other specificity are fully maintained. A mixture of target cells, each bearing one of the two immunizing private specificities, absorbs 100% of the immune lymphocytes and is totally destroyed by them. It is suggested that H-2 antigens are natural complexes of hapten-carrier type, in which the role of hapten is played by public H-2 specifities and that of the carrier determinant by either private H-2 specificities or structures closely linked to them. Various models of steric arrangement of MHC determinants recognized by receptors of effector T lymphocytes are discussed.

Animals↗
PubMed1984

The effect of HLA-A, -B matching on cadaver renal allograft rejection comparing public and private specificities.

Data collected prospectively on 3811 cadaver renal transplants performed between June 1977 and July 1982 by the 42 member institutions of the South-Eastern Organ Procurement Foundation (SEOPF) were analyzed to determine whether donor-recipient compatibility based on public rather than private HLA-A,-B specificities influenced the beneficial effect of HLA matching on outcome. HLA compatibility was calculated considering match and mismatch based on common private or various public (crossreactive group, [CREG]) specificities. Donor-recipient compatibility using certain CREG assignments provided an equivalent means of stratifying graft outcome by the degree of HLA-A,-B match or mismatch, and other CREGs assignments did not. Multivariate Cox regression analysis of donor-recipient compatibility based on certain public antigens showed as high an association (P less than 10(-5) between good matching and decreased graft rejection as did matching for private antigens alone. Patient stratification by HLA match provided a stronger association with graft outcome than by HLA mismatch, irrespective of whether private or public antigens were considered. The likelihood of finding a better match was significantly increased using CREG assignments, and patients with at least one matched private antigen had equivalent or better graft survival when additional public antigens were matched. These findings indicate that with conventional immunosuppressive therapy: (1) matching of private or public HLA-A,-B antigens plays a highly significant role in decreasing renal allograft rejection; (2) matching based on certain public antigens can provide the same or a better association with outcome as private antigens; and (3) the association (crossreactivity) of various HLA specificities can be defined on a functional basis in terms of graft survival.

Cadaver↗
PubMed1996

Redefining private insurance in a changing market structure.

This discussion on likely changes and challenges for the health insurance industry over the coming decade assumes that significant national reform of health care financing for the privately insured population will not occur--or, if it does, that it will mirror the insurance market reforms that many states already have undertaken. First, the changes in private insurance coverage during the past several years are considered, with particular attention to the erosion of employer-based coverage and to the rising influence of public insurance programs--especially Medicaid--on the private insurance market. Next is a description of the changing web of state laws and regulations governing private health insurance. At this writing, virtually every state has enacted or is considering reforms of the small group market to limit what many perceive as unfair or destructive insurer practices and to set new ground rules for competition among insurance arrangements. The changing nature of private insurance contracts in the United States is considered next. Evolving from conventional fee-for-service contracts, private insurance is increasingly a complex mixture of capitation, partial capitation, and reinsurance of capitated arrangements. Finally, this chapter discusses three issues of increasing importance in shaping the marketplace for private insurers: (1) the federal preemption of states' regulatory authority over self-insured employer plans; (2) emerging state regulation to restructure competition in the health insurance and health care markets; and (3) the growing interest of both federal and state governments in medical savings accounts to finance health insurance and health care spending.

Capitation Fee↗
PubMed1988

A comparison of patients in private and public psychiatric facilities.

OBJECTIVE: To compare hospitalised patients in private and public facilities. METHOD: Retrospective medical record review of 100 patients admitted consecutively to both a private psychiatric hospital and a public facility in South Australia in January, 1985. RESULTS: There is a paucity of data about privately treated patients with psychiatric illness. Although several studies have suggested that patients treated in private are similar to those seen at public facilities, thus challenging some of the myths about private practice, a recent Australian study emphasised the differences between private and publicly treated hospitalised patients. The present comparison of hospitalised patients in private and public hospitals, whilst demonstrating some differences, was more marked by the similarities in clinical features. The relevance of the different results, the manner in which they may be interpreted, and the implications for administrative decisions which may affect patients with psychiatric illness are discussed.

Adult↗
PubMed1987

The relationships between public and private pension schemes: an introductory overview.

Only recently have social insurance and private pensions, collectively, come to be thought of in terms of a total social security benefit package. The economic problems brought on by the 1974 oil crisis initially triggered consideration of a common, integrated role for the two systems. The second oil crisis reinforced the relative expansion in private pension programs, as a supplement to social security. Before these events, private and public pension programs interacted in only a limited number of ways, confined to relatively few countries. These interactions were largely confined to collective bargaining, whereby private pensions were gradually extended to nearly all employees in France and Sweden; mandating, or legally requiring private supplementation of social security, debated in several countries in the early 1970's, but postponed by the 1974 oil crisis; and contracting out, or covering a part of the social security benefit under a private plan, as in the United Kingdom. Overall, the tradition of private pensions was not very strong or broadbased. The current debate centers on which public/private pension mix is desirable from the point of view of an old-age income-maintenance program. A new element is the rising support for a "third pillar"--individual tax-encouraged savings--not only as a supplement, but as an alternative to social insurance.

Aged↗
PubMed2004

Privacy, privatization, and the politics of patronage: ethnographic challenges to penetrating the secret world of Middle Eastern, hospital-based in vitro fertilization.

In recent years, in vitro fertilization (IVF) has spread around the globe, including to the Middle East. Privacy, privatization, and the politics of patronage are all key issues affecting anthropological research in Middle Eastern hospital-based IVF clinics. IVF-seeking patients generally desire privacy, even total secrecy, when pursuing these treatments, due to cultural issues of stigmatization, particularly regarding male infertility. Thus, ethical issues surrounding the informed consent process are of prime importance. Furthermore, privatization of medical services in the Middle East has left patients--and anthropologists--with few choices other than private IVF clinic settings in which to pursue treatment and research. Both the ethos of patient privacy and medical privatization affect the ability of anthropologists to "penetrate" the secret world of IVF. Permission to conduct ethnography in private hospital IVF clinics may be difficult to obtain without the help of highly motivated physician patrons, who are willing to recruit their private IVF patients for ethnographic interviewing. This article provides a personal account of some of these challenges as faced by a medical anthropologist during a 15-year career of hospital-based IVF research in the Middle East.

Anthropology, Cultural↗
PubMed2004

Is the corporate transformation of hospitals creating a new hybrid health care space? A case study of the impact of co-location of public and private hospitals in Australia.

A common feature of health reforms in western nations has been the transformation or (re)construction of health and health care as both a commodity and product. In the hospital sector, this transformation has become increasingly evident in the growth of for-profit involvement in service delivery. Investor-owned hospitals are now prominent providers of hospital care in Australia. This paper examines the changing nature of health care space through the changing portrayal and meaning of hospitals as represented by and encoded in the built environment. Public hospitals once occupied 'pride of place'. In contrast, up to the early 1980s, the private sector was seen as a cottage industry. However, increased levels of state subsidisation and government incentives and pro-market policies, combined with market-based opportunities for profit generation, have seen the emergence of large private hospital chains with a new corporate image to hospital care and the blurring of 'public' and 'private'. A significant factor in the reconstruction of hospital space in Australia has been the co-location of private and public hospitals. Co-location is a popular strategy proffered by State governments and one that has been quickly acted on by corporate providers. Using Mayne Health Ltd, Australia's largest for-profit hospital chain, and four specific case studies, this paper explores four variants of co-location. Each of these examples represent a different public and private hospital space. The growth of for-profit hospital chains signifies a new phase in the delivery of health care in Australia but also importantly the creation of a new hybridised 'health care' space. This space is neither private nor public but a reflection of the economic, political and social processes underlying this transformation.

Australia↗
PubMed2004

Why it is time to review the role of private health insurance in Australia.

The role of private health insurance (PHI) within the Australian health-care system is urgently in need of comprehensive review. Two decades of universal health cover under Medicare have meant a change in the function of PHI, which is not reflected in policies to support PHI nor in the public debate around PHI. There is increasing evidence that the series of policy adjustments introduced to support PHI have served to undermine rather than promote the efficiency and equity of Australia's health care system. While support for PHI has been justified to 'take pressure off the public hospital system' and to facilitate choice of insurer and private provider', and the incentives have indeed increased PHI membership, this increase comes at a high cost relative to benefits achieved. The redirection of hospital admissions from the public to private hospitals is small, with a value considerably less than 25% of the cost of the policies. The Commonwealth share of the health care budget has increased and the relative contribution from private health insurance is lower in 2001-02, despite an increase in PHI membership to nearly 45% of the population, compared with the 30% coverage in 1998. The policies have largely directed subsidies to those on higher incomes who are more likely to take out PHI, and to private insurance companies, private hospitals and medical specialists. Ad hoc policy adjustments need to be replaced by a coherent policy towards PHI, one that recognises the fundamental change in its role and significance in the context of universal health coverage.

Australia↗
PubMed2002

Equity, privatization and cost recovery in urban health care: the case of Lao PDR.

Along with the shift from a planned to market-oriented economy, as in many other developing countries, Lao PDR has promoted health care partnerships with the private sector, and cost recovery in public hospitals, to increase resources in the public sector, while at the same time attempting to ensure appropriate access to health care for those without means to pay. In a multi-case design, this study compares two neighbourhoods of different socioeconomic status comprising 10 households, representing urban districts in three provinces. In-depth interviews were conducted over a 1-year period with three visits to each household. Members of the households were interviewed on their perceptions and utilization of health care services. Focus group discussions of public providers and individual interviews of private providers, leaders of the villages and hospital administrators provided complementary perspectives. The study found that both socioeconomic groups utilized private health services as their first choice, including private clinics and treatment abroad for those with high socioeconomic status, while the low socioeconomic group preferred private pharmacies. The unwelcoming attitudes of health staff and procedural barriers have led both groups to meet their health care needs in the private sector. Here the health care they receive is strictly limited to what they can pay for. For the poor, in most cases, this means drugs alone, i.e. no examination, no diagnosis and only limited advice. Limited financial resources often means receiving inappropriate and insufficient medication. Equity in health care remains theoretical rather than practical and the social goals of the reform have not been achieved.

Acute Disease↗
PubMed1999

The diffusion of new medical technologies in the private sector of the U.K. health care system.

Eleven percent of the U.K. population holds private health care insurance, and 2.2 billion Pounds are spent annually in the acute sector of private health care. Although isolated from policy discussions about new medical technology in the National Health Service, the private sector encounters these interventions regularly. During 18 months in one company, a new medical technology was encountered on average every week; 59 leading edge technologies were submitted for authorization (18 on multiple occasions). There are certain constraints on purchasers of health care in the private sector in dealing with new technology; these include fragmentation of the sector, differing rationalities within companies about limitations on eligibility of new procedures while competing for business, the role and expertise of the medical adviser, and demands of articulate customers. A proactive approach by the private sector to these challenges is hampered by its independence. Poor communication between the public and private sectors, and the lack of a more inclusive approach to policy centrally, undermine the rational diffusion and use of new medical technology in the U.K. health care system.

Communication↗
PubMed1992

Study of patients who chose private health care for treatment.

A questionnaire survey was carried out in 1991 in Wessex regional health authority of a sample of private patients having inpatient treatment in eight independent hospitals, and in pay beds in three National Health Service hospitals. A total of 649 patients replied (response rate 60.7%). Sixty respondents to the questionnaire were also interviewed. The aim of the study was to discover which groups of people chose private care rather than using the NHS, and why. In view of the current emphasis on consumerism in health care, the study also aimed to examine how patients exercised choice in a market situation and how well informed they were when they did so. The questionnaire asked about the role and influence of the general practitioner in patients' decisions to use private health care for treatment. The largest group of respondents were in the 36-50 years age group (34.2%). Of the respondents 59.9% were women, 54.1% were in social class 2 and 77.3% were married or cohabiting. The most common reason for using private health care for treatment was to avoid NHS waiting lists (61.5% of respondents) although they did not necessarily know how long that wait would have been. Patients sought their general practitioner's opinion about whether to use private health care in 187 cases (28.8%). The majority of the 649 patients (71.2%) had decided to use private health care before consulting the general practitioner. However, patients were influenced by their general practitioner's advice on the choice of consultant and choice of hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Access to elective surgery at electoral ward level: the impact of the private sector.

BACKGROUND: Purchasers of health care receive no routine information on the use of the private health sector by their residents, and are consequently unaware of any resulting differentials in access to health services. This information would assist in assessing need for services on a locality basis. METHODS: For the period 1990-1992 surgical activity data from the single private hospital in Preston were examined by electoral ward of residence and compared with corresponding NHS data. RESULTS: For the procedures examined, the private sector contributed only 8 per cent to overall surgical activity within Preston. People from the more affluent wards were far more likely to use the private sector than those from deprived wards. CONCLUSION: The private sector did not introduce any inequity of access to surgery within Preston at electoral ward level. However, in districts with higher levels of private sector activity significant differentials in access may exist.

Elective Surgical Procedures↗
PubMed1996

NHS waiting list have been a boon for private medicine in the UK.

Health care: public, private or both? In Great Britain, about 13% of the population is covered by private health insurance, and everyone else is served by the public health care system known as the National Health Service, or NHS. Caroline Richmond, who examined the impact of private medical practice in Britain, says people become private patients for one compelling reason: to avoid the NHS's notoriously long waiting lists for surgery. According to Professor Alan Maynard, a health care researcher, the mainstays of the private sector are the "three h's" --hips, hernias and hemorrhoids-- along with some elective surgery, particularly in gynecology and opthalmology. Another small sector focuses on fertility regulation and cosmetic surgery. Although the levels are not monitored closely, physician consultants are not permitted to earn more than 10% of their income from private practice.

Canada↗
PubMedDate not supplied

Private health care in Canada: savior or siren?

In canada, health care is publicly insured and available to all at no charge. Recently, financial pressures have threatened the system and led to considerable debate about how to save it. One proposal is to permit privately funded health care alongside the public system, resulting in what is popularly called a two-tiered system. This paper presents some of the arguments for and against two-tiered health care. Using as an example cataract surgery-a procedure that is available both publicly and privately-the authors look at some common beliefs about private health care in Canada. They conclude that the growth in private sector cataract surgery does not appear to be related to cutbacks or rationing, that private access does not necessarily shorten waiting times, and that, contrary to popular belief, it is not only the well-to-do who pay for private surgery in Canada.

Canada↗
PubMed2005

Private sector, human resources and health franchising in Africa.

In much of the developing world, private health care providers and pharmacies are the most important sources of medicine and medical care and yet these providers are frequently not considered in planning for public health. This paper presents the available evidence, by socioeconomic status, on which strata of society benefit from publicly provided care and which strata use private health care. Using data from The World Bank's Health Nutrition and Population Poverty Thematic Reports on 22 countries in Africa, an assessment was made of the use of public and private health services, by asset quintile groups, for treatment of diarrhoea and acute respiratory infections, proxies for publicly subsidized services. The evidence and theory on using franchise networks to supplement government programmes in the delivery of public health services was assessed. Examples from health franchises in Africa and Asia are provided to illustrate the potential for franchise systems to leverage private providers and so increase delivery-point availability for public-benefit services. We argue that based on the established demand for private medical services in Africa, these providers should be included in future planning on human resources for public health. Having explored the range of systems that have been tested for working with private providers, from contracting to vouchers to behavioural change and provider education, we conclude that franchising has the greatest potential for integration into large-scale programmes in Africa to address critical illnesses of public health importance.

Acute Disease↗
PubMed2006

Enhancing the private provision of care through premiums for ability: the case of tuberculosis care in the Philippines.

This paper examines how premiums for ability are set and how these can enhance the quality of care provided in private markets. The specific context for this study is the market for tuberculosis (TB) care in the Philippines. While the most cost- and clinically-effective treatment method known as TB Directly Observed Treatment Short Course (TB DOTS) is increasingly being provided by the public sector, few private doctors have adopted this protocol. As findings of multivariate regression analyses of private physicians' fees suggest, this low adoption rate can be partly explained by the modest premiums private doctors receive for using TB DOTS. While the public provision of TB DOTS should be pursued in earnest, this paper argues that the complementarity between public and private provision of TB DOTS should be strengthened, especially since Filipino TB patients seem to prefer private doctors. This goal can be achieved through user fees that (i) include a sufficiently large premium for physician ability and (ii) are paid through the social insurance system.

Adult↗